Table of Contents

 Center for Surgical Weight LossTable of ContentsSection One - IntroductionWelcome and Introduction5Patient Education Consent for Bariatric Surgical Procedures6Vertical Sleeve versus Laparoscopic Adjustable Band…………………………….10Schedule of Appointments for Your Bariatric Procedure11Required Documentation for Bariatric Patients12Psychological Evaluations/Seminars and Support Groups13Appointment Instructions14Personal Journal22Calculating Body Frame Size23Calculating Your BMI24Our Surgeon25Section Two – Before SurgeryUsing the Guidebook26Bariatric Center Overview26Your Bariatric Team27Surgical Treatment – Types of Surgeries28 Adjustable Gastric Banding29 Vertical Sleeve Gastrectomy32Bariatric Calendar34Medication List35Medications36Herbal Medications36Healthcare Decisions36Stop Smoking37Breathing Exercises37Pre-op Diet for Weight Loss38Pre-Surgery Diet Practice Tips40Surgery Timeline417-10 Days before Surgery41Table of ContentSection Two – Before Surgery (Continued)Night before Surgery42Day of Surgery42During Surgery43After Surgery44Understanding Pain44Discharge Day45Questions46When Should I Call the Surgeon47Tips for Post-op Patients48Long-Term Guidelines49 Taking Medications49 Vitamins and Minerals49 Support Group49 Benefits, Expectations and Outcomes50 Achieving Success51 Follow-Up Schedule and Labs51Potential Challenges52 Diarrhea52 Nausea and Vomiting52 Lactose Intolerance52 Constipation52 Hypoglycemia52 Plateaus53 Weight Gain53 Hair Loss53Questions and Notes54Table of ContentSection Three – NutritionGastrectomy Sleeve – Diet Progression after Surgery55 Stage 2 (2 to 8 weeks post-surgery) – Pureed (blender)56 Stage 3 (8 weeks post-surgery) – Regular Diet59Gastric Sleeve Food Tip Basics61Information on Sweeteners62Food Labels63Protein65Protein Supplements……………………………………………………………….……..66Concentrated Sweets67Supplement RX68Section Four – Physical Therapy and Exercise InformationExercise69 Advantages69 Ideas for Increased Physical Activity through the Day/Behavior Modification70 Self-Monitoring70Section Five – Frequently Asked Questions How much weight will I lose?71 How will my body know when to stop losing weight? 71 Will I lose my hair?71 When can I go back to work?71 When can I exercise/swim?71 Can I take my medication after surgery71 When can I resume sexual intercourse?71Section Six – ResourcesResources72Section One: IntroductionWelcome and IntroductionWelcome and congratulations on your decision for a healthier life! Your surgeon has determined that you are an eligible candidate for weight loss surgery. This Guidebook contains an overview of the weight loss surgery program. Our multidisciplinary team of surgeons, nurses, dietitians, behavioral health specialists, and exercise specialists provide a comprehensive program of the highest standard. We believe that educating patients and preparing them for weight loss surgery is the foundation for success, and that support after surgery is essential for long-term weight loss. Please read this guidebook carefully and feel free to contact us with any questions.Plan to bring this guidebook with you to all your appointments.It is important that you follow the checklist provided to you and begin to make your required appointments. Once you have completed all your required appointments, we then will submit your reports and clinical information to your insurance company to obtain approval for surgery. Once approved, you will schedule a tentative surgery date and pre-operative appointment for blood work and diagnostic tests as requested by your surgeon. All testing is performed at Tennova Healthcare – Lebanon unless special arrangements are made to have testing completed elsewhere. You will also be scheduled for your pre-operative workshop.The pre-operative workshop will be scheduled prior to your surgery date and will take place at the surgeon office. It will consist of education on what to expect the day of surgery and how to care for you after surgery. Detailed nutritional and diet information will be provided during this session. Seven to ten days prior to the date your surgery is scheduled, you will begin your pre-operative liquid diet. You will be informed of your support group sessions at the 30 day evaluation follow-up call. These sessions will help transition your diet to fit your lifestyle and to address any issues that may arise post-operatively. It is a great avenue to connect with other patients to compare progress and suggestions that may be working in their daily situations.If you smoke cigarettes or use other tobacco products, you will have to discontinue use of these products. Nicotine interferes with wound healing, and smoking reduces lung capacity and stamina. Tennova Healthcare – LebanonPatient Education Consent for Bariatric Surgical ProceduresPatient Name: _______________________ Date of Birth: ________Date: ________After discussion with the surgeon, bariatric surgery has been recommended. Morbid obesity has various health risks associated with it, and bariatric surgery, or surgery for morbid obesity, is major surgery, and is only performed for strict reasons. The option available includes the restrictive procedure vertical sleeve gastrectomy. There are other alternative to surgery including medications, diet and exercise, and behavior modification. Patient initials: _____The benefits from bariatric surgery include improvements in all associated co-morbidities such as diabetes, sleep apnea, arthritis, and high blood pressure. A weight loss of 50-80 percent of the excess weight, and general improvement in quality of life is possible. The benefits are not guaranteed, and are dependent upon the patient making the necessary lifestyle changes for success. Some patients may not lose as much weight, or still may require treatment for medical problems after bariatric surgery. Some patients may gain back some or all of the weight lost after bariatric surgery. Bariatric surgery is not a cure for obesity. Compliance with the dietary and lifestyle recommendations is necessary for maintenance of lost weight in the long term. For example, it is recommended that all patients maintain a healthy diet consisting of low-fat, low-sugar foods rich in lean protein, whole grains, fruits, and vegetables. Regular exercise including aerobic activity and weight training is encouraged. Patient initials: _____Eliminating habits that could be detrimental to your health such as drinking alcohol or smoking is required for all patients. The risks of smoking and alcohol use after bariatric surgery include anesthesia complications, stomach ulcers, liver diseases, and malnutrition. In addition, research has shown an increase in sensitivity to alcohol particularly after gastric bypass procedures resulting in rapid increases in blood alcohol levels.Patient initials: _____Patients with a food addition may transfer their addiction to another substance such as drugs or alcohol. Bariatric surgery does not cause addictions. Instead, people who are addicted to food may find a new compulsion once they are unable to overeat. Not all food addicts develop a transfer addiction after bariatric surgery, as many of them may continue to abuse food after having weight loss surgery. Dieting and surgery will treat the symptom obesity, but not the issues that caused you to overeat initially. The best way to prevent transfer addiction or weight regain after surgery is to get treatment for food addiction with a mental health provider before surgery.Patient initials: _____Because bariatric surgery is considered major surgery, there are many potential complications that could arise. Some of the problems are related to the bariatric procedure itself, while others are related to anesthesia and operating on the abdomen. Serious potential complications include: blood clots in the legs and or lungs (deep venous thrombosis/pulmonary embolism); leakage of digestive contents into the abdomen (gastrointestinal leak); serious infection (sepsis); injury to adjacent organs such as esophagus, spleen, pancreas, liver, and diaphragm (requiring interventions or surgical removal); excessive bleeding; or organ failure. These complications can be life threatening. The overall risk of death (mortality rate) from bariatric surgery is .5% (1/200), but can be as high as 2-5% for some patients.Patient initials: _____Complications requiring re-operation may occur, either immediately after initial surgery, or later in the recovery process.Patient initials: _____Immediately after bariatric surgery, admission to an intensive care unit may be required for close observation.Patient initials: _____If I weigh over 400 pounds, I understand that I may be too large for x-ray tables and this may limit my doctor’s options for diagnosis of complications, as well as increase my risks associated with surgery.Patient initials: _____Other potential complication which are rarely serious include: wound infections or seromas (fluid collection under skin); hernias (breakdown of tissue holding in abdominal contents); gastritis or stomach ulcer (inflammation of the stomach); bowel obstruction (blockage of the intestines); formation of gallstones; formation of kidney stones or urinary tract infection; or pneumonia.Patient initials: _____Food intolerances may occur after bariatric surgery. These may include sugars, fats, lactose (milk sugar), meats or pasta. Tastes for certain foods may change as well. Vomiting and changes in bowel habits may occur, but are usually a result of eating too fast, taking too large a bite, inappropriate food choices, or not chewing properly. Chronic vomiting may be a result of tightening (stenosis) in the stomach pouch and intestine, and may require treatment with endoscopy or surgery. Rarely feedings through tubes into the digestive tract or into the veins are required for nourishment.Patient initials: _____Over time, and especially with forced overeating, the stomach pouch may stretch (dilate) or the staple lines may break. This can result in weight regain, ulcer formation, or both.Patient initials: _____Females undergoing bariatric surgery are recommended to prevent pregnancies for at least 12-18 months following surgery. Pregnancy during the rapid weight loss phase can be dangerous and harmful to both the mother and fetus.Patient initials: _____Vitamin and mineral deficiencies can occur after bariatric surgery. Patients are instructed to take vitamin and mineral supplements daily for life. Failure to comply with these recommendations could result in weakness, nerve or brain damage, confusion, fatigue, rashes, anemia, hair loss, bone loss, and mood changes. Lab work may be done at regular intervals to assess for vitamin deficiencies. It is imperative patients having bariatric surgery receive continued follow-up care by their surgeon, or other clinician experienced in the area of Bariatrics.Patient initials: _____After weight loss, the skin of the arms, legs, abdomen, neck, and face may become wrinkled, droop or sag. Rashes and infections may occur between the skin folds. Cosmetic surgery may be indicated in some cases. Patient initials: _____Psychological changes may occur with weight loss as a result of bariatric surgery, which can affect relationships with loved ones.Patient initials: _____Follow-up appointments are essential.I agree to scheduling appointments with the surgeon and following this schedule of appointments after surgery:1 week,2 weeks,8 weeks,6 months,8 months,12 months or one year,AnnuallyPatient initials: _______________________________________________________________________________________________________________________________________________________I have read the above and have had the opportunity to discuss the material with my surgeon. I understand the risks, benefits, possible complications, and alternatives available to bariatric surgery, as well as the specific operation which my surgeon recommends in my case. Though common risks and complications have been discussed, I understand that less common complications may occur that are difficult to anticipate.Sign Name: ________________________Sign Physician: ______________________Print Name: ________________________Print Physician: ______________________Date: _____________________The figures given are estimates based on averaging established commonly held statistics from multiple sources. Risk and success is dependent on the individual situations, guarantees are not expressed or implied.Vertical Sleeve GastrectomyLaparoscopic Adjustable Band70-90% success with weight loss60-70% success with weight loss1 - 1 ? years to lose weight2 – 3 years to lose weight1 ? day hospitalizationOvernight hospital stay1 – 4 weeks off work1 – 4 weeks off workAdjustments approximately every 3 monthsNo mechanism to stop “junk food” eatingResponse depends upon patient’s ability to make wise food choicesRisksRisks0.5 – 1 % mortality (reported)0.5 – 0.0005% mortality (reported)Deep vein thrombosis (blood clot)Deep vein thrombosis (blood clot)Staple line leakBleedingBleedingStomach perforation (extremely rare)VomitingBand slippageNauseaBand erosionWeight regain (possible)Port malpositioningIn Summary: IrreversibleIn Summary: Less invasiveProcedure with more risk but greater success than LAP-BandOperation, reversible, less risk, longer effect for weight lossSignature: _______________________________________________Date: ____________________Schedule of Appointments for Your Bariatric Procedure(A “Check-List” to guide you through the insurance process.)_____ Attend One Free Informational SeminarDate: ___________________________ Complete the Health Questionnaire Date: ___________________________ Verification of our benefits for surgery is the responsibility of the patient. Contact your insurance company and ask if bariatric services is a covered benefit. If no coverage, cost of services will be the responsibility of the patient. Contact billing at 615-443-6831._____ When all of your insurance company’s criteria have been met, a letter will be sent to them for pre-determination._____ All patient’s will have a surgeon consultation, a dietary consultation, a physical therapy consultation, and a psychological evaluation. We will schedule these appointments.Surgeon consultationDate: __________Time: ____________Physical TherapyDate: __________Time: ____________Dietary ConsultationDate: __________Time: ____________Psychological Eval.Date: __________Time: ____________Support Group MeetingDate: __________Time: ____________Patients planning to self-pay should contact the surgeon’s office to schedule a consultation.Name: __________________________________________________________________Address: ________________________________________________________________Phone: ________________________________ Date of Birth: ______________________Procedure: _______________________________________________________________ Surgeon: _________________________________________________________________Date of Surgery: __________________________________________________________ Required Documentation for Bariatric PatientsAside from the visits on the previous page, the following documentation is required:_____ Patient has BMI of 40 or greater or BMI of 35 with co-morbidities such as diabetes, hypertension, sleep apnea, etc._____ A letter of recommendation from patient’s primary care doctor outlining medical conditions as well as recommending bariatric surgery. (If applicable per insurance carrier)_____ Six consecutive months of documented supervised weight loss attempt through the primary care doctor’s office._____ An evaluation from a dietician._____ A psychological evaluation from a psychiatrist/psychologist/counselor._____ Attend our bariatric seminar and a support group meeting._____ An evaluation from a physical therapist or exercise therapist._____ A consult visit and letter of recommendation from the surgeon.Always verify that your insurance has obesity/bariatric coverage (patient responsibility).Complete all requirements.Verify all requirements have been received by surgeon’s office.Surgeon’s office will submit clinical records to insurance.When approved, you will be notified and a surgery date will be scheduled.Psychological Evaluation/Seminars and Support GroupsThis evaluation is a recommendation for all patients by the National Institute of Health, most surgeons and most insurance.Approximately 90% of appropriate candidates for bariatric surgery report depression. The psychologist can often make suggestions to help you through the process and have greater success post-operatively.Your surgeon will make the referral to appropriate medical provider that performs the psychological assessment.The psychological evaluation will determine if you are a candidate by establishing that you have the ability to understand and comply with instructions and recommendations by following strict dietary guidelines, taking vitamins and mineral supplements, following an exercise program, and setting realistic goals in understanding how your life will change after the surgery. Patients are evaluated to determine that there are no psychiatric conditions such as psychosis, severe behavioral disorders, or severe neurosis, that there are realistic expectations of surgery, ability to understand the goals of surgery and the potential risks and complications.Tennova Healthcare – Lebanon offers a Weight Loss Seminar. The seminar is designed for the benefit of presenting the types of surgical procedures available for weight loss and is conducted by the surgeon. Information is given to those who are considering the surgical weight loss option. It is expected for patients considering the surgery to attend at least one meeting to help them understand what to expect and develop a support line.You are required to attend support sessions to assist with your transitional diet. Support sessions will be scheduled bi-monthly. Prior to your surgery, you will be required to attend at least one session. Occasionally, we will have guest speakers, who present important issues and discuss interesting topics.Instructions for a Six (6) Month Physician Based Weight Management Program4507230635000A six (6) month weight management program directed by a physician means: MAKE ONE (1) APPOINTMENT EACH MONTH FOR SIX (6) CONSECUTIVE MONTHS!The appointments are for weight management. They need to include attempts at weight loss, exercise regiment, life style changes, vital signs with height and weights, behavioral interventions that reinforce healthy eating, physical activity and if prescribed a weight loss medication (this should be included if this applies to you).There CANNOT be gaps in these appointments; they must be six months in a row.Weight loss attempts MUST be made. Each patient’s insurance requirements are different. (Please see the Insurance Specialist with questions). Each patient is expected to lose some weight from their initial consult weight. (Please note this does not include weight loss from the supervised weight loss plan.)Sheets are provided by the Bariatric surgeon to take to your PCP to fill out. Please note the questions on each sheet must be completed. Although the diet, exercise, and goals do not have to change from month to month; a simple “Yes” does not address the question.Medical records are acceptable if they include all of the above information on EACH visit. Otherwise the forms will need to be completed.A Letter of Medical Necessity will be required for insurance approval. This must be written by your PCP. It must include a medical clearance for surgery.Example – Bariatric Monthly Documented VisitToday’s Date: 1/1/2011Patient Name: John DoeDOB: 5/10/75Today’s Weight: 262Beginning Weight: 258Weight Lost or Gained: +4Height: 5’7”BMI: 41.0Blood Pressure: 117/70Temperature: 98.0List Obesity Related Co-Morbidities:Impaired Fasting, Glucose/Insulin Resistance, Hypothyroid, Hypertension, Sleep Apnea List Current Medications:Lisinopril, Metformin, SynthroidCurrent Weight Loss Diet Plan Discussed:Increase Water Consumption, ADA, Low Sodium, Low Fat DietExercise/Activity Discussed for Weight Loss:Increase Aerobic Exercise, Walk/Jog 30 Minutes X 3 DaysList Behavior/DIET GOALS for This Patient:Lose 1-2 lbs. per Week_________________________________________________________________ MD/RD/NP SignatureDateBariatric Monthly Documented VisitToday’s Date: ______________________________________Patient Name: ______________________________DOB: _________________Today’s Weight: ________________Beginning Weight: _________________Weight Lost or Gained: _________Height: _________BMI: _____________Blood Pressure: _________________Temperature: _______________List Obesity Related Co-Morbidities:________________________________________________________________________ ________________________________________________________________________List Current Medications:________________________________________________________________________________________________________________________________________________Current Weight Loss Diet Plan Discussed:________________________________________________________________________________________________________________________________________________________________________________________________________________________Exercise/Activity Discussed for Weight Loss:________________________________________________________________________________________________________________________________________________List Behavior/DIET GOALS for This Patient:_________________________________________________________________________________________________________________________________________________________________________________________________________________ MD/RD/NP SignatureDateBariatric Monthly Documented VisitToday’s Date: ______________________________________Patient Name: ______________________________DOB: _________________Today’s Weight: ________________Beginning Weight: _________________Weight Lost or Gained: _________Height: _________BMI: _____________Blood Pressure: _________________Temperature: _______________List Obesity Related Co-Morbidities:________________________________________________________________________ ________________________________________________________________________List Current Medications:________________________________________________________________________________________________________________________________________________Current Weight Loss Diet Plan Discussed:________________________________________________________________________________________________________________________________________________________________________________________________________________________Exercise/Activity Discussed for Weight Loss:________________________________________________________________________________________________________________________________________________List Behavior/DIET GOALS for This Patient:_________________________________________________________________________________________________________________________________________________________________________________________________________________ MD/RD/NP SignatureDateBariatric Monthly Documented VisitToday’s Date: ______________________________________Patient Name: ______________________________DOB: _________________Today’s Weight: ________________Beginning Weight: _________________Weight Lost or Gained: _________Height: _________BMI: _____________Blood Pressure: _________________Temperature: _______________List Obesity Related Co-Morbidities:________________________________________________________________________ ________________________________________________________________________List Current Medications:________________________________________________________________________________________________________________________________________________Current Weight Loss Diet Plan Discussed:________________________________________________________________________________________________________________________________________________________________________________________________________________________Exercise/Activity Discussed for Weight Loss:________________________________________________________________________________________________________________________________________________List Behavior/DIET GOALS for This Patient:_________________________________________________________________________________________________________________________________________________________________________________________________________________ MD/RD/NP SignatureDateBariatric Monthly Documented VisitToday’s Date: ______________________________________Patient Name: ______________________________DOB: _________________Today’s Weight: ________________Beginning Weight: _________________Weight Lost or Gained: _________Height: _________BMI: _____________Blood Pressure: _________________Temperature: _______________List Obesity Related Co-Morbidities:________________________________________________________________________ ________________________________________________________________________List Current Medications:________________________________________________________________________________________________________________________________________________Current Weight Loss Diet Plan Discussed:________________________________________________________________________________________________________________________________________________________________________________________________________________________Exercise/Activity Discussed for Weight Loss:________________________________________________________________________________________________________________________________________________List Behavior/DIET GOALS for This Patient:_________________________________________________________________________________________________________________________________________________________________________________________________________________ MD/RD/NP SignatureDateBariatric Monthly Documented VisitToday’s Date: ______________________________________Patient Name: ______________________________DOB: _________________Today’s Weight: ________________Beginning Weight: _________________Weight Lost or Gained: _________Height: _________BMI: _____________Blood Pressure: _________________Temperature: _______________List Obesity Related Co-Morbidities:________________________________________________________________________ ________________________________________________________________________List Current Medications:________________________________________________________________________________________________________________________________________________Current Weight Loss Diet Plan Discussed:________________________________________________________________________________________________________________________________________________________________________________________________________________________Exercise/Activity Discussed for Weight Loss:________________________________________________________________________________________________________________________________________________List Behavior/DIET GOALS for This Patient:_________________________________________________________________________________________________________________________________________________________________________________________________________________ MD/RD/NP SignatureDateBariatric Monthly Documented VisitToday’s Date: ______________________________________Patient Name: ______________________________DOB: _________________Today’s Weight: ________________Beginning Weight: _________________Weight Lost or Gained: _________Height: _________BMI: _____________Blood Pressure: _________________Temperature: _______________List Obesity Related Co-Morbidities:________________________________________________________________________ ________________________________________________________________________List Current Medications:________________________________________________________________________________________________________________________________________________Current Weight Loss Diet Plan Discussed:________________________________________________________________________________________________________________________________________________________________________________________________________________________Exercise/Activity Discussed for Weight Loss:________________________________________________________________________________________________________________________________________________List Behavior/DIET GOALS for This Patient:_________________________________________________________________________________________________________________________________________________________________________________________________________________ MD/RD/NP SignatureDateJournalWe encourage you to journal your thoughts and feelings during your journey. We think it is appropriate for you to begin with why I decided to have weight loss surgery? Your thoughts and feelings will serve as inspiration and motivation in the months to come.Date: _________________I, _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Before PhotoAfter PhotoCalculating Body Frame Size:Body frame size is determined by a person’s wrist circumference in relation to his height. For example, a man whose height is over 5’5” and wrist is 6” would fall into the small-boned category.To determine the body frame size, measure the wrist with a tape measure and use the following chart to determine whether the person is small, medium, or large boned.Women:Men:Height under 5”2”Height over 5”5”Small = wrist size less than 5.5”* Small = wrist size 5.5” to 6.5”Medium = wrist size 5.5” to 5.75”* Medium = wrist size 6.5” to 7.5”Large = wrist size over 5.75”* Large = wrist size over 7.5”Height 5”2” to 5”5”Small = wrist size less than 6”Medium = wrist size 6” to 6.25”Large = wrist size over 6.25”Height over 5”5”Small = wrist size less than 6.25”Medium = wrist size 6.25” to 6.5”Large = wrist size over 6.5”What is Your BMI?Body mass index (BMI) is a number based on both your height and weight. It can help determine the degree to which a person is overweight and assesses their total body fat. The normal BMI is 20 to 25. Use the chart above to find your BMI.Our SurgeonDr. Nancy Barrett is a board certified laparoscopic and general surgeon. She is a fellow of the American College of Surgeons and a diplomat of the American Board of Surgery. She is also a member of the American Society of Breast Surgeons, Wilson County Medical Society, and the TN Medical Association. A native of Florida, she, her husband Shane and their three sons moved to Lebanon in 2009. Dr. Barrett has a special interest in laparoscopy, including hernia, biliary, and colon surgery. 1-634Dr. Barrett obtained a Bachelor’s Degree in Biology at Emory University in 1993. She graduated with a Medical Degree from Duke University in 1998 and did surgical residencies at the University of Massachusetts, Memorial Healthcare and Vanderbilt University Medical Center, completing in 2003. She had a successful solo practice in Vero Beach, FL until relocating to Lebanon. She was board certified in 2004 by the American Board of Surgery. She is the Chairman of Surgery for Tennova Healthcare-Lebanon. Dr. Barrett is committed to providing compassionate and professional surgical services to her community.Section Two: Before SurgeryWe are pleased you have chosen Tennova Healthcare-Lebanon to have bariatric surgery. Our team looks forward to assisting you in making the most important health related decision of your life. We are aware of the challenges you have faced, frustration with repeated diets, the health problems you have experienced, and the desire to reclaim your life. Weight loss surgery can result in improved health, strength, and mobility.This guidebook is designed to assist you through your weight loss pathway.Using the GuidebookThe Guidebook will assist you with:What to expect.What you need to do.Strategize toward a healthier lifestyle and dietYour doctor, nurse, dietician, or therapist may add or change any of the recommendations. Always use their recommendations first and ask questions if you are unsure. Bariatric Center Overview We offer a unique program to encourage discharge from the hospital one to two days after surgery. Program features include:Nurses, nutritionists, and therapists trained to work with bariatric clientsCasual clothesPrivate roomsFamily and friends as “coaches” Bariatric Care Coordinator who coordinates discharge planning with support group therapy for the next annual yearPatient Guidebook3619500114300Rise up and be thebest you can bebecause yourworld is waitingfor you!3619500114300Newsletters about weight loss/recipesEducation seminars Your Bariatric TeamGeneral Surgeon - will perform the procedure.Registered Nurse (RN) - will ensure orders by your doctor are completed.Physical Therapist (PT) - will guide you through functional daily activities and teach you exercises to regain your strength/motion.Dietician/Nutritionist - will guide you with dietary planning.Bariatric Coordinator will:Review at-home needs after surgery.Assess and plan for anesthesia and medical clearance for surgery.Coordinate discharge plan.Act as your advocate throughout treatment.Answer questions and coordinate hospital care.Surgical Treatment963930578485Weight loss surgery is a tool that can help you lose weight and keep it off, but surgery will not work alone. To get the best result possible, you must commit to improving your health by following all instructions regarding nutrition, post-operative care, and exercise.When comparing the long-term effectiveness of three types of treatment for obesity, diet and exercise result in a weight loss of 2%-5%, medications 0%, and Bariatric Surgery 50%-70%. Success is measured as a 10% loss of the initial body weight. Surgery has the most favorable long term outcomes and 50-70% of patients were able to keep excess weight off for five years.Types of SurgeryThere are various types of bariatric surgery procedures, however, there are two general ways that they work through restriction and malabsorption.Restrictive Procedures work by reducing stomach size and limits the amount of food you are able to eat. This is accomplished through the use of a gastric banding device around the stomach or be the creation of a surgically smaller stomach pouch. Restriction helps you feel satisfied with less food.Malabsorptive Procedures work by rearranging a portion of the small intestine. This limits the amount of food that can be absorbed, which will cause you to lose mon bariatric procedures include:Gastric BandingSleeve GastrectomyGastric Bypass (not performed at Tennova Healthcare – Lebanon)Biliopancreatic diversion with duodenal switch (not performed at Tennova Healthcare – Lebanon)Adjustable Gastric Banding137160427355Adjustable Gastric Banding is an outpatient surgical procedure. The surgery is performed by placing a band around the outside of the upper stomach to make an hourglass shaped stomach. This creates an upper small pouch with a narrow outlet. This band helps you gradually lose and control your weight by reducing the amount of food that your stomach can hold at one time. The special device used to do this is made of implantable silicone material and contains an adjustable balloon. The balloon allows the surgeon to adjust the function of the band without re-operation.The advantages of this surgery are:It can be inserted laparoscopically without a large incision.It does not require any opening in the gastrointestinal tract.It is an outpatient procedure.There is no staple line.It is adjustable and allows for personalized steady, healthy rate of weight loss. It is reversible. While it is intended to be a long term treatment, the adjustable gastric band can be removed at any time and in most cases laparoscopically. The stomach and other anatomy typically return to their original state.Band AdjustmentsPlacement of fluid in the band is purposely delayed until 4-6 weeks after surgery in order to allow the band to “settle in” and the patient to get used to the sensation of having the band in place. Despite the fact that no restriction is added to the band initially, patients may lose weight during the first 4-6 weeks. Most patients need a “fill” or band adjustment by the sixth week after surgery. In most cases, adjustments are made in the office and take just a few minutes. On a rare occasion, the adjustment port is too deep to feel in the office and patients will need to be adjusted in the radiology department at the hospital under fluoroscopy.Band adjustments are made by having the patient lie down on the exam table in the office and “do a sit-up” to enable the practitioner to feel the port under the skin and fat of the abdomen. The port is located and the skin is prepped with alcohol. Then, a special needle attached to a syringe filled with a small amount of sterile saline (salt water) is passed through the skin into the port. Patients tell us that the adjustments are nearly painless. After the adjustment, you will need to resume a liquid diet for 48 hours.The first year after surgery, the average patient will have up to seven band adjustments to maintain weight loss. The second year, an average of one or two adjustments can be expected, and the third year, probably no adjustment will be necessary.Lifelong, patient will need small adjustments to the band from time to time because there is a small amount of saline that will diffuse out into the band system over time. As a patient, you will be given clear instructions about what constitutes readiness for the next adjustment including diminishing weight loss, ability to eat more at meals, increased hunger, and difficulty following the eating rules. You will also be given clear instructions on what would occur should the band be too tight. Some of the symptoms of a band that is too tight are salivation, inability to eat solid food, coughing, and regurgitation of food. Patients, who have a band that is overfilled, will begin to engage in dysfunctional eating. Dysfunctional eating occurs because patients are unable to eat solid foods therefore eat softer or looser foods that are easier to pass through the band. These foods are often high in fat, high in sugar and high in calories. Patients with bands that are too tight will also have poor weight loss over time. The “Green Zone” is the best place for you to be. One of the major advantages of the adjustable gastric band is that it can be adjusted if patients become ill or pregnant. The band can be loosened to allow for better nutrition, and retightened when indicated. In the event of a catastrophic illness, the band can be removed.Band Adjustment: Figure 1 - Accessing Port with Needle Stay in the Green Zone: Adjusting to Optimize Weight LossHere are a few questions to help you identify within which zone you're currently residing.?Question?YellowGreenRedAre you mostly eating?Any amount of bread, pasta, rice along with proteins and vegetables?Chicken, eggs, fish, fruit, vegetablesCandy, chips, ice cream, pastries, pies, soda, soups, protein drinksThe size of your meals are?Large, full plate (10-12 inch plate)Small/medium (half plate) with a protein and a vegetable or fruitSmall/medium (half plate of soft food)Most meals take you?10 minutes, (you are able to eat fairly fast without paying too much attention15-30 minutes60 minutesYou stop eating when?My plate is empty, but I could eat more?I feel satisfiedVomiting occursYour appetite is?Always hungryGreat, small meals satisfy and it lasts until it's almost time for my next mealNever too sure, it varies based on what I was able to eat during the previous mealYou eat this many times/day?Always, meals don't hit the spot, and I snack no matter how hard I try not to?3 meals/dayUnpredictable, but very hungry at timesSwallowing food for you is?Very easy, I can eat anythingOk, if I take small bites, take my time and chew properlyUnpredictable and difficultYou regurgitate/vomit?Rarely or never, only if I swallow a large piece or fail to chew properlyRarely or never, only if I eat too quickly, or take too big of a biteMore than 2x per week, unpredictableAt night, you cough or wheeze?NeverNeverOftenVertical Sleeve GastrectomyThe Vertical Sleeve Gastrectomy is a restrictive weight loss operation. It involves removal of a substantial portion of the stomach leaving a narrow tube along the lesser curve of the stomach. It is larger than the stomach pouch created during the Roux-en-Y bypass and is about the size of a small banana. Weight loss is achieved by restricting the amount of food that can be eaten. There is no by-pass of the intestines or malabsorption of food. The nerves to the stomach and the outlet valve (pylorus) remain intact with the idea of preserving the functions of the stomach. The removed stomach is thought to play a role in the hormonal regulation of hunger. Upon its removal, the hormonal stimulation of hunger is reduced. The operation is generally performed laparoscopically and requires an overnight hospital stay.This information is meant to be a brief summary comparing the LAP-Band and the Vertical Sleeve Gastrectomy. It does not fully encompass all information regarding these procedures. Bariatric CalendarWrite in the date for your appointments for pre-op labs or tests; pre-op class; and any additional appointments to see your primary care doctor or specialist.MondayTuesdayWednesdayThursdayFridayWeek 6Week 5Week 4Week 3Week 2Week 1Medication ListPlease fill out the Medication List with the requested information.Name:Family Doctor:MedicationName/DosageInstructionsReason for TherapyDurationWhat is the name of your medication? What is the dosage?When and how do you take this medication?Why are you taking this medication?How long have you been taking this medication?Once surgery is performed, certain continued medications will need to be crushed or opened for administration. Medications Aspirin and non-steroidal anti-inflammatory drugs (NSAIDS) can cause prolonged bleeding in normal individuals. Therefore, we recommend that you discontinue all aspirin and NSAID products two weeks before surgery. Use of these products after surgery is linked to gastric ulcers. If you must take something for a headache, menstrual cramps or other aches and pains, you may take TYLENOL (acetaminophen). We recommend that you read the label of many over the counter medications to determine if they contain these contents. Estrogen or Birth Control pills can increase the risk of blood clot formation, ask your surgeon if these should be discontinued and another form of birth control used. The recommended timeframe is a least two weeks before surgery.Ask your surgeon if you should discontinue any cholesterol medication, Coumadin, or Plavix five days before surgery.Herbal Medicine 385572057785Herbal medicines and supplements can interfere with other medicines. Check with your doctor to see if you need to stop taking your herbal medicines before surgery. Examples of herbal medicines: echinacea, ginkgo, ginseng, ginger, licorice, garlic, valerian, St. John’s wort, ephedra, goldenseal, feverfew, saw palmetto, and kava-kava. Healthcare DecisionsAdvance Medical Directives are printed instructions that communicate the patient's wishes regarding healthcare. There are different directives. Consult your attorney concerning the legal implications of each.A Living Will explains your wishes if you have a terminal condition, irreversible coma, and are unable to communicate.Appointment of a Healthcare Agent (sometimes called a Medical Power of Attorney) lets you name a person (your agent) to make medical decisions if you become unable to do so.Healthcare Instructions are your choices regarding use of life-sustaining equipment, hydration, nutrition, and pain medications.If you have an Advance Medical Directive, bring a copy of the document with you to the hospital. Stop Smoking461010038100 Oxygen circulation is vital to the healing process.461010038100Smoking:Delays your healing process. Reduces the size of blood vessels and decreases the amount of oxygen circulated in your blood.Can increase clotting which can cause heart problems. Increases blood pressure and heart rate. If you quit smoking before surgery, you will increase your ability to heal. If you need help quitting, ask about hospital resources. When you are ready:Decide to quit and choose the date.Limit the area where you smoke; don’t smoke at home. Throw away all cigarettes and ashtrays.Don’t put yourself in situations where others smoke.Reward yourself for each day without cigarettes.Remind yourself that this can be done – be positive!Take it one day at a time – if you slip, get back to your decision to quit.Check with your doctor if you need products like chewing gum, patches/prescription aids.Breathing ExercisesTo prevent problems such as pneumonia, practice breathing exercises using the muscles of your abdomen and chest.Deep BreathingBreathe in through your nose as deep as you can.Hold your breath for five to 10 seconds.Breathe out as if you were blowing out a candle. Notice your stomach going in. Breathe out for 10 to 20 seconds.Take a break and then repeat the exercise 10 times.CoughingTake a slow deep breath. Breathe in through your nose and fill your lungs completely.Breathe out through your mouth and concentrate on your chest emptying. Repeat.Take another breath, but hold your breath and then cough hard. When you cough, focus on emptying your lungs. Repeat all steps twice.Incentive SpirometerAn incentive spirometer is a device that measures how deeply you can inhale (breathe in). It helps you take slow, deep breaths to expand and fill your lungs with air. How do I use an incentive spirometer?Sit up as straight as possible. Do not bend your head forward or backward. Hold the incentive spirometer in an upright position. Place the target pointer to the level that you need to reach. Exhale (breathe out) normally and then do the following:Put the mouthpiece in your mouth and close your lips tightly around it. Do not block the mouthpiece with your tongue.Inhale slowly and deeply through the mouthpiece to raise the indicator. Try to make the indicator rise up to the level of the goal marker.When you cannot inhale any longer, remove the mouthpiece and hold your breath for at least 3 seconds.Exhale normally.Repeat these steps 10 – 12 times every hour when you are awake, or as often as directed.Pre-op Diet for Weight Loss SurgeryPre-operative weight loss is desirable to decrease the risk of compilations for our patients scheduled for weight loss surgery. Weight loss before surgery reduces the risk of conversion from laparoscopic surgery to an open procedure. Pre-operative weight loss also reduces the severity of co-morbidities, reduces operating room and recovery time. To be specific:Reduces liver size and intra-abdominal fat, and improves visual fieldReduces co-morbiditiesIncreases patient’s understanding of post-op requirementsReduces operative time and reduces post-operative riskIt is very important that you adhere to the pre-op diet that your surgeon is recommending for you. Situations have occurred where patient’s surgery was cancelled due to non-compliance with the pre-op diet. Please understand this can occur to you if you do not follow the guidelines. If you find yourself struggling with the guidelines, please call the office for support and guidance.Pre-operative ProtocolIn order to lose weight pre-operatively, the meal replacements are recommended for every patient. (3-5 shakes per day – 64-96 ounces of water – 700-900 calories per day)***Please remember clear liquids ONLY the day before surgery***Bariatric Advantage/FusionOur program recommends Bariatric Advantage/Bariatric Fusion Meal Replacements for our pre-op surgery patients. They provide a complete line of nutritional supplements that have been specially formulated to meet the unique demands of both the pre-operative bariatric surgical candidate, as well as the post-operative bariatric surgical patient.The Bariatric Advantage/Bariatric Fusion High Protein Meal Replacement comes in an economic 35 – serving bag with a measured scoop to make accurate dispensing easy. Each 150-160 calorie serving provides 27-28 grams of protein, with only 7 grams of carbohydrates (of which 5 grams are fiber and 1 gram is sugar) and 1.5 grams of fat. Meal Replacement come a variety of flavors: chocolate, vanilla, strawberry, banana, orange cream, iced latte, etc.The first 48 hours on a liquid diet is the most challenging. You will be hungry until your body induces ketosis. Ketosis occurs when the amount of carbohydrate fuel (fuel that is needed to run the body) drops below a critical level, forcing the body to turn first to protein and then to fat reserves to do the work carbohydrates normally do. You will experience a sensation of improved well-being and absence of bothersome hunger in the second or third day of a fast. The feeling is due to a chain of reactions set off by the release of ketones. Ketones inhibit the release of insulin and the stress hormones. As a result, the blood sugar becomes more stable and hunger is calmed. Anxiety is reduced also. You must drink 64-96 ounces of water daily to remove waste from the blood stream. Side effects of a liquid diet: dizzy, dry mouth, ketosis breath, headache, fatigue and bowel changes.Bariatric Advantage/Fusion Products Order Options1. Online: , Go to the Meal Replacement tab for listings.High Protein Meal Replacement Bags (35 serving bag with measured scoop)High Protein Meal Replacement Ready-To-ShakeHigh Protein Meal Replacement Tubs (21 serving with measured scoop)High Protein Meal Replacement PacketSome flavors offered:Bariatric Advantage ProductsBariatricFusion ProductsBananaChocolate MousseCookies and CreamStrawberry shortcakeOrange CreamMint Chocolate Ice CreamVanillaFrench VanillaChocolateCinnamon BunStrawberryOrange CreamIced LatteCappuccino/Chocolate Peanut Butter2. Gibbs Pharmacy 1427 W. Baddour Pkwy #B Lebanon, TN 37087 (615)449-3355 Pharmacy offers the above items/flavors at the same online pricing. Additionally, the pharmacy offers a starter kit that includes a package of each flavor with a shaker bottle. Individual orders will also be provided.Pre-Surgery Lifestyle Practice Tips1.Choose low-fat foods, and avoid fried foods.2.Stop using sugar. Use sugar substitutes such as Sweet & Low, Stevia, Equal, or Splenda.3.Decrease intake of desserts and candy.4. Stop drinking sugar-sweetened beverages such as regular soda and sweetened Kool-Aid.5.Start weaning off of caffeine and carbonated beverages.6.Start cutting back on fast food and eating out. Begin making healthy meal choices when eating out and at home.7.Eat three meals a day. Do not skip breakfast.8. Start decreasing portion sizes.9.Eat more fruits and vegetables.10.Practice drinking water and other fluids between meals, not with meals.11. Drink 64 ounces water a day.12. Practice sipping liquids.13. Avoid alcohol.14. Begin some form of exercise.15. Practice chewing foods thoroughly, 20-40 times or to paste consistency.16.Purchase your protein drinks or supplements and start them.17.Purchase your vitamin and mineral supplements.18.Begin planning a schedule for mealtime, fluids, vitamin and mineral supplements.19.Stop Smoking.Surgery Timeline7-10 Days Before SurgerySurgeon Pre-operative VisitThis will provide you with information regarding your 7-10 day liquid diet and what to expect on the day of surgery and post-operatively. Start liquid diet (Patient may have started diet prior to office visit based on phone confirmation of surgery date.)The diet is to help shrink your liver to make surgery safer.Daily ActivityPhysical activity will improve your cardiac function before surgery. It will also assist in weight loss, improve your recovery time and help to establish a new habit before surgery that will be practiced after surgery.Stop any aspirin or NSAID productsConsult with primary physician regarding any long acting medicationsPAT AppointmentEnsure you go to your pre-admissions appointment made for you by your doctor’s office. What to Bring:X-raysAll medical records / clearances in your possessionA list of all current and past (last 3 years) specialists and or PCP’s with contact informationList of all drug allergiesList of all medication (correct spelling, dose and frequency).Pre-operative testing is offered Monday-Friday from 7:30AM to 4:00PMYou will first register in the Outpatient area and then be directed to the Pre-admission Testing area.The pre-admission nurse will take your history, and perform a nursing assessment.You may go to the laboratory and X-ray departments for additional testing as ordered by your surgeon or by anesthesiaA visit with an anesthesia provider may also occur. You should expect your preoperative testing to take approximately 1.5 – 2 hours.You will receive an Incentive Spirometer. Bring with you on the day of surgery.Time of SurgeryYour surgery time will be discussed with you at the time of this appointment. If your surgery time is changed by the hospital for any reason, the nurse will contact you the day before your surgery after 5:00PM. If you have any questions, please call 615-443-6002.Notify Your Surgeon if you develop a sore throat, fever, head cold, flu or other illness a day or two before your procedure. Your surgery may have to be delayed until you are feeling better.Night Before SurgeryShower with antibacterial soap (provided at your pre-admit visit)Nothing to eat, chew gum or smoke after midnight.Day of SurgeryShower with the antibacterial soapDo not wear jewelry, alcohol based cosmetics or hair productsTake medications if instructed (example Beta Blockers) with a tiny sip of waterDo not bring valuables to the hospitalBring your CPAP if you have a history of diagnosed sleep apnea**REMEMBER**Do not eat anything after midnight the night before your operation.Do not chew gum.Bring your Incentive SpirometerDrink 20 oz. Gatorade on way to hospital, G-2 if diabetic.Hospital Care - What to ExpectDay of SurgeryIt is recommended that you have a reliable adult to stay with you for the first few days after surgery.Take medications as instructed (Example a beta blocker) with a tiny sip of water.Nurses in the Same Day Surgery Unit (SDS) will:a. Complete your paperworkb. Start an IV (intravenous)c. Give you any necessary medications, such as an antibiotic to prevent infections and an anticoagulant (blood thinner) to prevent the formation of blood clots.d. Apply sequential compression device (SCD) on your legs. These are air filled stockings that alternate inflation and deflation to improve circulation. This helps prevent blood clots and phlebitis.Your anesthesiologist will review your information to evaluate your general health. This includes your medical history, laboratory test results, allergies, and current medications. Before you receive the anesthesia, monitoring devices will be attached (blood pressure cuff, EKG, and other devices). You will wait in the preoperative area until your surgery time. You may have one family member wait with you in the holding area; all other family and friends can wait in the waiting area. Your surgeon will talk to them after your surgery is complete and you are in the post anesthesia care unit (PACU).During SurgeryThe anesthesiologist will manage vital signs — heart rate and rhythm; blood pressure; body temperature and breathing; as well as monitor your fluid and need for blood replacement if necessary.After Surgery You will recover in our post anesthesia care unit (PACU) where you are monitored closely for:a. Changes in vital signs, and level of consciousnessb. Independent and effective breathingc. Pain managementd. Nausea and vomitinge. Oxygen level – if you have been diagnosed with sleep apnea, you should plan to bring your C-PAP machine.Once discharged from the PACU, you will then be transferred to either an inpatient room or to the outpatient surgery department. In either of these settings, you will be monitored for:a. Changes in vital signs and oxygen levelb. Painc. Nausea and vomitingYou will also:a. Get out of bed to ambulate on your post-operative day/night of surgeryb. Keep the head of the bed elevatedc. Take deep breaths, and use the incentive spirometer every hour while awake.d. On day after surgery, take sips of water once NPO (nothing by mouth) has been removed per your surgeone. Meet with the dietician to review your post-op dietf. Meet with the nurse to review your post-op instructions and to answer any questions.Understanding Pain3975100190500From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong’s Essentials. of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc.? Reprinted by permission.3975100190500-4063936195Pain ScaleUsing a number to rate your pain can help the Bariatric Team understand and help manage it. “0” means no pain and “10” means the worst pain possible. With good communication, the team can make adjustments to make you more comfortable.Discharge DayHave someone available to drive you home.Return home to rest.Do not drive until released or cleared by your surgeon.Pain – It is not unusual to have pain after surgery. Pain medicine should be taken before pain becomes severe and repeated as prescribed. It is not uncommon to experience chest, shoulder or back pain, which is related to air that is instilled in your abdomen in order to do the surgery with the laparoscopic approach. Moving around is the best way to relieve this pain. If you are having intense pain, you should call the office and let your surgeon know.Activity – Walking is encouraged beginning the day of your operation. It is very important to get up and move to help prevent blood clots, pneumonia, constipation, and other complications that can occur after surgery. It is better to take your pain medicine and ambulate than to stay in bed. We encourage you to go outdoors and take short walks. No heavy lifting, no more than 10 lbs. is allowed until the surgeon sees you on your first post-operative visit. When you are able to return to work will depend on the physical demands of your job and the rate of your recovery.Deep Breathing – To help prevent pneumonia or other breathing problems, you will need to take at least ten deep breaths per hour while you are awake. Deep breathing and coughing are also important in preventing respiratory problems.Diet – When you are discharged, please follow the instructions provided to you in the hospital. Drink plenty of fluids. Sip, Sip, Sip! DO NOT progress to the next phase without being told. Your new stomach pouch needs time to heal and the diet is designed in phases to allow time for healing. (Rapid progression of the diet can result in irritation or obstruction of the pouch.)You may shower 24 hours after surgery, if your incision is closed with steri-strips or surgical glue. You must cover your drain site with plastic wrap/saran wrap.Wound – Routine incision care includes cleansing the wound with soap and water every day and patting it dry. Your incision was closed with sutures and steri-strips. Leave the steri-strips in place until they fall off by themselves. You will be discharged with a Jackson Pratt drain to monitor your stomach suture line. Drainage will be strawberry Kool-Aid color. Should there be a change in this coloring, call surgeon’s office. The drain will be removed in your one week post-op office visit. Medications – Resume routine medications the day after surgery unless instructed otherwise. Remember to crush all medication if not contraindicated (extended release (ER), sustained release (SR) or long acting mediations cannot be crushed). If you are unsure, please ask your pharmacist. You will need to crush your medications for two weeks (until your first post-op visit with your surgeon).Questions?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Congratulations on your journey to the new you!When Should I Call the Surgeon?If you experience any of the following, call your surgeon’s office.Severe or increasing pain that is not controlled by your pain medication.Swelling, redness, increase tenderness, new or increase drainage around your incision or around the drain insertion site.Temperature above 101 degrees F for more than four hours.Nausea or vomiting that does not subside within six hours.Trouble breathing/shortness of breath.Excessive or uncontrolled bleeding or drainage from your incisions.If a drain is present:Swelling, redness, increase tenderness, new or increase drainage around the drain insertion site.Drainage in the J/P bulb that looks or smells like pus.Change in color from the normal strawberry Kool-Aid color.The bulb will not stay compressed or fills with air.The drain comes out.If you have questions or concerns, do not hesitate to call the office.Caring For Your Jackson-Pratt Drainage Tube1905117145Your doctor discharges you with a Jackson-Pratt drainage tube. Doctors commonly leave this drain within the abdominal cavity after surgery. It helps drain and collect blood and body fluid after surgery. This can prevent swelling and reduces the risk for infection. The tube is held in place by a few stitches. It is covered with a bandage. Your doctor will remove the drain when he/she determines you no longer need it. HOME CARE:Don’t sleep on the same side as the tubeSecure tube/bag inside your clothing. This prevents tube from being pulled outEmpty your drain at least twice a day. Empty it more often if the drain is full. Wash and dry your hands before emptying the drain.-Lift the opening on the drain and drain the fluid into a measuring cup-Record the amount of fluid each time you empty the drain. Include the date and time it was emptied. Share this information with your doctor on your next visit.-Squeeze the bulb with your hands until you hear air coming out of the bulb if your doctor has instructed you to do so (sometime the bulb is used as a reservoir without suction) and close the opening. Check with your doctor about specific drain instructions.Change the dressing around the tube every day.-Wash your hands and remove the old bandage.-Wash your hands again-Wet a cotton swab and clean the skin around the incision and tube site. Use normal saline solution (salt and water). Or, you can use warm, soapy water.-Put a new bandage on the incision and tube site. Make the bandage large enough to cover the whole incision area and tape the bandage in place.Keep bandage/ tube site dry when you shower. Ask your healthcare provider for the best options.“Stripping” the tube helps keep blood clots from blocking the tube. Ask your nurse how often you should strip the tube. Stripping may not be needed, depending on where and why your doctor placed the tube. It may even be dangerous in some cases.-Hold the tubing where it leaves the skin, with one hand to keep it from pulling on the skin.-Pinch the tubing with the thumb and first finger of you other hand.-Slowly and firmly pull your thumb and first finger down the tubing. You may find it helpful to hold an alcohol swab between your fingers and the tube to lubricate the tubing. -If the pulling hurts or feels like it’s coming out of the skin, stop. Begin again more gently. ()Tips for Post-op PatientsMake consistently healthy food choices (protein first).Maintain portion control.Eat breakfast.Chew your food thoroughly (at least 20 times a bite).Take your vitamins, EVERYDAY!Take your time when eating (at least 20 minutes per meal).Drink plenty of water throughout the day, but not with meals. Carry your water bottle with you at all times to avoid getting dehydrated.Increase your fluid intake to 64 ounces of water and other zero calorie liquids every day. This helps with weight loss.SIP…SIP…SIP… no gulping!Don’t force yourself to take that “extra bite” no matter how good it tastes. You will pay for it later by feeling sick. Also, you do not want to stretch your new pouch.Substitute positive things in your life when you feel like eating. Try exercising, journaling your feelings, talk to a friend, pampering yourself…etc.Plan your meals and follow your plan.Exercise on a regular basis.Keep food and exercise journals.Get adequate rest.Utilize healthy support system (support group meetings and on-line support, individual counseling if needed).Try only one new food at a time so that you can find what agrees with you. In time, you will be able to tolerate more foods. What does not agree with you today may agree with you in 2 months. Your pouch may “get irritated.” Go back to eating bland tasting foods until the feeling passes.Learn the difference between “head hunger” (thinking you want to eat when you are not physically hungry) and “real hunger.” Learning the difference will make your long-term weight loss more successful.Don’t weigh yourself every day, once a week is best. Weigh at the same time of day with the same amount of clothing each time.Section Three: NutritionGastrectomy Sleeve – Diet Progression After SurgeryThe diet after gastric sleeve surgery progresses through several stages. Your surgeon will let you know when it is okay to progress to the next stage. In the hospital, you will receive a clear liquid diet. Stage OneThe first week, take in shakes and water. This includes 3-5 shakes per day that you have become familiar with prior to surgery.Stage Two (3 to 8 weeks post-surgery) – Pureed (blenderized):Everything that you eat on the pureed diet should be sugar-free or no sugar added, low fat and blended to the consistency of baby food or smooth applesauce.Eat PROTEIN foods first. Then if you are not too full, try vegetables or fruits.Make sure foods are well-blended or you can purchase baby food.Start slowly. Start with 1 oz. (2 Tablespoon) portions – no more than 4 Tablespoons at the most. Listen to your body and stop eating as soon as you feel full. If you do not tolerate pureed foods, go back to the liquid diet and try again in a few days.Remember to drink liquids between meals, not with meals.Continue protein drinks or protein supplements every day. (80 g.)Helpful Hints for BlenderizingCut foods into small pieces before putting into the blender or food processor.Remove seeds, skins and fat.Add liquid for ease of blending. Add enough liquid to cover the blades. Options include skim milk, broth, strained low-fat cream soup, low-fat gravy, low-fat or non-fat sour cream or fat-free half & half.Blend the item to a smooth, applesauce consistency.Make sure there are no particles, seeds or lumps remaining. If so, put through a sieve or strainer.If you have leftover blenderized foods, try freezing in single serving portions in ice cube trays and put the frozen cubes into plastic freezer bags.Meats – Very lean and dry meats puree better by adding a small amount of fat (Margarine, oil, light mayonnaise, gravy, etc.) fish also tends to be dry. Improve the texture by adding small amount of lemon juice, light mayonnaise or strained low-fat tartar sauce.Starches – Try pureed peas, canned beans, and sweet potatoes. Starches puree better when hot. Rice and potatoes tend to puree into a gummy paste and are not recommended. Substitute cream of rice cereal prepared with a flavorful broth and seasoned with margarine. Pasta or noodles are not recommended as they are not well-tolerated.Vegetables – Cook vegetables until soft. If using canned vegetables, drain first. Add melted margarine and puree. Add a small amount of liquid until it reaches the smooth applesauce consistency.Fruit – If using canned fruit, drain first. Add a few drops of lemon juice to help prevent them from discoloring.Begin to take advantage of your favorite leftovers before surgery. Process these foods, and freeze them in an ice cube tray. (Each cube is approximately ? to 1 oz.). When frozen, pop out into Zip-lock bag; label and date, and freeze cubes until needed.Meal Guidelines for the Pureed DietOnce you begin to eat pureed foods (which are considered solids), you will want to start differentiating between liquids and solids - meals should include pureed foods, and so liquids (including protein drinks) should be taken separately from your meals.You should eat three meals a day with protein drinks between meals.Protein drinks containing at least 20 grams of protein per serving should be consumed as needed to meet 80g/day goal.Start with a portion size of 1-2 tablespoons of pureed food for the first month.At first you may not be able to tolerate this amount. Eat your protein source first, and then if you have room a small amount of fruit, vegetables or other foods may be consumed.Hints for Measuring FoodsLiquids or soft-pureed foods are best measured in measuring cups or spoons; they can be measured in ounces, tablespoons or mls.1 cup8 fluid ounces240 ml16 tablespoons? cup6 fluid ounces180 ml12 tablespoons? cup4 fluid ounces120 ml8 tablespoons? cup2 fluid ounces60 ml4 tablespoons1/8 cup1 fluid ounce30 ml2 tablespoons1 Tablespoon = 3 teaspoons? Tablespoon = 1-1/2 teaspoonsPureed Food OptionsRecommended FoodsFood That May Cause DistressPortion/Timing InstructionsLiquidsCrystal Light, decaf coffee or tea, unsweetened fruit juice, vegetable juice, sugar-free non-carbonated beverages, fat-free or 1% milk, high-quality nutrition drinks such as Diet Instant BreakfastSugar sweetened liquid; alcohol; carbonated beverages; sweetened condensed milk, chocolate milk, 2% or whole milk; ice creamGradually increase liquids to 4-6 oz. each feeding. Take liquids 45 to 60 minutes before pureed/semi-solid foods. Take at least 48 oz. (6 cups) low-fat, low-calorie liquids, milk, and water each daySoupsEgg drop soup, reduced-fat made with skim milk strained cream soups, fat-free broth, blenderized lentil or split pea soup, and bouillonRegular cream soups, soups with regular meats and vegetablesSince these are liquids, take 45-60 minutes before or after pureed/semi-solid foodsBreads/StarchesCooked, refined/strained cereals, unsweetened instant oatmeal (strained), cream of wheat or rice cereal, smooth polenta, hummus, or chips mashed potatoes without skinDry cereal2-4 oz. (4-8 tbsp) of total pureed or semi-solid foods at a time.VegetablesPureed vegetables, baby food vegetables or pureed cooked vegetables (no corn or peas), mashed winter squash, tomato juice or sauce, pureed salsa, marinaraWhole vegetables, raw vegetablesFruitsUnsweetened applesauce, pureed banana, other pureed fruit without seeds or hulls, unsweetened fruit juice (diluted, no sugar added)Sugar sweetened fruit, raw fruit, fruit peels, seeds, or hullsMeat/Protein/Protein SubstitutesPureed fish, tuna, poultry, pork or beef; low-fat cottage cheese, low-fat or non-fat cheese; sugar-free or fat-free yogurt (no fruit); baby food meats; mashed or pureed tofu; pureed egg or egg substituteRegular whole meats, fried meat or eggStage Three (8 weeks post-surgery) – Regular DietSteps for Adding Solid Foods:Try only 1 small bite of the new food and chew well. Wait awhile and if there are no problems, take another bite.If at any time you feel too full, nauseated or vomit, stop eating and rest. Take only clear liquids at the next meal and add blended foods and liquids at the following meal. Try one solid food again the next day. Also, ask yourself the following questions:Did I chew to a paste consistency?Did I eat too fast?Did I eat too much volume?Did I drink fluid with my real meal or too close to my meal?Did I eat something high in sugar or fat?Was the food moist or was it too dry?Rice, pasta and doughy bread may not be tolerated for six months or more.Try fresh fruits without the skin first. If tolerated, the skin can be tried the next time. Salads are generally well-tolerated if chewed well.Go slowly. Try a small amount to see how you feel.Avoid high sugar and high fat foods to avoid a high calorie intake.Solid foods will fill your stomach pouch more than liquids, so you will be eating smaller quantities of foods versus liquids.You may find that you tolerate a certain food one day and not the next. This is normal.Foods to Avoid:Hard /crunchy foods may always be poorly tolerated. Nuts and seeds are difficult to break down. Fried foods/greasy foods are hard to digest and are very high in calories.Corn chips, potato chips, tortilla chips, hard taco shellsNuts and seedsFried foods and greasy foodsRULES OF LIQUIDSNo liquids with your mealNo liquids AS your mealNo liquids with calories between mealsNo liquids with your meal and at least 45-60 minutes after a meal. If you go longer, that is even betterNo liquids AS your meal – soups are liquid, chili is a liquid, and oatmeal in the morning is a liquid.General RuleIf you have to ask “is this a liquid or not”, it is probably a liquidIf you have to use a spoon to eat it, IT IS A LIQUIDNo liquids with calories between mealsNo sweet tea, regular colas, orange juice, apple juice, milk, or “protein” shakes(May have diet colas) – Some people leave open for 10 minutes to release carbonationTypical breakfastProtein bar, or small muffin, or half piece of toast with butter/jelly………..Band Patients OnlyA “meal” should take no longer than 20 minutes – if you are taking longer to eat then you are probably trying to “out eat” the BandHeartburn at Night = Band is TOO TIGHT (Call us immediately)Food CategoryRecommended FoodsFoods That May Cause DistressPortion/TimingInstructionsLiquidsWater, tea, coffee, club soda, diet soft drinks, fat-free milk, unsweetened fruit juice, vegetable juiceSugar sweetened liquids; alcohol; whole milk, milk shakes, and ice cream; high calorie drinks; sweetened fruit juice4 to 8 oz. liquid at a timeBreads/ StarchesDry, coarse, or well-toasted bread; crispy crackers or baked tortilla chips; all cooked and dry cereal without added sugar; boiled, mashed, or baked potatoes; cooked pasta and riceSoft breads that become gummy; breads or cereals with nuts, dried fruit, or seeds, potato skins, sweet potatoes; noodlesDrink liquids 45-60 minutes before or after solid foodsVegetablesFresh, canned, frozen, or cooked vegetablesVegetables with tough skins or seedsLimit total portion of solid foods to 4-6 oz. (8-12 tbsp.) at a time. Eat all foods slowlyFruitsFresh, canned, frozen, or cooked fruits. Use caution with apples, grapes, or other fruits with skins or peels.Dried fruits; fruits with core, seeds, or skins; whole citrus fruits (juice okay)Drink a minimum of 48 oz. (6 cups) of liquids daily. 4-6 small feedings of solid foods per dayMeat/Protein/Protein SubstitutesAll diced to ? inchTough meats; meats with gristleChew meat slowly and thoroughly. Choose high quality protein foods such as scrambled eggs, Egg Beaters, low-fat cheese or cottage cheese, or lean meats such as tuna fish, chicken, or porkDessertFruit, sugar-free jelloDesserts with nuts, dried fruit, seeds, coconut; desserts and candy containing sugar; jams, jellies, marmaladesLimit desserts as these tend to be low in nutrients.FatsAll, in small amountsFried foodsInclude a small amount of fat (1 tsp.) 3 times dailyMiscellaneousSoups with large pieces of meat; popcorn, nuts, chili, and other highly spiced foods; chewing gum.Regular Meal SuggestionsBreakfastWhole wheat toast with peanut butter, apple butter, or melted cheeseBananaLunchmeat String cheeseMandarin orangesYogurt GrapesHard boiled eggBananaScrambled eggs with cheese, veggiesWhole wheat toastVeggie sausageMini pizza with cheese, Canadian bacon, tomato sauceFrozen whole grain waffle with light syrupPeachLunch Baked potato with shredded cheese and broccoli Beef stewBiscuit (dry)Chef salad with vinaigretteFruit cupPeanut butter on whole wheatAppleFrozen diet mealGrapesTuna/chicken/egg salad with crackersCarrot chipsApple Veggie pizza on thin crustSalad with vinaigrette Dressed ham sandwichPretzelsFruit cupDinner Chicken breastButter beansCooked greens Baked tilapiaBrown riceMixed veggiesSpaghetti with meat sauceBroccoliBBQ baked pork chop Green beans Roasted potatoesCooked applesRoastMashed potatoesAsparagusSmoked turkey sausageSauerkrautMashed potatoesGreen beansBeansKaleChicken/tuna casseroleSide salad with vinaigretteChicken/beef fajitasGrilled peppers and onions Salmon pattiesSalad or vegetablePeas*Keep in mind that the above suggestions are dependent on your level of restriction and that the portions sizes may vary.Gastric Sleeve Food Tip BasicsEat slowly and chew thoroughly – at least 25 times! Each meal should last 30 minutes. Avoid gulping foods and drinks. All foods must be well-chewed to a paste consistency. Using a small fork or spoon (i.e. baby utensils) can help control portion sizes. Have one place to eat (such as at the table) and avoid reading or watching TV while you eat. This helps you to enjoy your food, concentrate on eating slower and to realize when your stomach is full.Avoid concentrated sugars, especially those in liquid form. They are filled with non-nutrient calories and slow down weight loss.Limit fats and fried foods: they are a concentrated source of caloriesRemember the stomach can only hold 4-6 oz. after surgery. You will probably feel satisfied after 2-3 tablespoons of food. Do Not Overeat! Over time your stomach will stretch. It takes 6-9 months (possibly longer) for your new stomach size to stabilize and allow you to determine your normal meal amount.Stop eating when you feel comfortably satisfied. If ignored, vomiting will follow and you can stretch the size of the stomach. If you are unable to keep anything down and are having extreme difficulty staying hydrated, sip on Gatorade, which also has electrolytes necessary for normal cell function. Once you feel better, return to non-calorie beverages such as water and diet drinks.Drink at least 6-8 cups (8 oz.) of fluid per day to prevent dehydration. Drink slowly-sip fluids, never gulp. Calorie-containing beverages should be limited to skim milk and protein drinks. Limit juice to no more than 4 oz. per day. Consume zero-calorie beverages throughout the day. (Monitor for the following signs: headache, dizziness, nausea, lethargy, a white-ish coating on the tongue and dark urine.)Eat 3 small nutrient dense meals + 1 high protein snack a dayMeals should include: protein first, then vegetables and fruits, and then whole grains.Set up a schedule for supplements (vitamins, minerals and protein shakes; and medications; remember to take Calcium with meals and separate from iron supplements. You are required to take a multi-vitamin with minerals for the rest of your life.Introduce new foods one at a time in order to rule out intolerance. If a food is not tolerated, reintroduce it in 1 week.If you cannot tolerate dairy, substitute Lactaid for milk. You may need to take lactase pills with dairy to help digest the lactose. You can also try soy milk fortified with calcium and vitamin D.Exercise! This is the key to long term weight loss and maintenance. Walking should be the main exercise for the first 6 weeks. Between 6-8 weeks, more strenuous exercises can be added.Make sure you are tracking your calories and protein daily. There are helpful apps you can download on your phone to help with this.Potential ChallengesIn the process of deciding if surgical weight loss is the right decision for you, keep in mind that it is an elective surgery that can offer many benefits, but requires that you know and understand the challenges that you may face and how to overcome them.DiarrheaExperiencing diarrhea after surgical weight loss can periodically occur. Please contact your surgeon if you experience persistent diarrhea. Depending on your overall symptoms we may request that you return to a clear liquid diet for 48 hours and monitor your symptoms. We do not want you to become dehydrated. Imodium may also be recommended.Nausea/VomitingNausea, a common side effect of anesthesia may occur, but usually subsides within a couple of days. Nausea may be coupled with vomiting. If nauseated, stop drinking or eating and allow it to subside before resuming liquids or foods. Be sure to chew food well and eat slowly. If nausea persists and prevents you from consuming fluids, please notify the surgeon.Lactose IntoleranceSymptoms of lactose intolerance include bloating, cramping, gas and diarrhea. These symptoms occur when you consume cow’s milk or cow’s milk based products that contain lactose, a milk sugar. If your body is not producing enough lactase, an enzyme that breaks down lactose, these symptoms will occur. Substitutions for cow’s milk are soy milk and Lactaid milk.ConstipationYou may experience constipation due to a lack of fluid, fiber, or inactivity. To help relieve constipation, it is important you eat a balanced diet, drink your fluids, and stay active. A mild laxative like milk of magnesia or Miralax may be recommended by your surgeon.HypoglycemiaHypoglycemia is defined as a blood sugar level below 70mg/dL. Hypoglycemia symptoms include sweating, shaking, weakness, headache, irritability, hunger, rapid heartbeat, pale skin and in severe cases confusion and affect your coordination. If you experience any of these symptoms, please check your blood sugar if you are able. It is better to prevent hypoglycemia by eating regular meals, consuming the appropriate amount of calories and avoiding simple carbohydrates. If hypoglycemia should occur, then eat:2 crackers with peanut butter or cheese? - ? sandwich with deli meat1 cup low-fat milkBanana or small piece of fruitLong Term GuidelinesTaking MedicationsOnce you have been instructed to resume your medications without crushing them, it is advised to take your pills one at a time. Large pills and capsules may not be well tolerated because they may obstruct the opening in the band. Check with your pharmacist to determine if your large-sized medication (s) comes in liquid form. Another option for large-sized medications is to continue to crush them up and put them in sugar-free jello or applesauce. Remember, some medications should not be crushed because they are “time released.” Check with your pharmacist if you have doubts about any of your pills.Anti-inflammatory drugs that may irritate the stomach, such as aspirin, Motrin, Advil and Aleve or prescription steroids should be used with caution.Support GroupBariatric patient support groups have proven to be an essential part of the recovery process. Research shows that patients who regularly attend support group meetings have better weight loss. A Support group schedule will be provided to follow along your transitional diet, as well as, other dates throughout the year at Tennova Healthcare- Lebanon. All pre-op and post-operative patients and their families are invited to attend these meetings.Support groups offer a comfortable forum for patients who have already had bariatric surgery, as well as for new patients awaiting surgery. Patients can learn a tremendous amount when sharing individual experiences. Support groups tend to be upbeat and informative. We think that support group attendance is so important to patient education and patient recovery, that it is required that new patients awaiting surgery attend at least one support group meeting prior to having surgery.Benefits, Expectations and OutcomesGastric banding surgery is not a cure for obesity; it is a tool to help patients lose weight. It is not automatic, and the patient’s behavior after surgery plays a very large part in his or her outcome. Gastric banding works to help patients with weight loss in two ways:1) by creating a small stomach pouch so that less food can be eaten at a meal2) by curbing appetite. After small amounts of food sit in the stomach pouch, it triggers chemical message to the brain, which in turn provides an early sense of satiety (fullness).After adjustable gastric banding surgery, you can expect to feel full on smaller meals; have less hunger, feel an improved sense of self-control, and will find it easier to avoid snacking between meals. To be successful, you will want to avoid snacks and foods that will easily flow through the band, avoid high calorie liquids, and avoid drinking fluids for at least 30 minutes before meals, during meals, and for 30 minutes after meals. You will need to eat nutritious and healthy foods, be active and exercise, and make behavioral adjustments.You should lose weight gradually. Losing weight too fast creates a health risk and can lead to a number of problems. A weight loss of two to three pounds a week in the first year after the operation is possible, but one to two pounds a week is more common. Twelve to eighteen months after the operation, weekly weight loss is usually less.Research indicates that there is a variation of weight loss results among patients. Surgeons, who have followed up on their patients over the long term, have found that the great variation in weight loss is due in part to variations in dietary and exercise patterns. Patients who do well with weight loss tend to avoid snacks, eat nutritious foods, and are more active. Those patients who show a less than average weight loss over time tend to be the individuals who do not change their eating and exercise patterns, and/or return to snacking. It is a fact that patients who drink a lot of fruit juice and other high calorie drinks have poorer weight loss. Since there are so many factors involved in an individual’s eating patterns (genetic, social, emotional, and cultural), there is no psychological or medical test that can accurately predict who will do very well with weight loss and who will only lose a small amount. Planning meals and journaling food intake has proved to be a valuable tool in maintaining weight loss. We encourage you to manually journal or utilize the journaling features of the websites listed at the end of your guidebook.Weight loss after adjustable gastric banding surgery has been shown to dramatically improve medical conditions such as diabetes, high blood pressure, obstructive sleep apnea, reflux disease (GERD), and joint pain. Weight loss will improve conditions such as congestive heart failure, high cholesterol, high triglycerides, urinary incontinence, menstrual irregularity, back pain, etc. Patients also see a significant improvement in their energy level with increase endurance in physical activities and an overall improvement in their quality of life.Achieving SuccessOne of the most essential keys to success after weight loss surgery is to thoroughly understand that the surgery is not magical. The new pouch that restricts your capacity to eat and gives you an early feeling of satiety (fullness), is a “tool” you put to work to help you control your weight for life. This tool is only one part of a larger process that requires you to put forth great effort to achieve lifelong weight loss. In order for the tool to work, the rules of healthy eating and exercise must be followed. The sooner you become completely familiar with the guidelines in this booklet, the better you will do and the greater success you will enjoy!Follow-up Schedule and LabsYou will initially be seen two weeks after surgery and then monthly thereafter for the first year. After your first year, we will see you on a yearly basis or as necessary. It is important to keep your follow-up appointments so we can monitor your weight loss and make sure the band is providing the appropriate restriction. If you experience any difficulty with swallowing or vomiting, please call our office immediately so we can evaluate you.Periodic monitoring of your blood work is important so we can correct any potential deficiencies and help you maintain your optimum health. Your surgeon will require a CBC, CMP, Lipid Profile (if applicable), and HgA1c (if applicable) at 6 months and annually for life. Failure to have your blood work evaluated as advised could result in unnecessary complications. If you have your blood work performed by your primary care physician, please have him or her fax the results to the surgeon’s office before your scheduled appointment.PlateausSurgical weight loss causes rapid weight loss that is not your body’s natural way to lose weight. As you begin to lose weight your body is rapidly depleting itself. Your food intake and vitamin recommendations are provided to help you lose weight safely and effectively. However, it is very unusual for your body to lose all the weight consistently. You may go through a period of rest called a plateau to help your body regain balance. Plateaus may last 3-4 weeks and are necessary. It is understandable that hitting a plateau can be frustrating, especially since you have put so much energy and effort into your program.DO NOT think that you are doing anything wrongDO NOT cut back on your food volumeDO contact the dietician to ensure that your current diet and exercise is appropriate.Weight GainWeight gain can occur after surgical weight loss if you are:Consuming too many caloriesInactive – exercise is 50% of weight loss and 100% of maintenanceSnacking inappropriatelyKeys to keeping weight off:STAY ACTIVEDo not skip mealsMeet protein goal for the dayFollow healthy eating guidelinesMeet your fluid goalsTake your vitamins and supplements dailySuccessful weight loss and maintenance depends on your willingness to comply with healthy eating guidelines and exercise. If you get off track, please contact us.Hair LossHair loss is a side effect of weight loss surgery. You may not see hair loss initially due to the time it takes hair to grow from the root. You will see hair loss or breakage as the hair grows through the scalp. Often it takes several months after surgery for hair loss to show; and several more months for you to see the hair start growing back.Hair loss can occur from a low protein and zinc intake, and a severe decrease in overall nutrition intake. You must take in a minimum of 70 grams of protein per day. Adequate protein intake may help reduce (but not prevent) hair loss.If protein intake is meeting the minimum recommended guidelines and hair loss continues to be bothersome, you can try supplementing with zinc (no more than 50 mg. per day). On-going hair loss can also be a sign of iron-deficiency anemia.Question and Notes_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Information on SweetenersAvoid/Limit SugarsYou can avoid the problem of dumping by not consuming sweets, candies, or other sweetened foods and beverages. Certain high-fat foods, such as salad dressings, barbecue sauces, and mayonnaise may also cause problems.“Sugars” include: White sugar, brown sugar, honey, corn sweetener, corn syrup, maple sugar, molasses, raw sugar, sucrose, and turbinado sugar.Lactose (in dairy products), maltose (in breads) and fructose (in fruit or used to sweeten packaged foods) may be used in limited amounts. If they cause you discomfort, discontinue use.Sweeteners That You May UseSorbitol – Mannitol – Xylitol (use with caution – potential laxative effect)The sweeteners Sorbitol, Mannitol, and Xylitol are sugar alcohols. They may cause diarrhea. Found in sugar-free mints and hard candies.AspartameAspartame is marketed under the label NutraSweet?, Equal?, and Natrataste?. It is very sweet (180 to 220 times that of table sugar). Because it loses its sweetness when heated, it is effective only in foods that do not require cooking or baking.Acesulfame-KThis sweetener is marketed as Sunette? and Sweet One?. It does not break down at high temperatures and so can be used in cooking and baking.SaccharinKnown as Sweet-n-Low?, saccharin and is 300 times as sweet as sugar. It breaks down at high temperatures.SucraloseSucralose is marketed as Splenda?. It does not break down at high temperatures and can be used in cooking and baking. SteviaStevia is extremely sweet and only a few grains are needed to flavor a food or beverage.Food Labels(Adapted from the American Dietetic Association Tip Sheet)Become a smart shopper by reading food labels to find out more about the foods you eat. The Nutrition Facts panel found on most food labels will help you:178740Find out which foods are good sources of protein, fiber, calcium, pare the calories and nutrients in similar foods to find out which is better for you.Search for low-sodium foodsLook for foods that are low in saturated fat and trans fatsStart with the Serving SizeLook here for both the serving size (the amount for one serving), and the number of servings in the package.Remember to check your portion size to be the serving size listed on the label. If the label serving size is one cup, and you eat two cups, you are getting twice the calories, fat and other nutrients listed on the label.Notice the Calories Per Serving.Also look at the Total Fat, Carbohydrate and Protein Per Serving: Fats – total fat includes saturated (including trans-fat), polyunsaturated and monounsaturated fat. Saturated fat and trans fat are linked to an increased risk of heart disease.Carbohydrates – There are three types of carbohydrates: sugars, starches and fiber. The healthiest include whole-grains, fruits and vegetables. Simple carbohydrates or sugars occur naturally in foods such as fruit juice (fructose), or come from refined sources such as table sugar (sucrose) or corn syrup.Proteins – Proteins are found in meats, poultry, fish, dairy products and legumes.Check the Ingredient ListFoods with more than one ingredient must have an ingredient list on the label. Ingredients are listed next to the Nutrition Facts label. Ingredients are listed in descending order by weight. Those in the largest amounts are listed first.What Claims on Food Labels Really MeanFDA has strict guidelines on how certain food label terms can be used. Some of the most common claims seen on food packages:Low calorie – Less than 40 calories per serving.Low cholesterol – Less than 20 mg. of cholesterol and 2 gm. Or less of saturated fat per serving.Reduced – 25% less of the specified nutrient or calories than the usual productGood source of – Provides at least 10% of the DV of a particular vitamin or nutrient per serving.Calorie free – Less than 5 calories per serving.Fat free/sugar free – Less than ? gram of fat or sugar per serving.Low sodium – Less than 140 mg. of sodium per serving.High in – Provides 20% or more of the Daily Value of a specified nutrient per serving.()ProteinProtein is the most important nutrient to concentrate on when resuming your diet. Why is protein important?Wound healingSparing loss of muscleMinimizing hair lossPreventing protein malnutritionRemember to eat protein foods first at each meal, followed by vegetables and fruit. The table below shows some good sources of protein.Protein SourcesServing SizeProtein (g)Skim or 1% milk1 cup8Evaporated skim milk (canned)1 cup19Soy milk beverage1 cup (8 ounces)7Non-fat dry milk powder1/3 cup powder8Non-fat, sugar-free yogurt1 cup (8 ounces)8Non-fat or low-fat cottage cheese? cup (4 ounces)14Non-fat or low-fat cheese slices – String cheese1 ounce/1 slice6LEAN meats – skinless chicken or turkey breast, fish, beef, ham, Deli meats1 ounce7Egg or Egg substitute1 egg or ? cup subst.7Peanut Butter (creamy)1 Tablespoon5Tofu? cup5Legumes; dried beans, peas or lentils, chili, bean soup? cup cooked? cup7-96-7Soy/vegetable patty (like Gardenburger)1 patty8-10Hummus? cup6Measuring Hints:1 ounce of meat = 3-4 tablespoons of chopped or ground meat.1 ounce of grated or cottage cheese, tuna or egg salad is ~ 1/4th cup (4 Tablespoons).3 ounce portion size of chicken or meat is about the size of a deck of cards.PROTEIN SUPPLEMENTSThese supplements are only allowed once released from your liquid diet.Because of the limited volume capacity of the stomach, it will be nearly impossible to meet your protein needs from food sources for up to a year after surgery.-8318490You will need to consume a protein drinks to get a total of 80 g. protein per day – This would be 2 protein drinks with 40 or more grams per serving, or 4 servings of a protein drink with 20 grams of protein per serving.Once off of the liquid diet, it is best to consume your protein drinks between meals, rather than as a meal.How to choose a protein supplement:Review the label to find a product that is high in protein, low in carbohydrate or sugar and low in fat.Choose a product with at least 20 grams or more of protein per serving.Whey protein is preferable, especially whey protein isolate.Choose a product that is low-sugar or sugar-free and sweetened with sugar-substitutes such as Nutrasweet (Aspartame) or Splenda (Sucralose) or Acesulfame K. The sugar content listed on the label should be no more than 6 grams per serving.Avoid drinks such as Ensure, Boost, or Slim Fast. They tend to have a lot of carbohydrate and fat compared to pure protein powder mixed with skim milk or water.Choose a product that is low fat: no more than 3 grams of fat per 100 calories. (For example: Atkins shakes tend to be too high in fat and are not recommended).Where to purchase protein drinks:GNCSuper SupplementsTrader Joe’sFred MeyerWal-MartRite-AidWalgreen’sGibbs PharmacyGrocery store pharmaciesOn-line ()Concentrated SweetsMost of the foods and beverages that contain concentrated sweets are filled with “empty” calories in the form of sugar. These products provide mainly calories with limited nutritional value, which means they often do not contain a good amount of vitamins, minerals, protein and fiber. These nutrients are essential after weight loss surgery to help you recover and receive the nutrition that you need.After surgery, every bite counts. Filling up on these “concentrated sweets” can prevent weight loss and can replace healthier foods in your diet with high calorie, high sugary foods. Take a look at the concentrated foods/beverages below and make a mental note of a healthier option for you.Note: Artificial sweeteners such as NutraSweet/Equal, saccharine/Sweet & Low, and sucralose/Splenda are OK to use.Ice CreamRegular soft drinksChocolate milkLemonadePuddingKool-AidSweetened, fruited or frozen yogurtSugared ice teaDried fruitsSnapple or fruit drinksCanned or frozen fruits in syrupTable sugarFruit juiceHoneySugar coated cerealCandyDoughnutRegular Jell-OPopsiclesSugar gumCakesMolassesPiesSyrupsCookiesSherbet/SorbetJelliesJams141859062864Supplement RXYou will require vitamin and mineral supplements for the rest of your life.Taking a vitamin and mineral supplement is vital to maintain your nutritional health and prevent vitamin and mineral deficiencies. You are now at greater risk for decreased absorption of vitamins and minerals because you are eating a significantly smaller amount of food in a day.After surgery, starting the first day you get home from the hospital.Take multivitamins with minerals daily. (Bariatric specific vitamins)Take with a mealExamples:One A Day CompleteCentrum CompleteCentrum Chewable for AdultsChewable multivitaminMust take 2 (double dose) bariatric vitamins for the first month after surgery.3314700647700If the multi-vitamin/mineral supplement makes you nauseous, do not take it on an empty stomach – take it with food or at night.3314700647700Section Four: Physical Therapy and Exercise InformationExerciseYou must include an exercise as part of your healthy lifestyle program. Start slowly and increase your time and intensively as you become more used to physical activity. Begin exercising before surgery and continue the program after surgery.Steps to Develop a Physically Active Lifestyle:Step 1:Consult your doctor to determine if your medical problems could interfere with exercise.Step 2:Examine your past exercise experience and determine what has and has not worked for you in the past.Step 3:Choose appropriate exercise. Different types of exercise expend different amounts of calories. You’ll notice that the more you weigh the more calories you burn, because in addition to benefitting from the exertion of the exercise itself, you are carrying extra weight which requires additional exertion.Step 4: Set personal goals and develop your plan. The best way to make a commitment is to develop a plan in writing. In addition to standard types of exercise like walking and using gym equipment you may want to consider walking in the pool, dancing, golfing, and doing yoga or kick-boxing.Advantages of Exercise Include:Builds muscle tissueStrengthens bones and reduces bone lossReduces joint stiffnessImproves heart and lung functionIncreases the metabolismImproves mobility and improves the basal metabolic rateIncreases the energy levelImproves self-esteem, and enhances the moodDecreases stress and anxiety40519341270Improves skin elasticityImproves memory and alertnessImproves sleepLowers blood sugar and blood pressureImproves cholesterol levelsHelps with the healing processIncreases life expectancyIdeas for Increasing Physical Activity Throughout the Day/Behavior ModificationsTake the stairs instead of the elevator. If you have to go up more floors than you can handle, walkup one or two flights and then take the elevator.Walk in the house during TV commercials.Use two, five pound weights while watching TV to exercise your arms.If you have a desk job, get up more often. Use a fax or copy machine that is farthest from your desk, or take the long way around when going to lunch or the break room.Don’t eat in front of the TV.Don’t read while eating.Pre-portion your food and put the box or package away.Keep tempting foods out of the house.Don’t go to the grocery store hungry.Make a shopping list.Use smaller plates and bowls.Keep healthy foods available.Focus on activities other than eating.Brush your teeth after meals or if feeling the desire to eat.Don’t eat standing up at parties or buffets.Don’t stand at the food table at the parties.Offer to bring a healthy food item to a party.Park your car far away from your destination.Get up to change the TV channel instead of using the remote control.Keep a food and exercise diary.416179097155Self-MonitoringNow that you have a plan, it’s time to start self-monitoring or keeping track of the exercise that you do, which has shown to help with motivation. By keeping track of what you do, you can see your progress. Slowly increasing the amount of exercise you do improves your body’s conditioning.Keep a record to track your exercise. Write how much and what kind of exercise you did. Pick the kind of record that you think will work best for you. The important part is that you practice self-monitoring.. Section Five: Frequently Asked Questions Post-opHow much weight will I lose?Approximately 80% of patients will lose 55-70% of their excess body weight during the first 12-18 months after surgery. Weight loss varies depending on activity level, body frame, pre-surgical weight and adherence to dietary guidelines.How will my body know when to stop losing weight?When you are eating to meet your metabolic needs and balancing calorie intake with calorie expenditure, your body will stabilize at a healthy weight. The Registered Dietician will guide you through your diet progression to meet your metabolic needs. Be sure to follow up with the dietician as well as the surgeon.Will I lose my hair?You have elected to have weight loss surgery and will be consuming a very low calorie diet for an extensive period of time which may cause temporary protein/calorie malnutrition. Hair thinning is the result of protein and calorie malnutrition. The temporary hair thinning will vary for each person and will last approximately 6 months. It is temporary as long as you follow the diet and vitamin recommendations.When can I go back to work?Return to work depends on the procedure done and the nature of your employment. No heavy lifting is permitted for a number of weeks. Those who do not experience any complication or extended discomfort may feel well enough to return to work sooner.When can I exercise/swim?We encourage you to engage in a walking program immediately. This is important to prevent the development of blood clots, respiratory complications or bowel complications. Swimming is allowed several days after surgery, your surgeon will instruct you on when to start. When you engage in physical activity, it is extremely important to stay well hydrated.Can I take my medication after surgery?Yes, resume all of your pre-surgery medications as directed by the surgeon or primary care physician. One goal of surgery is to stop many, if not all, the medications you currently take. We recommend monitoring your blood pressure, blood glucose levels and lab work regularly. You need to be in regular communication with your primary physician to determine whether medication dose should be adjusted or stopped.When can I resume sexual intercourse?Sexual intercourse can be resumed when you feel comfortable.Section Six: ResourcesInternet Resources – This is the official website of Cumberland Bariatric Institute – This is the Tennova Healthcare website. You can stay abreast of all the events/educational sessions and other “happenings” in our community by reviewing the calendar. - The National Institute of Health (NIH) site for information regarding bariatric surgery. – Great website for keeping up to date on weight loss issues, staying in touch with other patients on the same journey, weight loss tracking system. - The National Association for Weight Loss Surgery (NAWLS) is a safe, loving and non-judgmental community for bariatric surgery patients. – Obesity Action Coalition, n non-profit organization whose sole focus is helping those affected by obesity.lap- - May be able to answer specific questions regarding lap-band. – May be able to answer specific questions regarding realize-band. – Tracking tool for food and exercise with an established food bank – Is a comprehensive modern online diet service – helping you change your lifestyle and achieve permanent weight loss. – Free, online calories counter and weight loss journal.Publications – WLS Lifestyles magazine is a national publication and media outlet dedicated to providing motivation education, guidance and support for people struggling with obesity or weight maintenance. ................
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