1. National Nutrition Month: Nutrition Tune-up
Heather Mackie, MS, RD, LD
March is National Nutrition Month!
Sponsored by:

2. 11 Lifestyle Changes of WLS Patients
Being Accountable
Personal Responsibility
Portion Distortion
Nutrition Basics
Hydration
Physical Activity and Exercise
Vitamins and Minerals
Protein
30 Rule
Support Group
Follow-Up
What do you consider to be some of the lifestyle changes or successful weight loss surgery (WLS) patients?
We are going to review the top 11 lifestyle changes to tune-up your lifestyle change

3. Being Accountable
Name some ways to hold yourself accountable nutritionally…
Online food journals
Nutrition follow-up appointments
Support group
Protein checklists
Weighing
Goal setting
Ask your group to name some ways to hold themselves accountable.
Online food journals:
Post-op ntr appts – these are crucial; mention to your patients how often you ideally would like them to see their RD after surgery
Support group – review the different support groups your program offers; have a list of them to handout with schedules. Do you have an online group too?
Protein checklists – are simple checklists that I created to have patients check-off how much protein they ate daily. One box equated to 10 grams of protein
Weighing – weighing and measuring your food or using items to approximate your portion sizes (ex: deck of cards = 3 oz meat)
Goal setting – do you set goals, how often do you evaluate yourself and your goals

4. Personal Responsibility
If I am having a problem, or I am not progressing as desired/expected, then whose responsibility is it to seek help?
Spouse/Partner
My surgeon’s
My exercise physiology
My mental health provider
Mine
Your team is here to help you, but they/we cannot do it for you.
Therefore it is your responsibility to seek help when you need it.
We know that asking for help is not an easy task but remember you picked this/our program initially to get help and we are still here to help.

5. Portion Distortion What does 3 oz of meat look like?
Deck of cards
Checkbook (fish)
How many servings of fruit is a banana?
2 servings of 1 large banana
What is 1 oz of cheese?
4 dice, 1 domino, 1 slice
Portion = one serving of what you eat for one meal or snack; you determine the size
Serving = actual measured amount of a food to eat
For example: one 20 oz soda is one portion for most people, however, its actually 2.5 servings
Discuss how portion sizes have expanded over time (use picture of bagel now and 20 yrs ago)
I have shown a serving bowl from 30 years ago versus a serving bowl that could be bought now (you can also demonstrate this with plates)
Discuss how when you go out to eat one portion is often 2-3 servings

6. Portion Distortion What is 1 serving of nuts?
Flat part of PALM of hand
What does 2 Tbsp of peanut butter look like?
Ping Pong Ball
What does 1 tsp butter/margarine look like?
1 normal sized stamp

7. Nutrition Basics How many soft drinks can you have each day?
Zero!!!!
What is considered a complex carb?
Whole grains (brown rice, whole-wheat bread, whole-wheat crackers, etc.)
Beans and legumes
Low-fat dairy
Fruits and veggies
Where do you find unsaturated fats?
Olive oil and canola oil
Nuts and seeds
Avocado
Fish (salmon, tuna, mackerel)
The program I used to work for did not allow sodas due to the irritation and expansion of the stomach (they believed it stretched the stomach over time)
Discuss difference between complex and simple carbs
Complex carbs digest in ~ 60 min
Simple carbs digest in ~ 30 min
Unsaturated fats = healthy fats but still have to limit how much you eat daily

8. Hydration How much fluid do you need a day? What counts as fluids?
48-64 oz
6-8 8 oz cups
What counts as fluids?
Decaffeinated
Non-carbonated (no bubbles)
Minimal calories (<8 calories/serving)
How do you tell if you are well hydrated?
Urine = pale and odorless
Discuss importance of hydration
Health of skin
Energy level
Headache (symptom of dehydration)
Muscle weakness

9. Physical Activity and Exercise
What is considered physical activity?
Activities of daily living:
Parking further away
Taking stairs
Gardening
What is considered exercise?
Structured, planned type of physical activity:
Aerobics class
Walking for 30 minutes
Band exercises
Work-Out Videos, Exercise On-Demand (on TV)
Strength Training
Discuss difference between physical activity (PA) and exercise

10. Physical Activity and Exercise
How many steps are recommended each day?
10,000 steps
But start with your normal and try to increase each week
How much exercise is recommended each week?
minutes each week to lose weight
How much activity is necessary?
Count steps or count minutes per week

11. Vitamins and Minerals
How long after surgery do you need to take your vitamins?
For Life! 
Do all patients take the same thing?
No!!!
Often determined by:
Surgery type
Lab levels
Your personal history
Feel free to put your recommendations here

12. Vitamins and Minerals Can you take all your calcium at one time?
No, you can only absorb ~ mg of Calcium in a 2-4 hour period
Can you take calcium and iron at the same time?
No because your body can’t absorb iron when calcium is present
How often should you get your blood work done?
Every 3 months for the first year after surgery
Then yearly
If something is abnormal, then re-check in 3 months
Of course, disclaimer: unless told otherwise by your surgeon’s program

13. Protein When do you eat protein during the meal?
First!!
What are other sources of protein besides meat products?
Low-fat dairy
Tofu and soy
Beans and legumes
Nuts and seeds
Veggies
Eat your protein first to ensure that you get it in enough throughout the day

14. Protein What percentage of your plate should be protein?
How much protein do you need a day?
AGB, RNY, or Sleeve: g/day
BPD-DS: g/day
These are the standard recommendations, which may be increased based on:
Weight loss, muscle mass, gender, metabolism, activity level, and age

15. 30 Rule What consistency should you chew your food to?
Applesauce consistency
Why should you not drink during meals?
Pushes food through faster > hungrier sooner > eat more > will not lose as much weight
Should you drink immediately following a meal? No
No drinking 30 minutes before or until 30 minutes after
How long should you take to eat your meals?
Roughly 30 minutes
Eat slow! 
30 Rule:
No drinking with your meals, 30 minutes before, or until 30 minutes after
Try to take 30 minutes to eat your meal (eat slow)
Chew each bite ~ 30 times (to applesauce consistency)

16. Support Group How often should you attend support group? Never
Twice per year
Every month
Every week
Patients who attend support group on a regular basis are more likely to be successful long-term!
Why?
You should attend support group as often as you can
Let patients discuss why they think patients are more successful when they attend support group versus those that don’t
Kept accountable
Learn more new items and continue to hear important items
Able to share your experiences with others and help them and yourself

17. Follow-Up
How often should you follow-up with your surgeon within the first year of surgery?
About every 3 months
How often should you follow-up with your surgeon after the first year?
Yearly or as needed
Fill-in your program’s recommendations here

18. Follow-Up
How often should you see your nutritionist and exercise physiologist within the first year?
About every 3 months
When should you see your counselor/mental health provider within first year?
As needed:
When perfectionism is getting in the way of your happiness
When you can’t get motivated
If experience problems that affect your health, job, or personal relationships
How often should you follow-up with your lifestyle management team after the first year?
Yearly or as needed
Fill-in your program’s recommendations here
Lifestyle management team = exercise physiologist, dietitian, mental health provider

19. Question and Answer Session
Open up the floor to discuss any other items that your patients feel makes a successful patient long-term and any other nutrition tune-ups.