1. Nutrition Management of the Bariatric Patient: Rosemary Mueller, MPH, RD, LDN, Advocate Weight Management and Emily Schumann, MPH, MS, RD, LDN, Advocate LGH and Bariatric/ Metabolic Center September 26, 2014 Breaking Down Barriers

2. Objective One:  Understand the barriers that bariatric patients’ face related to nutrition and weight management

3. Objective Two:  Recognize the various types of patients and how to best address their nutrition and weight management needs

4. Objective Three:  Learn key tips for improving your patients’ nutrition compliance and success at your facility or practice

5. Objective 1: Barriers to Nutrition Recommendations

6. Variable Stages of Change

7. Nutrition Myths & Mixed messages  “Do something different and the weight stays off.” Ex., raw food, gluten-free, eat based on your blood type, most current T.V. celebrity’s advice – whatever is popular at the moment.  “Just take a diet pill, tea, herb, colon cleanse, etc. and you will safely control your appetite and burn unhealthy fat without dieting.”  “You can diet and not exercise and still keep the weight off.”

8. Common Denominator: Sense of shame or failure over repeated diet attempts and inability to maintain weight loss

9. “ I really don’t eat that much..just don’t understand why I cannot lose more…must be my thyroid.” Denial is an ineffective way of coping with painful emotions and embarrassment about body size and weight. Minimizing and Distortion

10. Portion Distortion: “What is there, I eat, and what is there is not necessarily what I need to eat.”

11. Objective 2: Addressing Different Types of Patients

12. Type of Patient DescriptionBest Diet Approach The Rule Follower Follows all instructions to a “T” Give sample meal plan and/or encourage specific changes The Just Gets It Understands concepts- can understand moderation and is reasonable with choices Ask questions to find an area of improvement (diet recall) to help pt recognize need for change The Know-It-All Does not follow directions, gives up easily, claims they have tried everything, nothing works Encourage small change first and explore desires to make changes The FirecrackerExcited about changes, easily motivated, does well at first, then back to old habits Encourage 1-2 changes at a time and follow up often.

13. Open-Ended Questions Assessment Phase: What are your health concerns? How do you see your food affecting your health? How does your day go with respect to food? How do snacks fit in? Could you describe what your house is like at dinner time during the week? After Providing Information/Advise:#59): What is your response to this handout/information/suggestion? How do you see using this information? What are your thoughts? How might your life be different if you were to do this? Patient Expresses Motivation to Change: What steps are you ready for? What do you see as your next steps? Where do you want to go from here? What do you see yourself doing this week? After planned action: How might you do that? How do you see yourself doing this at home? During the weekdays? What could get in your way? What else? © 2011 Molly Kellogg, RD, LCSW www.mollykellogg.com

14. Objective 3: Most Important Nutrition Tips to Tell Patients

15. Key Tips  Frequent, smaller meals- 5-6/day  Protein at each meal to assist with satiety and sensation of fullness  Track your intake  Mindfulness and learning to discern hunger and fullness cues; slowed eating speed

16. Key Tips  Rethink your drink  Adequate fiber through vegetables, fruits, whole grains  Refer to a dietitian

17. Food journaling: facing facts

18. Sample Food Journals TimeFood Item(s) Portion SizeLength of Meal (Goal 25-30 mins) Name:_________________________Date: __________ Dietary Log:

19. So why don’t our patients journal their eating and exercise?  It is self-confrontational.  It takes some time and effort.  It destroys “magical thinking” and makes one accountable for changes in weight.  Some patients are embarrassed to share this with their dietitian or other health professional.

20. Keys to overcome this barrier: Encouragement  Accountability for journaling  Non-judgmental evaluation by health professional  Specific and personalized recommendations

21. Application: Patient Presentation  Frank, 44 year old male with arthritis in knee causing mobility issues. Family history of heart disease. Pt reports knows he should probably lose weight but he likes food too much and can’t stand “all that healthy stuff”. He says he knows you are going to tell him to eat less and more things that taste like grass. Weight has been gradually increasing over the last 10 years.

22. Application: Patient Presentation  Susie, 53 year old female with DM, HTN, BMI: 48 has tried Phentermine, Cranberry cleanse, and currently taking Garcinia Cambodia extract that she heard about on Dr. Oz. Has tried over 25 diets but only ever lost 5-8 lbs and gains back weight plus some. Pt feels she doesn’t eat that much food during the day (only eats breakfast and dinner) so doesn’t understand why she can’t lose weight.

23. Our Role as Health Care Providers

24. Our Objective: Restore hope, assist as change agents  Let patients know you care  Speak/inform/educate with frankness regarding nutrition/health risk  Frequent visits- accountability is key  Speak/inform/educate with respect about nutrition behaviors that need to change  Correct myths/distortions and provide guidance and tips for incorporating appropriate health behaviors

25. Summary  Understand where patients might be coming from and barriers they have or will face  Recognize that each patient is different  Ask open-ended questions and permission  Provide key tips to help them with behavior changes for weight loss  Refer to other professionals

26. References:  1. “Transtheoretical Model of Behavior Change”, James Prochaska, Ph.D.  2. Kellog, Molly. (2011). Counseling Tips for Nutrition Therapists Series 2011. Tip #108: Forming Effective Open Questions. Retrieved from http://www.mollykellogg.com/archive11.html# 108.

27. Questions?