Surgical Weight Management patient guide for Salem Hospital

Surgical Weight Management 1

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The material in these pages will be covered during the four wellness classes. Please bring this booklet to every class.

Program expectations: I recognize the benefits to my health and contract to do the following: A. I will treat the staff with respect.

B. I will maintain an exercise routine that includes minimal aerobic activity.

C. I will maintain a food journal, complete with measured amounts and detailed description of item(s) consumed. These will be turned into the dietitian at each appointment.

D. I will maintain a structured meal plan that includes a variety of healthful choices with 3 meals and 2 - 3 snacks.

E. I will wean off caffeinated beverages, soda, sport drinks, alcohol and fruit juice.

F. I will lose weight in a safe, steady manner with the goal of losing weight gradually. (between ½ pound to 1 pound a week, for example.)

G. I will continue to maintain this weight loss.

H. I will not miss any appointments. A missed appointment includes arriving late, canceling less than 48 hrs. before an appointment, or not showing at all.

For patients who are participating in therapy: I understand my compliance with psychotherapy is mandatory. Being compliant means keeping an open line of communication with my therapist, maintaining appointments and following through on the recommendations of my therapist. I understand it is expected that I will continue therapy up until and after surgery to help ensure my success after surgery.

For patients requiring CPAP: I will demonstrate compliance with CPAP (70% usage = to a minimum of 4 hrs/night) and follow-up with my pulmonologist.

For patients with Diabetes Mellitus: I understand the HG A1C must be < 9.0 at the time of surgery and I must be compliant with certified diabetes educators (CDE) if I am referred for appointments.

Surgical clearance: I understand that I must be cleared for surgery by the team, I may require additional visits with the nurse, dietitian or psychologist before I am cleared for surgery.

I will continue these lifestyle changes after completion of this program, up until and after surgery.

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Table of contents Class one Pre-operative liquid diet guidelines..................................................... 5 Nutritional expectations...................................................................... 6 Lactose intolerance............................................................................. 6 Eating techniques................................................................................ 7 Stage 1 food guide............................................................................... 8 Stage I sample menu.......................................................................... 9 Stage II food guide............................................................................... 9 Stage II sample menu........................................................................ 10 Food guide weeks four through eight............................................... 11 Stage III sample menu...................................................................... 12 Food guide for eight weeks and beyond.......................................... 13 Beyond stage III sample menu.......................................................... 13 Portion Sizes by hand........................................................................ 14 Lifetime Success................................................................................ 15 Mindful Eating.................................................................................... 18 Sample Food Journal......................................................................... 20 Class two Food label........................................................................................... 22 Checklist for stocking a healthy kitchen........................................... 24 Putting together a meal..................................................................... 25 Class three Physical activity and exercise........................................................... 28 Stress.................................................................................................. 30 The relaxation response - relaxation exercise................................. 32 Have you experienced....................................................................... 34 Stress warning signs........................................................................ 35 Patience vs. impatience................................................................... 36 Establishing long-term behavior change (notes)............................ 37 Class four Follow-up care - Laboratory protocol................................................ 38 Supplement requirements................................................................. 40 Bariatric basics.................................................................................. 41 Recommended reading..................................................................... 42

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Class one Pre-operative liquid diet guidelines Congratulations! Your surgery date is approaching and it’s time to prepare for the best possible outcome. Your surgeon has ordered a liquid diet for two weeks immediately preceding your surgery.

Liquid meals You must drink three liquid meals of Carnation® Breakfast Essentials™ each day.

• Do NOT use canned pre-mixed shakes. It is okay to drink regular Carnation mix pre-surgery.

• We strongly recommend using Hood Simply Smart Milk or Fairlife Fat Free Milk (lactose free) when you make your drinks. They contain 2 more grams of protein per serving compared to other brands.

Snacks In addition to your three liquid meals, you may also have the following snacks:

• Sugar-free Jell-O, any flavor

• Sugar-free popsicles

• Crystal Light (drink or drink mixes)

• Herbal tea, any flavor (unsweetened)

• Sugar-free flavored waters

• Bouillon or Broth, preferably diluted (limit to one cup daily)

Yogurt/pudding You may have ONE serving per day of the following:

• Fat-free Greek or Skyr yogurt usually has 100-130 calories per serving

• Fat-free, sugar-free pudding, any flavor. Must be made with either Hood Simply Smart Milk or Fairlife Fat Free Milk (lactose free). Do not use ready-made pudding cups.

Fruit You may also have ONE serving per day of fresh, frozen or canned fruit, e.g.:

• 1 cup melon cubes, any kind

• ½ cup pineapple

• ½ cup fruit salad (plain)

• 15 small grapes

• ¾ cup strawberries, blueberries or raspberries

• 1 medium apple, pear or orange

• 1 small banana

• 12 cherries Don’t forget

• You must wean yourself off all caffeinated and carbonated beverages ASAP.

• Sip slowly. Do NOT gulp your drinks. This is a good habit to develop now as it will be very important after surgery.

If you have any questions or concerns about this diet, please feel free to call us at 978-825-6505.

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Diet Nutritional expectations Following bariatric surgery, your diet will progress through four stages. You will begin with a liquid diet, progress to pureed/soft solid foods, and finally transition to a “modified” but normal diet. The diet progression gives your body time to heal and adjust.

Each of these post-surgical diets will ensure that you meet your protein and liquid requirements, while also meeting your nutritional needs. It is imperative that you follow this dietary progression and adhere to each diet’s regimen, to maximize healing and minimize the risk of unnecessary complications.

The size of your stomach pouch is about one ounce, or one to two tablespoons. At first your capacity will be somewhat limited, so be patient. You may find that two to three teaspoons of food fill you up.

This is expected. You may also find that you are able to eat more of one type of food than another.

That is okay, too. Over time, your stomach pouch will stretch. One of the changes that patients often comment about is the concept of “wasting food.” After surgery, your eyes and head still work the same way as they did before. However, because of your new stomach pouch, you will be satisfied with much less. It is critical that you listen to your body’s signals of fullness and not to your eyes that see food left on your plate.

Foods that contain sugar not only slow down your weight loss, but they can make you sick. Sugar may cause “dumping syndrome” in some patients who have had the gastric bypass procedure. Dumping, in short, is when sugars go directly from your stomach pouch into the small intestine and rapidly increase your blood sugar level causing heart palpitations, nausea, abdominal pain, and diarrhea. Symptoms may vary among patients. Dumping lasts about 30 minutes to an hour. Onset is immediate or up to three hours after eating/drinking.

Lactose intolerance Lactose intolerance is a set of symptoms resulting from the body’s inability to digest the cow’s milk sugar called lactose. Gastric bypass surgery can unmask lactose intolerance, but not cause it.

Depending on the individual, the symptoms may include cramping, diarrhea, bloating, gas and nausea.

If you experience these symptoms after eating dairy products, you may be lactose intolerant. Products that contain large amounts of lactose are cow’s milk and ice cream; smaller amounts of lactose are found in yogurt, cottage cheese and hard cheese. Prepared foods can also contain lactose, so look on food labels for whey, lactose, non-fat milk solids, buttermilk, malted milk, margarine and sweet or sour cream. Some breads, dry cereal and instant soups contain small amounts of lactose.

Although there are supplements that you can take, elimination of dairy is the best approach to solving the problems associated with lactose intolerance. Tell your dietitian if you are lactose-intolerent, or if you are having difficulty digesting dairy products.

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Eating Techniques Your new motto should be: “slow, small, moist and easy.” In the first eight weeks after surgery, these techniques will help you to maintain your weight loss over time and to avoid pain and vomiting, or rupture of staple lines. At this time, the tissue around the staples and sutures in the stomach pouch is very swollen and needs to heal. You also want to prevent obstruction of the area where your stomach pouch connects to your intestines (stoma). Swallowing food in chunks may block the stoma and prevent foods from passing into the intestine. It is critical that you eat slowly and chew your food well to lower the risk of getting anything caught in this area.

You may find the following tips helpful: • Set aside 30 to 45 minutes to eat each meal. Aim to chew your food 30 times with each bite.

Ground or soft foods may be necessary if you have dentures. Slow down—we have a lifelong habit of eating too fast. Slow down, enjoy the food and relax. Explain to friends and family why you must eat slowly so they do not urge you to eat faster.

• Take small bites of food and, as a visual aid, you may want to use a saucer in place of a plate to help with portion control.

• Pay attention to taste; learn how to savor your food. This is very important.

• Eat only at planned meal and snack times. Unplanned snacking, “picking” or “grazing” on small amounts of food throughout the day will sabotage your weight loss resulting in poor nutrition and weight gain.

• Never drink liquids when eating solid foods. Liquids should be avoided for a period of 30 minutes before and 30 minutes after eating solid food or meals. Combining liquids and solids may cause nausea, as well as push foods through the stomach pouch faster, enabling you to eat more.

• Eat mindfully. Stop eating as soon as you are satisfied (over-eating even one ounce can make you vomit and overstretch your pouch). Listen to your body’s signals, not the food left on your plate.

• Only eat the healthiest of foods • Purchase a food scale if you don’t have one. Use it to weigh meats, poultry, cheese and fish.

Use measuring cups and spoons to measure everything else. Weigh and measure cooked portions.

• Keep a food journal as you go through the day. Record time, what you ate and drank, and how much.

Recognizing fullness It is often difficult to understand the meaning of new sensations. “Feeling full” may feel differently than it did before surgery. Here are some sure signs that your pouch is nearly full:

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A feeling of pressure or fullness in the center of your abdomen, just below your rib cage.

A feeling of nausea, regurgitation or heartburn. You may not feel “full” until several minutes after you truly full. In other words, if your pouch is 30 cc. (one ounce), you can put 30 cc. of food in it, but you may not feel “full” until about five minutes afterward.

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Foods that may be difficult to tolerate

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Bread products Dairy products Pasta products Fatty foods and fried foods Candy, chocolate, any sugary foods and beverages Carbonated beverages Bran cereal and other bran products

• • • • • •

Dried fruits and skins of fresh fruit Coconut Celery Marshmallow Alcoholic beverages Caffeinated beverages

Food guide for the first week (Stage I) Goals of this diet:

1. To take in 60 grams of protein each day. Add unflavored protein powder to broth, and other fluids to increase the nutritional value.

2. To take in at least 64 oz. of fluid each day. All fluids count toward this goal.

3. Begin a food journal. Log your intake both solid and fluid to help you to stay on the right track.

Please measure and weigh foods and fluids.

4. To consume three Carnation® Breakfast Essentials™ Light Start drink mix shakes daily. During this very early period it is best to limit your intake to liquids. This will give your new stomach pouch time to heal properly.

This diet consists of clear, sugar-free fluids, cranberry juice, Carnation® Breakfast Essentials™ Light Start drink mix, and/or milk. You will start on this stage as soon as ordered by your surgeon while in the hospital, and will continue this diet through the first week after your surgery. The liquids should not be carbonated, caffeinated, or contain alcohol. Sip your liquids slowly and carefully, stopping whenever you feel full. It is normal to have a reduced appetite in the days following surgery.

Clear liquids that are well-tolerated:

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Unsweetened, non-carbonated beverages, such as iced herbal tea Clear beef, chicken or turkey broth Strained miso soup Sugar-free popsicles Sugar-free Jell-O® Caffeine-free beverages; NOTE: decaffeinated beverages are not allowed in this stage Limit to 8 oz. daily — ­ apple, grape or cranberry juice (dilute with an equal amount of water) Herbal teas

NOTE: The first 10 to 14 days you may benefit from diluted fruit juices, however, limit to 8 oz. daily. Limit fluids containing non-sugar sweeteners such as Splenda, Nutrasweet, Acesulfame Potassium, even though they are calorie free. These beverages should also be diluted with water.

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Stage I sample menu Breakfast:

• Carnation® Breakfast Essentials™ Light Start drink mix (blend with any soft fruit; this is optional) In between:

• 8 oz. regular or diet cranberry juice diluted with 8 oz. water, or 8 oz. of Hood Simply Smart Milk or Fairlife Fat Free Milk (lactose free) Lunch:

• Carnation® Breakfast Essentials™ Light Start drink mix Snack:

• Sugar-free Jello® gelatin, 1/4 - 1/2 cup.

Dinner:

• Carnation® Breakfast Essentials™ Light Start drink mix Snack:

• 8 oz. broth Drink an additional 8-12 oz. water in between meals and snacks as you are able.

Food guide for weeks two through three (Stage II) Goals of this diet:

1. To take in 60-70 grams of protein each day.

2. To take in at least 64 oz. of fluid each day.

3. To continue writing in your food journal, and continue to weigh and measure foods and fluids.

4. To continue consuming one to three Carnation® Breakfast Essentials™ Light Start drink mix shakes daily.

5. To begin eating three planned meals and two to three planned snacks daily. NOTE: The Carnation shake may represent one or two of these meals.

6. To avoid eating solid food and drinking liquids at the same time (at least 30 minutes between each)

7. Most important is to practice eating slowly and chewing your foods well, to the point of puree or liquid.

At this point your dietary choices start to expand. It is still very important to adhere to the guidelines as your new pouch is still healing and you are adjusting to a new way of eating. This diet consists of low-sugar foods that are liquid, puree, or semi-solid consistency such as hot cereal, unsweetened applesauce, or scrambled egg.

You should limit your intake to liquid or very soft foods. This diet permits a gradual transition to more solid foods. Eat until you start feeling full, and chew all food to puree or liquid consistency before swallowing. Remain on this diet until your surgeon or nutritionist allows you to advance to the Stage III diet.

Note: Try adding unflavored protein powder (for example, Tera’s Whey plain, unsweetened) to soups and cereal to increase the nutritional value. Make hot cereals with milk instead of water for extra protein.

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Stage II sample menu Breakfast:

• Carnation® Breakfast Essentials™ Light Start drink mix (you may blend this into a smoothie using fruit and 0% fat, plain Greek yogurt)

• 8-12 oz. of water (drink 30 min. prior or after eating.)

Snack:

• ¼ - ½ cup cottage cheese, fat free, 1 or 2%

• ¼ cup applesauce, unsweetened

• ½ banana with a tablespoon of peanut butter

• 8-12 oz. of water (drink 30 min. prior or after eating.)

Lunch:

• ¼ - ½ cup Cream of Wheat or pureed oatmeal made with Simply Smart milk, ¼ - ½ banana, or, Carnation® Breakfast Essentials™ Light Start drink mix (you may blend this into a smoothie using fruit and 0% fat, plain Greek yogurt)

• 8-12 oz. of water (drink 30 min. prior or after eating.)

Snack:

• 1 cup pureed chicken or beef and vegetable soup

• 8-12 oz. of water (drink 30 min. prior or after eating.)

Dinner:

• 1 scrambled egg with ¼ cup finely chopped, well cooked vegetables. Use olive oil or cooking spray in pan. If you prefer, you may instead drink Carnation® Breakfast Essentials™ Light Start drink mix (you may blend this into a smoothie using fruit and 0% fat, plain Greek yogurt)

• Drink up to 12 oz. water per hour in between meals and snacks.

• Use whey or soy protein powder (for example, Tera’s Whey plain, unsweetened) if you need help achieving 60-70 grams of protein.

• 8-12 oz. of water (drink 30 min. prior or after eating.)

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Protein

Fruit

• Cottage cheese (1%, 2%, or non-fat) • Greek yogurt or Icelandic yogurt (Chobani, Siggi’s) • Simply Smart milk or Fairlife milk • Low-fat cheese (part skim, 2%, or non-fat cheeses) • Ricotta cheese (part skim, or non-fat) • Eggs – any style except fried • Tofu

• Applesauce – no added sugar • Pureed fruit – any kind, strained to avoid skins, seeds • Canned fruit – light or in its’ own juice • Skinless, seedless fruit (peeled apple, pear, plum, peach, papaya, guava, ripe mango... chew well) • Banana • Melon – any kind • Avocado

Vegetable

Grains, Nuts, Legumes

• Pureed vegetable soups (may contain beans and meat, but should NOT contain rice, or noodles) • Soft- cooked vegetables (no skins, seeds) – should be able to mash with a fork such as cauliflower, broccoli, carrots, beets, turnip, roasted peppers (skinless, seedless), onions, asparagus, green beans • Potato – any kind including sweet potato but to be added in diet in limited amounts as this is a starchy vegetable

• Nut-butters such as peanut butter and almond butter • Hummus – any flavor • Pureed, plain cream of wheat or oatmeal, cooked with milk

Food guide for weeks four through eight (Stage III) Goals of this diet: 1. To take in 60–70 grams of protein each day.

2. To take in at least 64 oz. of fluid each day.

3. To establish a routine with your eating that includes 3 planned meals and 2 to 3 planned snacks.

Avoid eating unplanned foods and snacks between meals.

4. Chew foods well to the point of puree or liquid. You may choose to remain with puree or soft solid foods until you feel comfortable to move on to more solid consistencies. Only eat poultry or meats that are ground, shredded or deli-sliced.

5. To continue a food journal to help achieve the above goals. Continue to weigh and measure foods and fluids.

This diet includes semi-solid, soft and pureed foods that are easily digested. During the first six to eight weeks after surgery, the stomach and small intestine are still healing. Limiting your diet to the foods listed in Stage III is necessary to avoid a blockage or other complications. Introduce foods slowly. If you notice a problem, try to identify it and be wary of the speed and amount you eat.

Foods that are not tolerated well at this stage can often be added to your diet later. You may experience occasional vomiting, diarrhea, or cramping after eating during the recovery period. Return to the Stage I Diet for 24 hours if these symptoms are severe, and contact your surgeon if they don’t improve within 12 hours. Remember, always chew your food very well, and don’t drink fluids with meals. Sip water and other beverages throughout the day.

Gradually, try other sources of protein such as soy products, poultry, fish and seafood, and lastly, meats.

Tolerance of foods varies from one individual to the next. Once you are back on a more regular diet, through trial and error, you may find that you can tolerate some foods better than others.

There may be some foods that your digestive system cannot handle well. Raw vegetables with skins and seeds may not be tolerated. However, if you remove the skin and seeds (for example, on a cucumber), you may be able to eat it without any problem.

We advise patients to avoid red meats until their stomach is functioning very well, usually after the first two months after surgery. Red meats are not well tolerated and can cause vomiting. Sometimes the source of vomiting may be a specific food.

Do not avoid a food just because you vomit once after eating it. You may wish to wait a few days, but you can try that food again. Tolerance to foods will improve over time. Always be sure to chew your food very well, take small bites and eat slowly. Try only a very small amount at first. Cook foods without added fats.

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Stage III sample menu Breakfast:

• A single scrambled egg with two tablespoons of shredded cheese.

Add a ½ cup of tomato, shredded spinach and 1 tsp. of oil (to cook with).

• 8 – 12 oz. of water (drink 30 min prior or after eating) Snack:

• ½ cup cottage cheese, fat free, 1 or 2%

• ¼ cup fruit

• 8 – 12 oz. of water (drink 30 min prior or after eating) Lunch:

• ¼ - ½ cup tuna salad with ½ cup of cooked green beans

• OR ½ - 1 cup of chicken/beef chili (beans and vegetables are good to add to chili)

• 8 – 12 oz. of water (drink 30 min prior or after eating) Snack:

• ½ cup yogurt (Chobani, Siggi’s)

• ¼ - ½ cup of fruit

• 8 – 12 oz. of water (drink 30 min prior or after eating) Dinner:

• 2 – 3 oz. of lean meatloaf or meat ball

• ½ cup cooked broccoli

• 8 – 12 oz. of water (drink 30 min prior or after eating)

PROTEIN: 9 grams

PROTEIN: 12 grams

PROTEIN: 20 grams

PROTEIN: 12 grams

PROTEIN: 20 grams

This sample menu is approximately 700- 800 calories, with 65 – 75 grams of protein.

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Protein

Fruit

• Canned Tuna moistened with light mayo (may add finely chopped vegetables) • Chicken Salad – homemade with finely shredded chicken and mixed with light mayo (may add finely chopped vegetables) • Deli sliced Turkey or Chicken Breast • Lean Ground Meats – prepared in stews, meatball, or meatloaf form • Fish – moist cooked only • Eggs – any style • Tofu

• Fruit – any kind of fruit is allowed in stage 3. Fruit with skins and seeds may be consumed, as tolerated • Fruit juice consumption, though not encouraged, is allowed in the amount of up to 8 oz. daily of a pure fruit juice that is diluted with water

Vegetables

Grains/Legumes/Nuts

• Vegetables – Vegetables of any kind are allowed in stage 3. Vegetables with skins and seeds may be consumed at this time, as tolerated • Limit choices of “starchy” vegetables such as potato, sweet potato, corn, peas, winter squash (butternut, pumpkin, acorn)

• Legumes of any kind may be consumed – beans, peas, lentils – up to one serving daily • Nuts (any kind) chewed well, and Nut-butters such as peanut butter and almond butter may be consumed at this time. One serving daily • Hummus – any flavor • Grains and “starchy” foods such as breads, rice, pasta, cereal may be introduced after adequate consumption of protein, fluid, vegetables, and fruits is tolerated. Discuss with your dietitian at the three-week post-op visit.

Food guide for week eight and beyond Life-long goals: 1. Make healthy food choices to ensure maximum nutrition and minimum volume.

Choose good quality protein, fat, and carbohydrates, and get plenty of high fiber.

2. Avoid foods that are empty in calories.

3. Drink enough water to keep hydrated.

4. Refrain from drinking any alcoholic beverages for the first year.

5. In your second year post-surgery you may have one serving of alcohol up to three times weekly, but never more than one serving per day. Abstinence from drinking is always best.

Sample menu for week eight and beyond You are working your way up to this menu in the previous stage (Stage III). Do not get discouraged if you are unable to eat all of this once you begin this stage. It can take several weeks to be able to accommodate this quantity of food.

7 - 7:30 a.m.

• ½ - ¾ cup whole grain cereal, cold or cooked

• ½ sliced banana

• 4 oz. Simply Smart milk 8 - 9:30 a.m.

• 8-12 oz. water 10 - 10:30 a.m.

• ½ -1 cup non-fat Greek style yogurt, plain

• ½ cup chopped apple or other fruit such as crushed pineapple

• 2 tbsp. finely chopped nuts

• Sprinkle with cinnamon 11 a.m. - 12:30 p.m.

• 8-12 oz. water 1 - 1:30 p.m.

• 1 oz. lean ham or turkey

• 1 oz. light or reduced fat cheese

• ½ Josephs reduced calorie pita bread

• Fill with:

• 1 cup mixed green lettuce and chopped vegetables such as tomato, carrots, peppers, etc.

• 2 tsp. light mayo, dressing, or mustard

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2 - 3:30 p.m.

• 8-12 oz. water 4 - 4:30 p.m.

• 2 tbsp. hummus, any flavor, with 3 whole wheat crackers (Akmak brand)

• OR ½ sliced apple with 1 – 2 tbsp. peanut butter

• OR one cheese stick with six grapes or cucumber slices, carrot sticks, etc.

5 - 6:30 p.m.

• 8-12 oz. water 7 -7:30 p.m.

• 3 oz. protein: fish, chicken breast, pork tenderloin, etc.

• ½ cup cooked vegetable: asparagus, broccoli, etc.

• ¼ - ½ cup starch: potato, corn, peas, winter squash,

• whole wheat pasta, brown rice (optional)

• ¼ - ½ cup fruit, any kind (optional)

• 2 tsp. fat: Olive oil (for cooking and preparation) 8 p.m. and beyond

• Water, if needed This sample menu is approximately 1200 calories, 60 grams of protein, 35 grams of fat.

Portion sizes by hand:

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Lifetime success Fluids Drink one and a half to two liters (48–64 oz.) of water per day, between meals (increase this amount by 20 percent if you are sweating). Water is the recommended beverage. Diet, non-carbonated drinks or those that are sweetened with sugar substitutes are recommended in limited quantities only. Juices are high in calories and could cause you to “dump.” They provide very little nutritional value.

Tips:

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Avoid carbonated beverages. When a carbonated beverage is consumed, it warms and releases gases, distending the stomach pouch and stretching the stomach. It then creates undue stress and subsequently causes the stretching of the anastomosis (area where the bowel is rejoined to the pouch).

• Do not drink 20 to 30 minutes before or after meals. This prevents pouch stretching and vomiting. Do not drink fluids with meals and snacks. This must be adhered to as an ongoing practice.

• Sip slowly and carefully.

• Minimize caffeine. Many beverages contain caffeine, an appetite stimulant, which is detrimental to initial weight loss and long-term weight control. Caffeine may also irritate your pouch and contribute to ulcers.

• Sip fluids continually between meals and snacks to prevent dehydration. Avoid drinking from fountains or with straws, as it is more difficult to control the volume of your intake, and can introduce air into your pouch, causing gas.

•

Eliminate high-calorie drinks such as milkshakes, soda, alcoholic beverages and juices. High- calorie beverages tend to be low in nutritional value, contain simple sugars, and are quickly absorbed into the blood stream, causing a rapid rise in blood sugar levels, and increased hunger. Weight loss can be slowed down dramatically and even stopped.

Note: If your urine is dark or your mouth is dry, you are not drinking enough.

• No alcoholic beverages for the year after surgery. After that time, if you choose to drink alcohol, limit to one serving at a time, no more than 3 times per week.

Eating strategies and behaviors Frequent snacks slow down weight loss; however, you should not go long periods without any food. You will be more prone to overeat later and not meet your protein requirements. Try to eat three planned, low-starch, high-protein, nutrient dense meals and two to three planned, low-starch, high-protein snacks every day. Between meal “picking” or “grazing” on small amounts of food throughout the day will sabotage your weight loss and keep you from achieving your weight loss goal.

• Your body needs a minimum amount of protein each day. About 60-70 grams is adequate for most people. You need protein to preserve your lean muscle mass, which in turn is going to 15

help you continue to lose weight. You also need protein for your body to heal properly.

• Stop eating when you feel full or if feeling any discomfort.

• Eat slowly. Chew slowly and thoroughly at least 22 times. Put your utensils down on the table after every bite. Remember that the pouch can only hold a small amount of food and it is best not to stretch the pouch by forcing food. Do not overeat. Listen to your body’s signals—do not look at the food left on your plate. Set aside 30 minutes for each meal. Take your time to enjoy the food. Do not eat when feeling rushed or stressed as this may cause gastric upset. Do not take more than 30 minutes to eat, as you may develop grazing habits.

• Always cut food into small pieces and chew food very well to prevent vomiting, cramping or blockage. If food should stick, try a teaspoon of meat tenderizer in a glass of water, sipped slowly.

• Over the long-term, well-balanced nutrition is important. Your diet should consist of protein (beans, tofu, tempeh, eggs, fish, seafood, dairy, poultry, and meats), fruits and vegetables, healthy oils, and finally complex carbohydrates.

Do not overcook your meat as this makes it difficult to digest. Grill or broil, if possible.

• Do not fry or deep-fry your food. You will notice that it is easier to eat protein-rich foods if they are moist and juicy. An example would be chicken thigh meat versus breast meat.

• Even though you may not always experience “dumping syndrome,” too much fruit juice and foods/beverages with sugars will slow down your weight loss. It is best to restrict them to allow your surgery to work for you. Some fruit products are labeled “unsweetened” and that means that there is no added sugar, but, the product may still contain a significant amount of natural sugar. Be careful not to overdo fruit products. Non-carbonated diet beverages are permitted in small quantities only. If you do choose to drink diet drinks such as Crystal Light weaken them with water. Moderation and water is best.

• Introduce one food at a time in order to rule out food intolerance. Don’t be afraid to try new foods, but in small amounts to start. What does not agree with you now may be acceptable in a few more weeks. Keep in mind that one day, foods may be tolerated smoothly, while the next you may have some fullness or discomfort. These problems eventually disappear, so don’t be discouraged if they happen. If food intolerance becomes a chronic issue for several days contact your surgeon or nutritionist.

• Food labels are a great source of information. They give you in-depth information about the amount of fat, protein, carbohydrates, sugar, sodium, and fiber in the product you are purchasing. Become a label reader and become more aware of what you put into your body.

• Remember that it is okay to get pleasure out of food. Since you are restricted to small portions, we encourage you to become a gourmet and only eat the best! Make your dish visually appealing with beautiful tableware and enjoy your meal.

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Foods to avoid Here is a list of popular foods that are filled with concentrated sweets, simple carbohydrates, and empty calories with limited nutritional value that can provoke “dumping syndrome” as well as other health issues. Every bite counts after surgery. Avoid foods which contain sugar. Not only will they slow down your weight loss,but they can make you sick.

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Ice cream Pudding Sweetened, fruited or frozen yogurt Candied fruit Canned or frozen fruit in heavy syrup Fruit juice Sugar coated or sweetened cereal Sweet rolls and doughnuts Sports drinks Sweetened popsicles Pies Cakes and cookies Regular soft drinks and lemonade High fructose corn syrup sweetened beverages Alcoholic beverages Sugared ice tea Non-carbonated fruit drinks Table sugar Honey Candy and chocolate Sweetened gelatin desserts Chewing gum Molasses Syrups Sherbet/sorbet Jams and jellies Pancakes and waffles with syrup Milkshakes and chocolate milk Sweet pickles or relish White rice, white pasta, white potatoes, white bread

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Mindful eating Mindful eating means being aware of the sensations you feel and the thoughts you have while eating.

It means eating with the intention of caring for yourself, overriding troublesome feelings and urges.

Benefits of mindful eating: • Teaches you to be less reactive to stress.

• Helps you to manage emotions.

• Increases your awareness of unrecognized or unexamined triggers, thoughts, feelings that lead to overeating.

• Helps you create mental space between your triggers and your actions.

• When you understand why and how you eat, as well as the situations that make you start and stop eating, you are much more likely to be successful.

How to practice mindful eating: • Be more aware of sensations (hear, touch, taste, smell, and see).

• Be aware of you physical and emotional cues and your non-hunger triggers for eating.

• Make your food look good and it will taste that way.

• Notice whether you are mindlessly munching or tasting each bite. (Rushed eating often leads to dissatisfaction with meals and cravings. Sit down and eat slowly!)

• Be aware of what your mind is doing (obsessing, worrying, craving). Take a moment before you eat to quantify your hunger.

• Pay attention to how your hunger and fullness change with each bite (pay attention to how it changes your hunger and fullness.)

18

Food journal When filling out your food journals, be sure to rate how your stomach feels before, during and after each meal or snack.

Please use the number scale below.

Hunger/satiety scale 1 Extreme hunger, dizziness, headache 2 Very hungry, irritable 3 Strong signals to eat 4 First signals that it is time to eat 5 Perfectly comfortable 6 Slightly overeating 7 Starting to feel uncomfortable 8 Very full 9 So full you are starting to hurt 10 Absolutely stuffed

19

Sample food journal Date: __________________

Meal/Time Food/Drink kcals Protein grams (g)

Fluid ounces (oz.)

Hunger rating

2

Breakfast:

7 a.m.

1 packet Carnation® Breakfast Essentials™ drink mix

130

5

8 oz. Simply Smart Milk

120

10

8

One 6 oz. banana

110

1

10 a.m.

6 oz. Chobani 0% Blueberry Greek yogurt

147

14

Lunch:

1 p.m.

4 oz. turkey deli meat

120

24

2 slices of whole wheat bread

139

5

1 tsp. mayonnaise

90

3 slices tomato

15

1

Snack:

20

4

Meal/Time Food/Drink kcals Protein grams (g)

Fluid ounces (oz.)

Hunger rating

3

3

Snack: 4 p.m.

¼ cup almonds

170

Dinner:

6 p.m.

3 oz. roasted chicken (no skin)

170

19

1 cup spinach

41

5

1 tsp. margarine

30

½ cup brown rice

108

3

8 oz. Water

8

Snack:

8 p.m.

5½ oz. apple

80

93

16

TOTAL:

1470

6

4

Exercise What did I do? _______________________________________________________________ How many minutes? ____________________________

HR/BORG? ___________________

21

Class two Food label

22

23

How to stock a healthy kitchen To prepare healthy meals, you need to have the necessary ingredients readily available. Take this list shopping to help you stock your kitchen so you can put together a nutritious and delicious meal.

Cupboard:

• • • •

• • • • • • • • • • • • • • • •

Whole grains (i.e. brown rice, oatmeal, barley, bulgur, quinoa, whole wheat cous cous) Pasta (whole-wheat or multigrain) Dry cereals (oat, wheat and bran varieties) Dried or canned beans (i.e. garbanzo, black, kidney, lentils, etc; choose lower sodium) Whole grain breads (whole wheat flour 1st ingredient) Vegetables (potatoes-all varieties, winter squash, turnips, onions, garlic, etc.)

Peanut butter, and other nut butters (natural) Nuts & seeds (almonds, walnuts, ground flaxseeds, etc; choose unsalted or lightly salted) Canned fish, packed in water (tuna, salmon, sardines, clams, crab, etc.)

Canned vegetables (no added salt) Marinara/tomato sauce (lower sodium varieties) Salsa Canned fruits (in water, juice or light syrup) Dried fruits Oil (olive-oil, canola and other vegetable or nut oils) Cooking spray Vinegar (balsamic, red wine, etc.)

Condiments (reduced fat/light, lower sodium) Broth (reduced sodium) Flour (whole-wheat) Dried herbs and spices

Refrigerator:

• • • • • • • • • • •

Fruit (in a variety of colors) Vegetables (consider convenient to use bagged greens, shredded carrots and cabbage, etc.)

Eggs and/or egg substitute Skim or 1% milk Yogurt (low fat or fat free) Cottage Cheese (low-fat or fat-free) Cheese (reduced fat) Cold cuts (reduced sodium turkey, ham or roast beef) Margarine (light tub or spray for spreading, regular tub for cooking) Salad dressing (reduced fat or fat-free) Meat Alternatives (tofu, tempeh, seitan)

Freezer:

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• • • • • •

Poultry (white meat, skinless, extra lean ground turkey or chicken) Fish (fresh or frozen, rather than breaded and fried) Meat (extra-lean cuts such as round, loin and choice cuts, 90 –95% ground) Frozen vegetables (no sauces) Veggie burgers and crumbles (choose lower sodium varieties) Healthy Choice® or other low-fat/light meals (when in a hurry)

Putting a meal together Important to know:

•

• • • • •

•

•

Eat frequently. Choose either three small meals and two to three snacks, or four to six mini-meals.

Do not skip meals.

Eat protein first. Aim for 60 – 80 grams per day.

Next add vegetables and /or fruit.

Add starches last.

Consume water and other non-caloric, non-carbonated, decaffeinated fluids in between meals and snacks. Aim for 64 oz. per day.

Avoid added sugars (i.e sugar sweetened drinks, candy, desserts, sugary cereals and snack foods.)

Limit added fats and avoid fried, greasy and other high fat foods (i.e cheese, ice cream, chocolate, baked goods.)

But how exactly should you put together a meal?

Start with protein Protein foods are essential to help your body heal after bariatric surgery. Protein also helps you feel full longer in between meals. Aim for at 60 – 80 grams of protein per day. For example, 3 oz of meat contains approximately 21 grams of protein. Check labels to determine the protein content of foods.

Below are some protein rich foods.

• Skinless chicken or turkey • Seafood (baked, grilled or boiled) • Beef (loin, and round cuts) • Pork (loin and round cuts, lean ham) • Eggs or egg substitutes • Nuts and Natural nut butters • Beans (black beans, kidney beans, chick peas, navy beans, lentils, split peas) • Reduced fat dairy (yogurt, Greek yogurt, skim or 1% milk, reduced fat cheese) • Soy products such as tofu, edamame or unsweetened soy milk.

Cover half your plate with veggies Vegetables are low in calories, high in fiber and contain tons of vitamins and minerals. Aim to have a vegetable with two to three meals and one to two snacks daily. Choose colorful non starchy vegetables such as:

• • • • • • • • • • •

Artichokes Asparagus Beans (green, wax, Italian) Bean sprouts Beets Brussel sprouts Broccoli Cabbage (green, bok choy, Chinese) Carrots Cauliflower

Celery 25

• • • • • • • • • • • • • • • • • • • • • •

Chayote Cucumber Eggplant Hearts of palm Jicama Kohlrabi Leeks Mushrooms Okra Onions Pea pods Peppers Radishes Rutabaga Salad greens (lettuces, spinach, arugula, chicory, endive, escarole, radicchio, watercress) Sprouts Squash (cushaw, summer, crookneck, spaghetti, zucchini) Sugar snap peas Swiss chard Tomato Turnips Water chestnuts

A word about fruit Fruits are higher in calories and carbohydrates than non-starchy vegetables. Choose up to two to three servings of fruit per day. When choosing fruit, choose fresh, frozen or canned in water fruit in a variety of colors.Limit or avoid dried fruit and fruit juice. One serving of fruit is equal to about:

• • • •

1 tennis ball size fruit 1 4-inch banana ½ cup canned fruit (unsweetened or in water or natural juice) 1 cup fresh berries or chopped fruit

Choose high fiber starches Some starchy foods are not well tolerated after bariatric surgery, so keep your portions small (¼–½ cup). But starches can be a great source of fiber, energy and other nutrients so do include a small amount with meals. High fiber starches include both starchy vegetables and whole grains.

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Whole grains

•

• • • • • • • • • •

Whole-wheat flour (whole wheat breads, cereals, and crackers, whole wheat or multigrain pastas, etc), Oatmeal and oats Barley Brown and wild rice Bulgur (cracked wheat or kasha) Buckwheat Whole cornmeal Whole rye Wheat berries Quinoa Millet

Starchy vegetables

• • • • •

Potatoes (sweet and white) Corn (including popcorn) Peas Winter squash (butternut, acorn, spaghetti) Plantain

What about fats?

Fats in food can help your body absorb some nutrients better, as well as enhance the flavor and texture of your meal. Too much fat however can contribute to weight gain and may not be well tolerated after bariatric surgery. Choose plant fats over animal fats most of the time (i.e. olive oil rather than butter). Examples of healthy plant fats and serving sizes include:

•

• • • • • •

1 tbsp. olive oil, canola oil and other vegetable oils (excluding coconut oil, palm oil and palm kernel oil) 2 tbsp. light or oil based salad dressing 1 tbsp. light tub margarines (also known as soft spreads) ¼ avocado or ¼ cup guacomole 1 tbsp. seeds such as ground flax seeds, sunflower seeds and chia seeds 1 tbsp. nut butter (also contains protein) ¼ cup nuts (also contains protein)

27

Class three Wellness: physical activity and exercise A critical step for patient post-surgery is to become more active on a daily basis through comprehensive exercise. Incorporating a consistent exercise program into your lifestyle will make it possible for your weight loss to stick. We recommend that you take it in steps: #1: Move more!

Aim to be active daily. Spend less time resting or sitting than you did previously. #2: Steadily increase your daily activity. #3: Begin to add consistent aerobic exercise.

At least 10 minutes and working up to 60 minutes. Walking, biking, swimming, aerobic classes.

Warm up and cool down and stretch after all workouts. #4: Add intensity to your workouts.

The more intense the workout, the more calories you expend. #5: Add strength training to your aerobic workout

Weight machines, hand weights, tubing, or utilizing your own body weight. Seek out professional assistance prior to starting a strength training and be sure to see a staff member at Wellness before beginning.

Benefits • • • • • • • • • • • • • • • •

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Improves flexibility, strength, balance and endurance Improves tone of muscles, joints, tendons and ligaments Strengthens bones and deters osteoporosis and osteopenia Improves digestion and elimination Improves blood circulation: heart and lungs Aids in skin elasticity Reduces your risk for heart disease and stroke Lowers blood pressure Helps to lower blood sugar Improves posture Reduces stress Helps manage chronic pain Improves sleep Reduces stress Improves body image Increases mental alertness

Activity every day Begin to incorporate simple activities into your day to become more physically active. Stand up from sitting at least every hour, march in place, walk as much as you can, climb stairs, join an exercise class, etc.

Aerobic You cannot lose weight successfully without aerobic exercise. Aerobic exercise uses larger leg muscles as well as arms for a continued period of time. Walking, jogging, swimming, riding a bike, using elliptical, rowing or treadmill machines, participating in group fitness classes such as step aerobics, kick boxing, zumba dance, stationary bike, to name a few.

How long should you exercise?

Start with a minimum of 10-15 minutes if you are a beginner and increase the time up to 45-60 minutes. Your goal should be to exercise most days of the week for about 30 minutes. Your intensity or how hard you are working is a critical component in successful weight loss and improved metabolic functioning. The harder you work, the more calories you will burn.

Interval training* Interval training allows for maximum caloric expenditure if done safely and consistently. This involves alternating more intense bouts of exercise lasting for 20-30 seconds with less intense exercise for longer durations of 1-10 minutes. This type of exercise is excellent for all levels of ability and potentially can burn more calories than traditional exercise. *Please see our staff for assistance in this method first.

General exercise guidelines based on F.I.T.T. Principle: Frequency (number of sessions per week) • 3 sessions per week will improve overall health but only maintain your current fitness level • 4-5 sessions per week will improve both fitness and health levels • 5+ sessions per week will greatly improve both fitness and health

Intensity (measured by Heart Rate Check, Borg Scale and Talk Test)

The target Heart Rate range you should aim to maintain during exercise will be established by your healthcare team.

Borg Scale asks you to rate the amount of work you are doing, including your how hard you are breathing and how intensely you are working your legs and arms. An average scale number is 12-14 (“somewhat hard to hard”).

You should be able to talk comfortably to someone during the aerobic phase of your work out, excluding the interval phase.

Time (duration) of workout

A good starting point for beginners is 10-15 minutes per session working up to 20-60 minutes. The duration does not include warm-up and cool down times.

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Type of exercise • Walking, biking, swimming, jogging, dancing, Zumba, aerobic step, kick boxing, treadmill, stationary bike, elliptical rower, to name just a few.

Components of exercise program •

• •

Warm up 3 - 7 minutes Begin to loosen up your body at a slow pace/intensity Aerobic (actual time exercising) 10 - 60 minutes Cool down and stretch 7 - 10 minutes Cooling down allows your muscles to recover, improve muscular balance, reduce injury occurrence.

Strength training A sound, well balanced exercise program should always include a strength training segment. Your post-op program will include specifics on strength training.

General guidelines: • • • • • • • • • •

Wear loose fitting clothing and comfortable sneakers.

Journal your exercise session.

Do not exercise outdoors in extreme heat or cold.

Ideal temperature is approximately 40-80 degrees with humidity 65% or less.

Do not exercise on a full stomach.

Wait at least an hour and a half after eating a meal before you exercise.

Do not exercise if you have a fever.

Hydrate before, during and after your workouts.

Use variety in your workouts.

Some important signs and symptoms to be aware of include: - Pain, tightness or discomfort in the chest, throat, jaw or arms - Unusual shortness of breath - Palpitations or skipped heart beats - Dizziness or lightheadedness - If you develop any unusual symptoms during exercise, stop and rest and contact your health care provider if needed.

Stress Stress can be defined as your body’s response to any demand made on it or as the internal response to external situations in our lives. It can also be described as an “invisible force” that keeps us going.

Stress itself is not bad, rather it is the way we handle it and respond to it that differentiates between productive (positive) and non-productive (negative) stress.

Productive stress produces a pleasurable or healthy response and gives a sense of accomplishment and satisfaction (ie. successfully meeting an important deadline, competing in a sport you enjoy, etc.)

Non-productive stress causes discomfort and anguish (i.e., worrying about meeting that deadline, waiting in a line when you are late for an appointment etc.)

30

Too much positive or negative stress can lead to the body producing stress hormones, which gear us up to respond to perceived danger, also known as the “fight or flight” response. The heart rate increases, respiration becomes rapid and shallow, there is a rise in blood pressure and the brain moves into a primitive “survival” mode, suppressing normal thought functions (evaluation, planning, deciding, etc.) The result is that a person becomes unable to clearly evaluate and plan a response.

A body in a constant state of “fight or flight” can develop disorders including heart disease and stroke.

The stress response Symptoms of stress can be physical, emotional and/or behavioral.

• Headaches, back pain, neck pain, chest pain or discomfort, other pain, indigestion, nausea, shaking, sweating, dizziness, numbness or tingling.

• Crying, irritability, frustration, anger, impatience, inability to concentrate, memory problems, confusion.

• Decreased productivity, burnout, overeating, smoking, drinking alcohol in excess, etc.

• It is crucial that you are able to detect your own early warning signs of stress as they occur. If you have determined that stress is causing or contributing to your symptoms, you can manage your stress to minimize its impact.

Your stress symptoms: How do you know when you are feeling stressed?

______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Circumstances that cause you stress (stressors) can be physical, internal or external.

• Not getting enough sleep, lack of a nutritious diet, pain, alcohol, caffeine, nicotine, or suffering an illness or injury.

• Your perception of events can create fear, worry or anxiety, and changes in your thoughts, feelings, behaviors, or any pressures or concerns you put on yourself, such as concern for children or parents, can be stressors.

• Family turmoil, marriage, divorce, death, traffic, work setting, major life changes, illness, change in job etc. are common stressors.

What are your stressors? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 31

The relaxation response According to Dr. Herbert Benson, Associate Professor of Medicine at Harvard Medical School, the relaxation response is a physical state of deep rest that changes the physical and emotional response to stress ... and the opposite of the fight or flight response.” Physical symptoms that occur are a reduced heart rate, reduced blood pressure, reduced oxygen usage, lower metabolic rate and slower respirations.

Relaxation: through breathing The focus of meditation is the experience of a peaceful sense of being, which includes awareness of physical sensation, emotions and thoughts. Some goals of meditation include relief of stress related symptoms, relief of anxiety, freedom from the limitations and suffering caused by compulsive worrying, self-criticism or other negative thought patterns which can contribute to unhealthy behaviors including stress eating.

• The best time to meditate is in the morning before breakfast because the mind is less active after sleep. Do not practice two hours after any meal, since the digestive processes seem to interfere with the response.

• Choose a relatively quiet place where you will not be disturbed.

• Meditate in any position in which you can be comfortable with your back straight.

• There is no correct way to breathe. Just notice that you are breathing and be aware of the changes that take place as you become more or less relaxed.

• Use of a focus word: Repeat a word or words in your mind.

• Try to practice for 15-20 minutes daily or for a minimum of 5 minutes to focus on your breathing and self-awareness.

Relaxation: from the belly Deep abdominal breathing or belly breathing, helps establish a state of physiological calm and can neutralize the negative effects of stress. Here’s a step-by-step lesson: 1. Lie on your back and place a book on your belly. Relax your stomach muscles and inhale deeply into your abdomen so that the book rises. When you exhale the book should fall. You will still be bringing air into your upper chest, but now you will also bringing air down into the lower portion of your lung and expanding your entire chest cavity.

2. Sit up and place your right hand on your abdomen and your left hand on your chest. Breathe deeply so that your right “abdominal” hand rises and falls with your breath, while your left “chest” hand stays relatively still. Breath in through your nose and out through your nose or mouth, enjoy the sensation of abdominal breathing.

3. Place a clock with a second hand in view. Breath in slowly, filling your abdomen, for five seconds.

Then breath out slowly to the same count of five.

4. Perform deep abdominal breathing throughout the day, for example, when you awaken, before you go to sleep, and in any stressful situation.

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Muscular relaxation One of the most effective ways of reaching a quiet, peaceful state of mind and relaxed body (“the relaxation response”) is the practice of meditation. Mediation is a simple, natural process, which keeps your attention in the present moment. Here is a method, which you can adapt and modify to suit your own needs.

• Choose a quiet spot where you will not be disturbed. Sit in a comfortable position with your arms and legs uncrossed. Close your eyes.

• Take 4 or 5 slow, deep breaths, allowing the breath to go to the bottom of your lungs. Notice that you can feel the movement in your abdomen. Then let your breathing resume its natural, easy pace.

• Begin to relax all of your large muscles starting with your feet: With your feet flat on the floor, try to curl your toes under. Feel the tension, then relax and let go.

- To tense the muscles of your legs, press down hard on your heels. Feel the tension, then relax and let go.

- Next, squeeze the muscles of your buttocks, making, them hard. Feel the tension then relax and let go.

- Pull the abdomen in tightening the muscles. Feel the tension, then relax and let go.

- For the muscles of your hands and arms, make a fist with both hands. Feel the tension then relax and let go.

- Now shrug your shoulders up toward your ears. Feel the tension, then relax and let go.

- For the muscles of your jaw make a big wide smile then bite down lightly. Feel the tension, relax and let go.

- Last of all for the small muscles in the upper part of your face, wrinkle your nose, squint your eyes and raise your eyebrows. Feel the tension then relax and let go.

Meditate 1. You are now ready to begin the meditation. Close your eyes and become aware of your easy comfortable breathing. Notice the breath coming in and going out. Focus all of your attention on your breath.

2. Now begin to silently repeat a “focus” word or words in rhythm with your breath. This is a simple way of keeping your attention on your breath. You may say any words that are comfortable for you, including words from a prayer. To begin you might want to say “IN” as you breathe in, “OUT’ as you breathe out.

3. Enjoy this relaxation without worrying about how you’re doing. If you should drift into thinking about something, gently bring your attention back to your breath and focus word. Continue for 10 to 20 minutes.

4. Practice every day, modifying the technique to suit you. Repeated practice will lead to an increasing sense of calm.

33

Have you experienced?

Behavioral Symptoms Changed activity level Changed ability to sleep Changed appetite Nightmare/recurrent dreams Startle easily Inability to respond Considering/attempting suicide Increased drug/alcohol use Obsessions (circular though)

Yes q q q q q q q q q q

No q q q q q q q q q q

Confusion Anxiety Anxiety in specific situations (list below) __________________________ __________________________

q q q

q q q

Depressed Poor self-esteem Hostile Irritable Resentful Fearful Exhilaration Urge to be alone Over-concern with physical health

q q q q q q q q q

q q q q q q q q q

How Many

---------------------- ---------------------- ------------------------ ---------------------- ---------------------- ---------------------- ------------------------------------------------------------------------------------------

Feelings

34

---------------------------------------------------------------------

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Stress warning signs There are a variety of signs or signals to indicate that a person is under stress. Each individual has his/ her own unique set of signals. In order to prevent the build up of harmful stress, it is crucial that you be able to detect your own early warning signs of stress as .. they occur in daily living. Check any of the symptoms below that you’ve experienced during the last year. Estimate how often you have exhibited the symptoms and write the number in the blank.

Have you ever experienced?

Yes No How frequently Physical Symptoms q q -----------------------------------------------------------------------------------------------------------------Muscular tension/spasm q q -----------------------------------------------------------------------------------------------------------------High blood pressure. q q -----------------------------------------------------------------------------------------------------------------Headaches q q -----------------------------------------------------------------------------------------------------------------Neck aches q q ------------------------------------------------------------------------------------------------------------------Back aches q q ------------------------------------------------------------------------------------------------------------------Indigestion q q -----------------------------------------------------------------------------------------------------------------Irritable bowel q q ------------------------------------------------------------------------------------------------------------------Ulcers q q -----------------------------------------------------------------------------------------------------------------Constipation q q -----------------------------------------------------------------------------------------------------------------Diarrhea q q -----------------------------------------------------------------------------------------------------------------Tics/Tremors q q -----------------------------------------------------------------------------------------------------------------Fatigue q q -----------------------------------------------------------------------------------------------------------------Nausea/vomiting q q -----------------------------------------------------------------------------------------------------------------Urinary frequency q q -----------------------------------------------------------------------------------------------------------------Pounding heart q q -----------------------------------------------------------------------------------------------------------------Teeth grinding q q -----------------------------------------------------------------------------------------------------------------Itching skin q q -----------------------------------------------------------------------------------------------------------------Acne/eczema q q -----------------------------------------------------------------------------------------------------------------‘Lump in throat’ q q -----------------------------------------------------------------------------------------------------------------Sweaty palms/cold hands or feet q q -----------------------------------------------------------------------------------------------------------------Hives q q ------------------------------------------------------------------------------------------------------------------Excess perspiration q q -----------------------------------------------------------------------------------------------------------------Menstrual irregularity q q -----------------------------------------------------------------------------------------------------------------Hair loss q q -----------------------------------------------------------------------------------------------------------------Cold sores q q ------------------------------------------------------------------------------------------------------------------

35

Patience vs. Impatience

The quality of patience goes a long way toward creating a more peaceful and loving self. Becoming more more patient involves opening your heart to the present moment, even if you don’t like it.

Patience also involves seeing the innocence in others, adding a-dimension of ease and acceptance to your life.

Answer this questionnaire to find out how im/patient you are. Circle one.

Never = 0; Sometimes = 1; Often = 2; Always = 3.

36

While driving, I weave in and out of traffic.

0

1

2

3

When I’m in a traffic jam, I curse.

0

1

2

3

When my train is late in arriving at my station, I pace up and down the platform.

0

1

2

3

When the train or plane in which I am riding is late to my destination, I keep looking at my watch.

0

1

2

3

I get angry when a person I’m meeting is late.

0

1

2

3

When I’m late for an appointment, I become very agitated.

0

1

2

3

I get angry when a meeting starts late.

0

1

2

3

I get angry when I try to explain something and the other person doesn’t understand.

0

1

2

3

I get angry when someone eats something I’ve been saving for myself.

0

1

2

3

I get angry with myself when I can’t remember something.

0

1

2

3

I wish I were moving faster in my career.

0

1

2

3

I get annoyed when someone interrupts me while I’m working.

0

1

2

3

I get annoyed when someone calls me while I’m watching television.

0

1

2

3

I can’t stand when people talk softly.

0

1

2

3

I can’t stand when people talk slowly.

0

1

2

3

I can’t stand stupid questions.

0

1

2

3

I can’t stand when people think they’re correcting me - and they’re wrong.

0

1

2

3

I hate waiting in line.

0

1

2

3

I hate when I pick the shortest line and it turns out to be the longest.

0

1

2

3

I hang up the phone when I get put on hold.

0

1

2

3

I fume if a service person arrives late.

0

1

2

3

I feel anxious if something takes longer than I thought it would.

0

1

2

3

I feel that things that take a long time are not worth doing.

0

1

2

3

I can’t wait to see what happens next.

0

1

2

3

I can’t help telling secrets.

0

1

2

3

Establishing long-term behavior change NOTES:

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Class Four Agreement to participate in post-operative follow-up care Surgeon/follow-up visits When you receive your surgery date, you will be asked to immediately schedule the initial post operative appointment with your surgeon. Below is the schedule for follow-up visits with your surgeon:

1 week post-surgery 6 weeks post 12 months post* Annual visits thereafter

Post-operative evaluations at Wellness Center Your initial post-operative evaluation with a nurse clinician and registered dietitian from the Wellness Center will take place three weeks after surgery. We will ask you to set this appointment up as soon as you receive your surgery date (this appointment is required before you begin the post operative program.) Below is the post surgery schedule for Wellness appointments.

2 and 3 weeks post-surgery 8 weeks 3 months* 5 - 6 months 8 months* 10 months 15-18 months Annual visits thereafter

* Lab work must be completed 1-2 weeks before your 3rd, 8th and 12th month appointments, and then before all annual appointments thereafter. Annual appointments will be with your primary care physician.

Comprehensive Post-Operative Program Once cleared by your surgeon, you will begin a comprehensive post-operative program. This will consist of weekly hour sessions that include nutrition counseling, education in stress management, exercise and relaxation for long-term behavior changes.

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Nutrition/medical/follow-up care After completion of the post-operative program, you will have appointments with a dietitian and N.P. from Wellness. These will be scheduled as needed until your weight has stabilized (usually 18-24 months). Follow-up appointment will then happen once a year, for five years.

Post-op support group After surgery, regular attendance at our monthly support group is strongly suggested, and will increase long-term success.

Psychological care Initial pre-operative evaluation and testing will determine if post-operative care will be needed.

Psychological services are always available.

Following weight loss surgery, taking aspirin products and non-steroidal anti-inflammatory drugs (NSAIDS) will put you at greater risk for developing stomach and staple line ulcers. If you are taking any of these, talk with your primary care physician to find an alternative medicine to take when needed. Low-dose (81mg) enteric-coated aspirin is acceptable if prescribed by your doctor.

Following weight loss surgery, consumption of alcohol, cigarette smoking, and/or use of “street” drugs (including but not limited to marijuana, cocaine, and crack), is dangerous to your health and puts you at an increased risk for staple line and gastric ulcerations and hemorrhages.

Pregnancy should be postponed until weight loss has stabilized (usually 24-36 months). ______________________________________________________________________________________ When you are accepted into the Surgical Weight Management Program at Salem Hospital, you are agreeing to participate in the above plan of post-operative follow-up care, and agree to follow through with all appointments. You have been informed of and understand the risks of the procedure (gastric bypass or gastric sleeve) as listed, dated and initialed on separate sheets in the intake questionnaire. ______________________________________________________________________________________

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Supplement requirements post-bariatric surgery 1. When you are discharged from the hospital, begin taking one children’s chewable multi-vitamin with minerals (for example, Flintstones Complete. Do NOT take Gummies).

You should also start taking sublingual Vitamin B12.

2. At your 3-week post-op visits with Wellness Clinicians, you may switch to a non-chewable multivitamin tablet with minerals which has a minimum of 18mg of Iron. (eg Centrum A-Zinc). Continue taking Vitamin B12 500mcg, sublingual daily.

3. Begin taking Citrical Maximum 2 Tablets 2x day. These tablets are 315 mg each, 630 mg total.

At this point you can take these 3 supplements as follows:

Morning: Multivitamin with iron

Vitamin B12 500mcg, sublingual Afternoon:

2 Calcium Citrate + D (315mg each)

Evening:

2 Calcium Citrate + D (315mg each)

Iron supplements may be added if determined to be deficient by blood work. Iron may be take with the multivitamin and should be taken with vitamin C. It is never to be taken with calcium supplement.

Constipation may develop as a result of taking iron supplement. Your stools will also become darker when taking iron.

If you become constipated: 1. Increase your water intake and increase your walking daily.

2. Try 4 oz. prune juice, sipped slowly, each morning. If no relief, then go to #3.

3. Take a stool softener (eg Colace) 1-2 times a day with iron. If no relief, then stop Colace and go to #4.

4. Take PeriColace 1-2 times a day. If still no relief, then try #5.

5. Take a mild laxative such as Correctol or Milk of Magnesia, or Miralax. If no relief, then call your PCP.

40

Bariatric surgery basics It is recommended that you begin following these guidelines before surgery for the optimal post surgical outcome. After surgery, compliance is necessary for the best results and minimizing the risk of complications.

1. “Chew for 22”- Each meal or snack should take 20 to 45 minutes to consume. Chew each bite of food at least 22 times or to the point of pureed consistency. Your pouch or sleeve can only hold a small amount of food after surgery and eventually it can hold more. If you eat large amounts of food, you may stretch the pouch or damage the esophagus.

2. Pay close attention to early signs of fullness and stop eating. You may feel discomfort at the breastbone. If ignored, vomiting or pain may result.

3. Avoid concentrated sugars and fats. These types of foods can slow down weight loss. Avoid high calorie liquids (sports drinks and fruit juice) and high fat foods. This may trigger “dumping syndrome” (sugars go directly from stomach pouch into the small intestine causing a rapid rise in blood sugar levels causing heart palpitations, nausea, abdominal pain and diarrhea).

4. Drink at least 64 oz. of fluids, preferably plain water, per day to prevent dehydration and constipation. Take frequent sips. Do not eat and drink at the same time (except soups, stews and cereal) and do not drink until 30 minutes after eating. Carry a water bottle.

5. Carbonated drinks, straws, mints and chewing gum cause gas and bloating and should be avoided.

6. Avoid caffeine for 6 months after surgery as it can cause dehydration and stimulate the bowel resulting in diarrhea or cramps. One cup of caffeinated tea or coffee per day is allowed after six months. Plan on weaning off all caffeinated beverages prior to surgery 1 cup coffee = 6 oz 7. Eat 3 balanced protein containing meals and 1-2 protein containing snacks. Goal is 60-80g protein daily Please refer to your dietary nutrition guide for more information.

8. If you cannot tolerate dairy try using Lactaid or soymilk. Use a high protein containing milk (>10g).

Do not use coconut, almond or rice milk as they have a low protein content. You can also add Lactase or Dairy Ease drops to milk.

9. Eliminate all alcohol for one full year after surgery. Thereafter, alcohol may be consumed on occasion- one drink no more than 3 times weekly. 1 drink = 12 oz beer, 1.5 oz liquor, 5 oz wine.

10. Be consistent about taking your vitamins/minerals. Follow the schedule that you were given by the program and remember not to take calcium and iron together.

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Recommended reading The Emotional First Aid Kit “A Practical Guide to Life After Bariatric Surgery”

by Cynthia Alexander, PsyD This book is available online and it is also available in Spanish.

General Information

Nutrition

asmbs.org healthfinder.gov nhlbi.nih.gov/health americanheart.org Eatright.org diabeticlivingonline.com

myfitnesspal.com oldwayspt.org eatingwell.com cookinglight.com

Exercise/Fitness

Wellness

my.fitday.com caloriesperhour.com fitness.gov acefitness.org onlinefitnesslog.com

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nmha.org wellness.com sleepfoundation.org stress.org

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