Program Process

Initially, a candidate:

• Fills out a patient application form and sends it to Guadalupe Regional Medical Center
• Patient applicaiton is evaluated by the Program Coordinator/RN.
• Attends free seminar after selection
• Insurance authorization process begins

A candidate selected for the Program then receives:

• a surgical consultation,
• a nutritional consultation,
• two psychological consultations,
• a fitness consultation, and
• a date for surgery.
• attends one support group meeting

Following surgery, a patient.

• Receives a Medical Center dietary consultation while admitted
• Does not return to work for 1-6 weeks. (This varies on type of work performed and type of surgery)
• Is seen by the bariatric surgeon in weeks one, four, ten, sixteen, twenty-four and yearly for five years
• Attends monthly support group meetings
• Receives a psychotherapy consultation at week ten
• Receives a nutritional consultation at weeks four, ten and twenty-four
• Receives a fitness consultation at week ten

Post Surgery Gastric Bypass Nutrition

You will be required to have dietary consultation sessions both before and after surgery. Before surgery, you will be required to have one pre-operative consultation with the Dietitian. In this consultation you will learn about the amount and types of food you will be able to eat. It is imperative that you understand that the dietary changes are lifelong and permanent.

After surgery, you will be required to have three post-operative consultations with the Dietitian. In these consultations you will review the information learned and discuss any dietary issues you may have.

Diet

The changes made to the gastrointestinal tract will require permanent changes in your eating habits, these changes are essential in the weight loss process. It is important that you follow the guidelines provided by the Program Dietician. You may hear of other patients that follow different dietary guidelines than have been recommended for you. Remember, however, that every surgeon does not perform the same weight loss surgery and that the dietary guidelines may differ.

The Roux-en-Y gastric bypass surgery is a restrictive surgery, it will provide you with an excellent "TOOL" to limit the amount of food you can eat. But, it does not do the work, you do. You must put forth the effort to make good food choices and behavioral changes to gain optimum results. In addition to reducing your stomach to a one to two ounce pouch, the pouch will swell post operatively. Because of this, it is important that you adhere to the dietary guidelines to reduce discomfort and avoid stretching of the pouch, protecting the integrity of the staple line.

Because the surgery also is a "malabsorption" procedure, bypassing the first part of the small intestine, you may experience the "dumping syndrome". The dumping syndrome occurs when too much food passes too quickly from the stomach pouch into the intestines. Symptoms may include nausea, sweating, diarrhea, cramping, weakness, and /or fast heart rate.

What Will My Diet Be Like After Surgery?

After gastric bypass, your eating patterns and food choices will change dramatically. The diet after surgery progresses from a clear liquid diet, to a full liquid diet, to a soft diet, and then a modified regular diet. The diet progression is designed to allow your body to heal. In the first couple of weeks, the diet will help you meet your protein and liquid requirements, and later, to assist you in meeting your nutritional needs. It is imperative that you follow the diet's progression and adhere to this regimen to maximize healing and minimize the risk for unnecessary complications.

For the first few weeks after surgery, the tissue around the staples and sutures in the stomach pouch is very swollen and unhealed. This is the reason for starting with liquids and slowly progressing to more solid foods in a few weeks after your surgery. Progressing to solid foods prematurely could cause nausea and vomiting in turn causing undue stress to the pouch, possibly leading to complications. This also allows you a little time to get used to the new size of your stomach "pouch" and the "rules" that go with it.

The size of your stomach pouch is about 1 ounce or 1 to 2 tablespoons and in some cases, smaller because of the swelling post operatively. At first, your capacity will be somewhat limited, so be patient. You may find that 2 to 3 teaspoons of food fills you up. This is okay and is not unusual. You may also find that you may not be able to tolerate certain foods at all. That is okay, too. However, in time you should be able to tolerate a variety of foods (except for sweets). Over time, your food pouch will stretch. By six months after surgery, it may stretch to 8 ounces or 1 cup. Long term, the size of your pouch is likely to be 8 to 12 ounces or 1 to 1 1/2 cups. Even though this is larger than the capacity of your pouch immediately after surgery, it is far smaller than the gallon size capacity before surgery.

The primary source of nutrition should be protein. In fact, 70 to 75% of all calories consumed should be protein based (eggs, fish, meat, etc.) Carbohydrates (bread, rice, potatoes, etc.) should make up only 10 to 20%, and fats (butter, oils, etc.) only 5 to 15% of the calories that you eat. A diet consisting of 600 to 800 calories and 60 to 70 grams of protein should be the goal for the first 6 months.

Avoid foods which contain sugar. Not only will they be used as energy rather than your own fat stores, they slow down your weight loss and have the potential to make you really feel sick! Sugary foods cause the "dumping syndrome" in patients who have had the gastric bypass procedure. This is not a pleasant experience.

To maintain a healthy weight and to prevent weight gain, you must develop and keep healthy eating habits. You will need to be aware of the volume of food that you can tolerate at one time and make healthy food choices to ensure maximum nutrition in minimum volume. A remarkable effect of bariatric surgery is the progressive change in attitude towards eating. Patients begin to eat to live — they no longer live to eat.

Rules of the "Tool"

• When eating solid food you must chew thoroughly.
• Do not drink fluids while eating.
• Do not eat foods that have sugar listed as one of the first three ingredients, thus preventing the "Dumping syndrome".
• Do not drink carbonated beverages.
• Do not eat high calorie nutritional supplements.
• Stop eating right before you feel full.
• Avoid alcohol.
• Limit snacks between meals.
• Take two multi-vitamins with B-complex and Iron daily (liquid or chewable is recommended).
• Take 1500 mg of Calcium Citrate daily.
• Sublingual B-12 250 mg daily.

Post-Surgery LAP-BAND® Nutrition

After Surgery, you will have a new nutrition plan. Our surgeon and dietician will help you learn about and get used to the changes in lifestyle and eating habits you need to make. It is very important to follow the eating and drinking instructions beginning immediately after the operation.

In the first few weeks after your surgery, you will be on a liquid diet since only thin liquids will be tolerated by your stomach at that time. As you heal, you will gradually progress to pureed foods (three to four weeks post-op) and then soft foods (five weeks post-op). Eventually you will be able to eat solid foods.

When you can eat solid foods without problems you will need to pay close attention to your diet. The LAP-BAND® System is designed to restrict solids, not liquids, so drinking liquids will not make you feel full. You also should not drink liquids during or immediately after meals as they will flush food through the reduced stomach pouch, which means you will not get the prolonged feeling of satiety needed to help you eat less. However, staying hydrated and drinking lots of water throughout the day is important. You will also need to learn to eat slowly and chew your food very thoroughly.

It is recommended that you eat only three small meals a day and make sure that these meals contain adequate nutrients. You will need to make good food choices and learn to avoid problem foods, such as high-fiber, high-fat, and dry foods, since these are more difficult for the small stomach to digest. Good food choices include fruit and vegetables, lean protein, some bread and cereal, and some dairy products. Foods that have a concentrated supply of calories with little nutritional value, such as milkshakes, syrups, jam, and pastries, should be avoided as much as possible. (Courtesy of Inamed, makers of the LAP-BAND® System).

Exercise Recommendations Following Weight Loss Surgery

Before surgery, you will have a consultation with the Fitness Specialist to design a home or Wellness Center exercise program. This consultation will include a general fitness assessment and survey, measurements, and an exercise prescription.

Beginning an exercise program before the surgery has many important functions. First it helps to reduce your risks for any possible surgical complications. It helps to increase your heart and lung function, which may be stressed during the operation. It is also an important step in preparing your body and mind for the important lifestyle changes that you are about to make.

There are steps you can begin today to increase your daily activities. For example, parking further away from your destinations, vacuuming, mopping, shopping and performing other daily activities at a brisker pace. Try getting up to change channels on the TV, stations on the radio, etc... instead of using remote controls. Just remember, all of these "little" activities add up throughout the day.

When choosing activities for an exercise program, four things to keep in mind during your exercise sessions are frequency, intensity, time and type (FITT). These four principals apply to any cardiovascular exercise (walking, aerobics, jogging, biking, swimming, etc...)

• Frequency should be daily, possibly even twice a day until surgery.
• Intensity should be light without severe breathlessness. If you are unable to speak, you are exercising too hard.
• Time should begin with 5-10 minutes each day. After the first week of exercise, add 1 minute to the duration of time each day. The ultimate goal is to exercise at least 30 minutes each day.
• Type refers to the type of exercise performed. It may be best to start with water exercises or walking. Be sure that any type of exercise performed is low-impact (easier on the joints).

Strength Training

Another very important aspect of an exercise program involves strength training. Not only do the heart and lungs need to be "in shape," but so do the muscles of the body. A strength training program will also help prepare the body for the significant changes it is about to endure. During extreme weight loss, the body will actually use its own muscle mass as energy. Which means that you will not be losing fat; you will be losing muscle mass.

To avoid this situation, you MUST EXERCISE and participate in STRENGTH TRAINING. Strength training helps to improve muscle strength, bone density and strength, balance, coordination, and increases the metabolism by building muscle.

The following are guidelines for a regular strength training program.

• Two to three times per week. (Usually about 30 minutes)
• Eight to twelve repetitions per set (2-3 sets should be performed).
• Make sure that each major muscle group is worked (biceps, triceps, hamstrings, etc...).
• There should be at least one day's rest in between workouts.
• Muscles should feel slightly exhausted by the end of 2-3 sets.
• Never hold your breath while lifting weights.
• Keep all movements slow and controlled.

Warning Signs When Exercising:

As with any exercise program, it is important that you pay attention to how you feel while exercising. The following are signs and symptoms for stopping exercise:

• Chest discomfort or chest pain.
• Discomfort that spreads to your neck, arm, shoulders, jaw, or back
• Dizziness or light-headedness
• Nausea or vomiting
• Irregular, rapid, or skipped heart beats
• Shortness of breath
• Extreme fatigue or weakness
• Headache
• Sudden loss of balance
• Sudden increase in sweating
• Blurred vision
• Anything else that feels abnormal

Remember that when starting an exercise program, begin slowly and gradually increase your time. By taking this very important step of beginning an exercise program, you not only prepare your body for surgery, but you also prepare it for what will take place after the surgery.

After Weight Loss Surgery

After the weight loss surgery, you will meet with the Fitness Specialist again sometime between 6 and 10 weeks post surgery. This consultation will include taking additional measurements, an exercise prescription to include more resistance training, and to answer any of your questions regarding exercise. This will be a very important step in the lifestyle change process; YOU WILL NEED TO EXERCISE FOR THE REST OF YOUR LIFE.

Other Benefits of Exercise

Studies have shown that physical activity can double your benefits of bariatric surgery by helping you look and feel good while reducing risk of premature death. Patients that exercise have been shown to lose more weight and at a slightly faster pace than those patients that do not exercise.

Exercise Can	Exercise Can
Reduce: appetite blood pressure risks of heart disease stress risk colon and other cancers depression anxiety weight	Improve: muscle tone connective tissues balance independent living digestion self-esteem flexibility energy levels sleep over all quality of life

Behavior Modification

You will receive two pre-operative and one post-operative psychological consultation with our Program Psychotherapist.

The rationales for the pre-operative consultations are to evaluate your willingness to make permanent lifestyle changes and to assess your coping mechanisms and support systems. This is to provide the highest level of safety and best opportunity for success. During the second pre-operative consultation you will take a test that will test your knowledge of the procedure, necessary lifestyle changes, exercise information, and dietary information. All of this material will be presented to you in your consultations. Once you complete the test with a satisfactory score and have medical clearance, you will be scheduled for surgery.

The post-operative consultation will provide some guidance for you if you are experiencing any emotional troubles following the surgery.

All of the information obtained and discussed in the psychological consultations is strictly confidential and is not released to anyone without your written consent.