Good evening, the Association for Bariatric Endoscopy, a division of the American Society for Gastrointestinal Endopathy, welcomes you to this evening's presentation titled Nutrition in the Post-Procedural Population. My name is James Janssen and I will be the facilitator for this program. Please note that this presentation is being recorded and will be posted on GI LEAP, ASGE's online learning management platform. You will have ongoing access to the recording in GI LEAP as part of your registration. Following the presentation, there will be a question and answer session. Questions can be submitted at any time online by using the Q&A icon at the bottom of your screen. Please don't use the chat box for submitting questions. Our presenter for this program is Catherine E. Page, RD. Catherine is a registered dietician currently specializing in endoscopic bariatric nutrition. She also works with laparoscopic bariatric surgery patients and weight management patients at Brigham and Women's Hospital Center for Weight Management and Wellness. Besides working with bariatric patients, her background includes pediatric, geriatric, and oncology nutrition. Her previous position allowed her to become familiar with a wide range of patient nutritional interventions, including unplanned weight loss, dysphagia, enteral and parenteral nutrition, and nutrition-related comorbid conditions such as diabetes and cardiovascular disease. Catherine lives in Massachusetts with her husband and enjoys running, traveling, cooking, and sewing. Catherine, I now turn the presentation over to you. All right. Thank you, James. I'd also like to thank the Association for Bariatric Endoscopy and its parent organization, the American Society for Gastrointestinal Endoscopy, for providing this forum and inviting me to speak. So no known conflicts in relation to this presentation. The objectives for tonight's presentation are to understand the importance of patient pre-procedural nutritional assessment, learn about nutrition interventions and education of post-endoscopic bariatric patients, learn how to create nutritional education handouts for endoscopic bariatric patients, and understand the importance of having a dietician as a member of the care team. So the first thing I'd like to do is a quick review of the endoscopic bariatric procedures. These include suturing procedures on both primary and revision. Primary endoscopic bariatric procedures include the endoscopic sleeve gastrectomy, or ESG, the primary obesity surgery endoluminal, or the POSE. Endoscopic revisions for gastric bypass include the ROSE procedure, or repair of surgery endoluminal, the TOR procedure, or transaural outlet reduction endoscopic, as well as the APC, or argon plasma coagulation procedure. Revision procedures for gastric sleeve include the sleeve-in-sleeve procedure. Other bariatric endoscopic procedures include the intragastric balloon and the Aspire assist device. I do want to note that the Aspire assist device is no longer being used or provided, but there may still be patients that are getting support, have had the Aspire assist device placed, and need support from bariatric programs. So the first thing that you want to do when you have a patient considering working towards an endoscopic bariatric procedure is a full evaluation. So it should include anthropomorphic measurements, such as height and weight. It should include a full medical history, including ortho-morbidities, as well as medications, especially those that can cause weight gain or weight loss. The pre-procedure evaluation should include a full lab work, especially to assess deficiencies. This is especially important for revision patients, gastric bypass patients especially, whom are at greater risk for deficiencies. So lab work should include a CBC to assess for hemoglobin and hematocrit, a comprehensive metabolic panel, which should look at blood glucose and blood calcium, endocrine evaluation, which should check A1C, insulin, TSH, or thyroid stimulating hormone, PTH, parathyroid hormone levels, PTINR to assess for coagulation, as well as a full vitamin and mineral panel, including vitamins A, B, B1, B12, folic acid, and an iron, iron binding, and ferritin evaluation. And as if needed, a copper and zinc evaluation. Both the ASMBS and the British Obesity and Metabolic Surgery Society guidelines both strongly encourage a full lab panel on any patient being assessed for bariatric surgery. And as many of our patients are revision patients, I do recommend a full lab panel, including vitamins and minerals. And then the ASMBS, as well as research, shows that a full nutrition assessment should be done on a patient. This should include diet assessment, including a 24-hour recall for food frequency. Common eating patterns should be evaluated, looking at skipping meals, larger portions, higher calorie fluids. An eating disorder assessment should be done to assess for food avoidance, bulimia, purging, lack of use, or a binge eating disorder. While the ASMBS in their guidelines says that an eating disorder is not necessarily contraindicated unless it's a case of untreated bulimia nervosa. So if a patient is being treated for an eating disorder, they would still be able to have a bariatric. And then you do want to assess for eating tendencies, stress eating, boredom eating, emotional eating. Sheriff Dagan did a review of literature, and one thing that they did note in their study was that patients who do have tendencies towards emotional eating or stress eating do have a higher likelihood of going back to those behaviors after their procedure. You do want to assess for those. So part of the program, part of the diet progression should include a pre-procedured diet. Patini et al. did a study to look at dietary approaches before and after bariatric procedures or bariatric surgeries. And what they did find was that patients who follow a pre-op diet are more likely to be compliant in terms of dietary requirements after their procedure. What they did also note was that pre-surgery weight loss was not necessarily a strong indicator of post-procedure weight loss. So in our pre-procedure diet, we have it start two weeks before the procedure. We have patients start on a 1,200 calorie diet. We provide them with a meal plan to follow, which discusses portions, protein choices, fruits and vegetables, starches, as well as discussing mindful eating techniques, such as eating slowly, taking small bites, separating solid foods and liquids. It may result in a small weight loss, 5%, 10% for the procedure, but it's not necessary. It's more about getting patients to start thinking about their approach to food and diet. The two-week point is also when you want to start discussing with patients any medication adjustments. Diabetic medications, patients should be discussing with their endocrinologist because they may need to be adjusted with the lower calorie intake and when they should, patients should be notified of when they need to stop any anti-coagulation medications. I also discuss with patients that they will need to change their medications from a swallowable version to a crushable or chewable form. So I do recommend a discussion with their pharmacist on what medications can be crushed and what can't, and getting in touch with the prescribing provider to have any medications adjusted. The second week of the pre-procedure diet should transition patients from a high-fiber diet with lots of fruits and vegetables to a low-fiber diet starting five to seven days before the procedure. As a unit, you want to discuss how low a fiber diet you want your patients following. The Academy of Nutrition and Dietetics in their nutrition care manual has two different types of low-fiber diets. They have what they call a fiber-restricted diet, which is a 13-gram-per-day diet. This is typically for individuals who have a history of Crohn's disease, IBS, and they have an excellent handout in the nutrition care manual specifically designed for patients to put them on a fiber-restricted diet. Below that is what's known as a very low-fiber diet. That's an eight-gram-per-day low-fiber diet. This is typically provided for individuals who are having gastroparesis or diverticulitis flare-up or a Crohn's flare-up or IBS flare-up. So again, the nutrition care manual does provide a really great handout for patients. For our patients, we have them follow a very low-fiber, almost no-fiber diet for those five days before their procedure. We actually have them start their protein shakes five days before to start everything getting cleaned out of their system. You also want to address in this second week stopping iron and any vitamins that have iron before then. And then I do discuss with my patients their day before PrEP day. I always tell my patients, if you've ever had a colonoscopy, the day before PrEP is similar to that. And I tell them, for those who have not had a colonoscopy, you're in for a real treat. So I do address the clear liquid diet the day before, low-calorie beverages like Gatorade Zero, Propel Zero, avoiding red food coloring, and then bowel PrEP that will be necessary for the day before. And I talk about day of procedure and the dietary expectations, nothing to eat that day, water up to four hours before their procedure. And then we as a unit, as a center, we follow the enhanced recovery after surgery or ERAS protocols. Specifically for the endoscopic side, we call them the ERASE protocols. That second E stands for endoscopic. For those who don't follow the ERAS protocols, it's a perioperative program designed to help with early recovery after procedures and surgeries. And so it's designed to help maintain blood sugar levels, blood pressure levels. There are stages that deal with pain management, post-operative nausea and vomiting. And then there is a nutrition component where patients intake 10 to 12 ounces of a high carbohydrate fluid three hours before their procedure. For those having a revision, especially a gastric bypass patient, you want to be aware they are going to be at a greater risk of dumping syndrome. So they do need to be assessed for that. They may need a different liquid rather than a high carbohydrate fluid to decrease the risk. For our patients who are at greater risk of dumping syndrome, we will do a sugar-free Gatorade or Powerade recommendation so that they're still getting the electrolytes without the high carbohydrate amount. And then I do discuss fluids after procedure recommendations and the best way to get them, whether they're recovering in the hospital or recovering at home. So I run a pre-procedure introduction nutrition class for patients, and this covers as everything in terms of getting patients prepped for their procedure. So I cover the pre-op diet, the prep day, the day of procedure. The day of procedure. I discuss the post-procedure dietary stages that patients are going to go through. I cover their nutritional and fluid requirements after their procedure. So expectations for their calories, their protein, their fluids, their vitamins. I talk about fresh medications and what they need to be aware of, as well as chewable vitamin requirements. I discuss post-procedure meetings and appointments. And then this is where I provide their pre-procedure handouts, the nutrition guidelines, and other resources. Part of my nutrition introduction nutrition class, I do include a very general description of the procedures. So as a unit, I do recommend discussing where you want to have this in terms of pre-procedures information for patients. If you want to have it as part of an introduction nutrition class, I recommend keeping it very general. If you're going to have it as something that a provider is providing, they can get it a little bit more detailed. I started with a disclaimer of if you have questions about the procedure that you're having, the technique, the timing of it, anything like that, I do recommend handing those questions off to your gastroenterologist. They're better trained to answer those questions. And I will admit, I keep it so general that I will tell people there's a grasping tool and a stitching tool. They have actual medical terms. I don't know what they are. I don't know if I could pronounce them if I did know what they were. So I call them the grasping tool and the stitching tool. And I keep it a very basic explanation so that patients know the terminology when they hear it following their procedure. Ideally, this introduction nutrition class should happen at least two weeks prior to the procedure to give patients a chance to read through their handouts, purchase what they need to purchase for after their procedure. So one of the biggest handouts that we provide patients is their nutrition guidelines handout. I call it the great big book of everything. Because it does cover a lot of information from their pre-procedure all the way out. So there's a section on getting ready for their procedure, meaning what tools they're going to need, measuring cups, measuring spoons, protein shakes, vitamins, a food scale, a body weight scale. A section in it should cover day before prep. So what medications they need to pick up, what guidance they need to follow. Each dietary section should be described from procedure day all the way out until patients are on regular food. So it should include both the duration and goals of each stage. I frequently have patients where they will tell me, you know, how long do I have to be on this stage? And they'll circle those dates on the calendar so they know exactly what dates their diet is getting advanced. So you want to have that information available to them, as well as fluid goals, protein goals, calorie goals. You want to make sure it includes examples of food labels so patients know where to find information on the actual product. Examples of fluids that we recommend. Meal plans for each dietary stage. They can be very simple, but they're very helpful. We include a section on problems and solutions. If you're having stomach pain, if you're having nausea, if you're having diarrhea, here are some things you can try. We do want to include contact information. So with a disclaimer saying, if you have tried these and it's not working, do reach out to your physician, your physician's assistants, and let them know that you're having issues. We include a section on skills for success. These include things like mindful eating, being in touch with your team, keeping up on your appointments. The section, the nutrition guidelines also includes a section on tracking intake and exercise. So this can be part of your whole nutrition guideline packet or it can be done as a separate handout if it's something you want to give to them later on once a patient's progressed. So one of the big things is deciding on what you want your protein shakes, what your recommendations are for your protein shakes. For us, our recommendations are 150 to 200 calories per serving of a protein shake. They should have at least 15 grams of protein per serving. And I do tell patients they can have more, but they should have at least 15 grams per serving, less than 10 grams of sugar per serving, and up to five grams of fiber per serving. And you do want to talk about having a variety of choices of protein shakes and drinks, because they do vary in terms of type. There's milky ones, there's soups, as well as clear protein drinks and protein water. And so one of the handouts that I provide, free procedure, is a protein shake handout. And it's just a long list of protein shakes. When you create yours, it should include the name of the protein shake, a picture of it. For low literacy patients, where or how to purchase it. So store names or online links, the cost of the protein shake, as well as the calorie and protein content. I do recommend including the protein shake requirements. So having these requirements at the top of the page, because patients do tell me they bring these handouts with them when they go shopping. So if they're looking at a protein shake that's not on the list, having those requirements available so they can compare it to the label is very handy. The list should include both pre-made shakes and protein powders. There is a difference between them. Some patients prefer one over the other. You do want to let them know that there's options. It should include lactose-free options, as well as clear protein drinks and super broth type protein shakes. We offer a separate list of plant-based and non-dairy-based protein shakes, as well for patients who are vegan or vegetarian or have a significant lactose intolerance or dairy sensitivity. So we do offer that. You can include it as one whole protein shake handout, but depending on how many protein shakes you're offering, and again, I do encourage a good variety. It can be overwhelming to have both non-dairy and dairy-based shakes in your handout. And then vitamins are a requirement, and you do want to emphasize to your patients that this is a forever thing. As a bariatric patient, especially for gastric bypass patients who are at higher risk of developing deficiencies, you want to make sure that they're taking vitamins that are complete and that meet the ASMDS guidelines. And this list here shows what all the ASMDS guidelines are for all the basic vitamins, as well as the minerals. Calcium ASMDS guidelines are 1,200 to 2,400 milligrams, depending on if a patient has had a gastric bypass or specific type of bariatric surgery. The calcium recommendations change. Calcium, even for bariatric vitamins, is not going to be included in a complete vitamin. The higher dose of calcium is going to affect the absorption of iron. So patients typically need calcium as a supplement. I do let patients know their calcium can come in both from a supplement and from their protein shakes or their food. So if their protein shakes are providing 300 milligrams of calcium each and they're drinking four per day, theirs are 1,200 milligrams. Once they transition, if they're not taking in calcium-rich food, they will need to adjust their calcium supplement up. If they are, they can adjust it down. And then you want to make sure that your patients are taking a complete vitamin. So typically, we rule out gummy vitamins because they don't tend to contain most of the minerals, zinc, copper, selenium, and magnesium that are necessary for bariatric surgery. So another handout that should be provided to patients is a vitamin handout. And just like protein shakes, this should be just a complete list of vitamins. You want to create both a chewable vitamin list and a non-chewable vitamin list. They should include, again, the name of the vitamin, a picture, where and how to purchase, the cost, and the daily dosage of the vitamins. And this is important because it helps patients make an educated decision. If you have a patient that's on a lot of medication, they may be willing to pay more for a vitamin if it means they only have to take one dosage per day. Whereas if some patients feel that they don't want to pay the extra cost, they're willing to purchase a less expensive vitamin even if it means taking multiple doses during the day. You also want to include some bariatric multivitamin choices and some non-bariatric multivitamin choices. What we do in our vitamin handout is we provide a ranking of bold and silver. So for example, bold ranked bariatric vitamins typically require only one dosage per day. They're well tolerated, prices are reasonable. Whereas the bronze ones, it may either require more than one dosage or it may be a non-bariatric vitamin that will need additional supplements. So you also want to include any discrepancies between what the vitamin provides and what your patients need. For example, if the vitamin doesn't provide enough B12, patients are going to need to know that they will need to take a separate B12. So you want to have examples or lists of those vitamins as well. And then your vitamin handout can include calcium choices. And again, name, picture, where or how to purchase, the cost of the calcium vitamins and daily dosage. So in terms of dietary stages for an endoscopic bariatric patient, they include the clear liquid stage, which is 24 hours post procedure. Then the liquid stage, soft solid stage, and regular texture stage. The liquid stage, again, as a unit, you want to decide how long your patients are able to live. So you want to make sure that they are on this stage. We, as a unit, have decided we have our patients on their protein shake or liquid stage for six weeks. We want to ensure that everything is fully healed before we advance their diet. I did look up some of the information from the original MERIT study, the endoscopic sleeve gastroplasty study that was done. And as part of that study, patients were on a four-week liquid diet. So when we discuss the liquid diet, we progressively bring in liquids over the course of those six weeks. So for the first two weeks, patients start with protein shakes, protein soups, clear fluids, Crystal Light, Powerade Zero, Gatorade Zero, things like that. At their two-week mark, they can introduce other fluids like milk, non-dairy milk, which they may already be using to mix protein powder with, thin tomato soup, vegetable juice. At four weeks, they can continue the protein shakes, milk, non-dairy milk, and we've introduced Pureade broth-based soup to our suturing patients, ESG, O's, Rho's, et cetera patients. So this is Pureade Chicken Noodle Soup, Pureade Beef Farley Soup, Butternut Squash Soup. We allow them to bring it in at four weeks. At four weeks is when intragastric balloon patients advance to soft solids. And then at six weeks, we advance our suturing patients to their soft solid stage. And then the soft solid stage is a two-week stage so we talk about soft proteins. They can have proteins up to three ounces, which I do emphasize to patients is the size of a deck of cards or an average woman's hand. The proteins should be minced consistency to small dime-sized bites. So these can be things like shredded meats, shredded chicken leg, chicken thigh, canned chicken, canned tuna, flaky fish, so baked salmon, baked cod, baked tilapia, mashed or pureed beans or lentils, things like refried beans would come in at this stage, emphasizing that they should be soft and moist. So patients may need to add broth to them or water or a small amount of fat to get them moist and make them easy to digest. And then discussing non-protein foods. So this would be things like cooked vegetables that are soft enough to be mashed with a fork, canned or frozen fruits, soft, unsweetened cereals. So it could be hot cereals like oatmeal or it could be something like plain Cheerios or plain cornflakes that have been allowed to go soft in milk. And then again, emphasizing the importance of fluids in between their meals. And then from there, we have, after two weeks, we have patients start to bring in regular texture foods. Calories should be based on exercise and continued weight loss. So minimally, we typically start patients at 900 to 1200 calories per day, but they may need to be adjusted. So for example, a person who's five foot one, who's doing low intensity exercise would do great with a thousand calories, 900 calories, something like that, versus someone who's six foot one who might be doing high intensity exercise, their calorie requirements are gonna be more in order to keep up their metabolism and keep up their weight loss. So you do wanna adjust calories when they get to the regular texture stage individually. And then meal planning at this stage becomes really important, talking about the maximum servings per day of fruit, vegetables, proteins, starches, servings of fats, and their fluid requirement in the regular texture stage. And I always emphasize to patients that this is entered slowly. Take your time with entering it and bringing in and introducing new foods. There's no reason to rush into the regular texture stage. And then always encourage mindful eating techniques. No matter where patients are post procedure, mindful eating techniques become really important. So they should be emphasizing to take 30 minutes to eat a meal or drink a protein shake. They should be taking small sips, small bites. And a few things that I recommend is if they're in the liquid stage, the medicine cups that come with cough syrup are a great thing. These are a one ounce measuring cup and everybody has them in their house. So I tell people, pull one of these out of your medicine cabinet, use these to measure out the protein shake and use it as a way to slow down how quickly you're drinking your protein shake over 30 minutes. In terms of food, I tell patients cut up your food before you take that first bite. So that way you know you're cutting it up into dime sized pieces. Practice putting your utensils down in between bites so that you're pacing yourself out. And then waiting 30 minutes between eating and drinking. So if I have a patient that I'm taught, when I assess them and they're saying they're having a lot of nausea, they're having stomach pain, one of my first questions is how long are you taking to eat or drink? How long are you pacing out between your meal and your next meal, or when you start going between your meal and your fluid intake? And reminding them that it's really important to take it. So for ourselves, our dietician post-procedure follow-up visits are at two weeks. The two week visit is a group visit. From my point of view, it's an assessment visit. So I do assess each patient in the group. I ask about their protein shakes, how well they're tolerating them, how much hydration they're getting. I ask about vitamin and medication compliance. If they're having GI issues, constipation, nausea, anything like that, I get an updated weight. As part of the group visit, I cover common problems that they may be experiencing and solutions. So I talk about constipation, I talk about weight loss stalls. I also talk about what new liquids they can introduce at this stage, as well as at their full week mark. From my patient point of view, I call this visit the misery loves company visit because it forms a nice little support group. What I tell patients is through this journey, this is one of those visits where everyone in this group has had their procedure around the same day, if not the same day. So everybody's in exactly the same spot at exactly the same time. So they're all going through the same types of things. They're getting bored with drinking protein shakes. They may be dealing with the same GI issues. Some of them may have found solutions. And so it's a chance for them to share with people that know exactly where they're coming from. And also hear solutions that have worked for their peers in terms of helping with things like boredom, pain, things like that. So it's a nice support group that also allows patients to get to know each other. Two-week post-procedure handouts. I send them a list of new liquids that can be introduced. That list should include examples of them. I do send out a whole list of all different types of non-dairy milks, how much proteins in them, how much calories, what their sugar content is. I include skim milk in that as well. I include portions in it. I also send out a list of recipes. We had an intern as one of their projects. They created a protein shake recipe booklet and they took protein powders, protein shakes, protein soups, and created recipes with them as a base. And so I provide that to my patients at their two-week post-procedure visit to, again, give them some variety over the six weeks that they're on liquids. And then after that, their next visit should be the diet transition visit. For our patients, that's at six weeks. And for us, we do it again as a group visit. So I do an assessment on each patient. So again, I ask about protein shakes, if they're still drinking them, what they're getting into hydration. I ask if they've started to introduce soft, solid foods. If so, what and how well they're tolerating. Because I want to be aware if they've started introducing solid foods and they're having some issues, that's something I want to keep track of. I ask about the vitamins, medication compliance, GI issues at the six-week visit, and I take an updated weight. Then I talk about introducing soft proteins and non-protein foods, the importance of protein shakes, non-protein foods, the importance of their fluid intake. I discuss the importance of mindful eating and things to be aware of, as well as a brief discussion on transitioning them back to normal texture. Six-week post-procedure handouts. Again, they should include a list of soft proteins and soft non-proteins with examples and portions. So for example, cottage cheese, three ounces. Pureed or refried beans, half a cup. Baked salmon, three ounces. I provide my patients with sample menus and meal plans to follow. I do find for those first few weeks when they transition, a lot of patients find it handy to have some basic menus to follow until they start getting more comfortable with meal plans. And then I provide a list of non-chewable vitamins for patients to transition from their chewable vitamins. As long as their nutrients are being met with the chewable vitamins, that's fine if they want to stay on them. But I do have plenty of patients that don't care for the flavor of chewable vitamins. And so they're quite happy to transition to non-chewable vitamins. And then after that, patients meet with me every three months through their first year. And these are one-on-one visits. So as part of it, I collect food history or food recall. We set individual goals. If patients are having issues, pain, nausea, things like that, I will send a message to the medical team to alert them that this is going on. If they're starting to have ravings or hunger at any of these post-procedure visits, again, I will send a message to the team to alert them that it may be time to have a discussion about weight management medication with patients depending on the level of their hunger. But we also talk about calorie intake. We talk about fiber intake and making sure that they're bringing in fruits and vegetables to help themselves feel full, making sure that they're getting in their protein, again, to feel full and meet their needs, as well as their fluids to make sure that they're not getting dehydrated. And we set goals for exercise as well. So if your unit, if your organization doesn't have a dietician as a team member, it is one thing that I do recommend you consider, partly because I'm a dietician and it is very near and dear to my heart, but also to take the pressure off of you as a provider. We are the specialists in the field of nutrition. So we can answer the questions about foods, about textures, things like that. And there are studies out there. Mitchell did a study on the effectiveness of dietary consultations on a weight management program and found that patients that were followed by a dietician did better in terms of both their compliance to the diet and in terms of the weight loss. And then Belagoli also did a, they did a web-based weight loss program, part of which patients just had the web-based interaction. And part of it, patients also worked with a dietician online coaching them. And their study did show that patients who had the dietician online coaching did better, not just with the compliance, but they also did better with their weight loss overall. So if you are trying to convince your human resource person, your chief financial officer, the need for a dietician as part of your team member, there's these two research studies here. There are others as well. I know dieticians that I work with are more than willing to supply research studies to help you have fuel for that argument to hire a dietician as a team member. Couple of things I do suggest in terms of a skillset that a dietician should have. You do want a dietician with some counseling in weight management and bariatric experience. They should be comfortable presenting to groups. And you do want to decide if you want your dietician to be seeing both endoscopic, bariatric and non-bariatric patients. They should be comfortable seeing both types of patients. I myself do see both bariatric patients and non-bariatric patients. So I do see home patients, TIF patients, Zenker's patients. So I do work with them primarily. I see bariatric patients and they are very similar in terms of their diets and diet pressures. But you do want to have someone that's comfortable working with. So I do thank you all for participating and attending in this. We'll open it up for questions. One thing I am going to do, if we don't have time to answer everybody's questions, I will put my email in the chat so that if you have a question that doesn't get answered, feel free to email me. I am going to stop my share so that James can take over. Thank you, Catherine, for that very insightful and informative presentation. At this time, Catherine will address questions received from the audience. As a reminder, you can submit questions through the Q&A icon at the bottom of your screen. So, Catherine, our first question here is, how do you get patients to be compliant with the six weeks post-op fluids requirements? That's a really good question. I have actually had patients where they will tell me they don't feel they can do, they can have the endoscopic bariatric procedures simply because they don't feel they could maintain the six weeks of liquids. Big thing is managing expectations. I let patients know across the board right away, they will be on, and so does the entire team. The expectation is that they will be following a liquid diet for six weeks. What I do tell patients is you have the support you need, and that's really important. I tell my patients, here's contact information for everybody, here's my contact information. You will see me at two weeks, but if you're struggling, let me know. If you feel like you're on that edge and you're about to jump off, let me know. I will talk you down from the edge. So, managing expectations and letting patients know that that is the expectation of six weeks, letting them know why that they need the six weeks for the healing to be complete, and then letting them know that they are supported through that six weeks really helps to improve compliance. Okay, another question. Do you recommend patients to start their vitamins before their procedure? It depends on if they're having deficiencies. So, for revision patients, gastric bypass patients, sleep patients, they should be on a vitamin already. And when I do my assessment with them, that is one thing I ask them. If they're having a deficiency, then yes, I do recommend that they get started on a vitamin and they may need an additional dosage depending on what the deficiency is. So, it does depend on the patient. Primary endoscopic patients don't typically need to start beforehand again unless they have a deficiency. Okay, and another question we have here. What are your exercise requirements post-procedures? So, I always tell patients start low and slow, 15 to 20 minutes of cardio exercise, walking to start with, if someone hasn't done any exercise prior. If they've been exercising and they're comfortable with a more high intensity exercise, a Zumba class, a spin class, something like that, and they've worked up to that, then absolutely fine. We do, and I hate to use the word discourage, but we don't necessarily encourage patients when they're on the liquid stage to be doing high intensity exercise because they're going to burn through all their calories and that's going to slow down their weight loss. So, I do tell people, if you want to take a leisurely walk when you're on the liquid stage, that's fine, but we don't expect high intensity exercise for the six weeks around liquid. Once they've transitioned to regular food, then minimum 15 to 30 minutes three times per week to start if they've never exercised, and at least once a week of some amount of strength training as well. Thank you. Just to remind the participants, we do have some, still have some time for more questions. So, please use the Q&A box at the icon at the bottom of your screen to put those in. I have one more here for you, Catherine. Do you provide introduction group classes for all of the endoscopic bariatric procedures? No, I do not. The majority of the patients that I see are suturing patients, ESG, POSE, ROSE, or APC. So, because we have so many of those patients, I do the introductory nutrition group classes. The intragastric balloon patients, we have so few. I typically do a one-on-one intro with them to cover everything that they need. And same thing with the Aspire devices. When they were still being placed, I would do it as a one-on-one. Same thing with non-bariatric procedures. I see so few of those. I typically do them as a one-on-one introduction nutrition session. Great, thank you. Well, I have no more questions. So, this will conclude our presentation. We hope this information is useful to you in your practice. Also, we want to hear from you. Following this webinar, you will receive an email with a link to a survey for feedback about this webinar. We appreciate your participation in this survey. As a reminder, you can access a recording of this webinar by logging onto GILeap by going to learn.asge.org. That's L-E-A-R-N.A-S-G-E.O-R-G. Thank you again for your participation and have a good night. Thank you.

Nutrition in the Post-Procedural Population

Catherine E. Page

endoscopic bariatric nutrition

pre-procedural nutritional assessment

dietary stages

post-procedure patients

compliance

care team

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