Egészségügy | Dietetika, táplálkozástudomány » Ruth M. Christner - Early Healthy Eating Education For Bariatric Surgery Patients

Early Healthy Eating Education For Bariatric Surgery Patients Ruth M Christner NED 690 Thesis Seminar in Nutrition Education Immaculata University Spring 2015 i Table of Contents Page Abstract.ii List of Tables.iii List of Figures.iv Chapter 1: Problem, Purpose, Hypothesis - Introduction.1-3 Chapter 2: Review of Literature.4-17 Chapter 3: Methods.18-23 Chapter 4: Results.24-26 Chapter 5: Discussion.27-31 References32-35 Appendices.36-66 a. Recruitment flyer37 b. Recruitment phone call script38 c. Pre-Test40-41 d. Post-Test43-44 e. Lesson Plan46-47 f. Ethics training certificate – Ruth Christner49-50 g. Ethics training certificate – Steven Clarke52-53 h. Ethics training certificate – Rosenie Balde55-56 i. Letter of Authorization, Temple Bariatric Surgery Program Director58 j. Letter of Approval, Immaculata University Educational Review Board60 k. Approval Document, Temple University Hospital Institutional Review Board62 l. Letter from Temple University Institutional Review

Board64 m. Consent Document66 ii Abstract Background: Weight loss success after Bariatric surgery is significantly dependent on development and maintenance of healthy eating behaviors. Many Bariatric surgery programs include demonstration of preoperative weight loss as evidence of lifestyle change into practice protocols. Nutrition education by a Registered Dietitian has been shown to increase success with preoperative weight loss and postoperative weight loss and maintenance. Objectives: Develop, implement, and determine the effectiveness of an interactive lesson on healthy eating habits for weight loss, delivered early in the preoperative period to patients of Temple Bariatric Surgery Program, located in Philadelphia, Pennsylvania. Methods/Procedure: During two Dietitian-led presentations, bariatric patients learned how to monitor calories, choose proper portion sizes, read food labels, and select healthy meals. Pre and post-tests assessed both knowledge gained during the

presentation and change in self-efficacy. Results/Conclusions: Comparison of pre and post-test results indicated that patients’ knowledge of healthy eating concepts improved, and degree of confidence to lose weight increased. Interpretation of data was limited by small sample size, as only two patients attended the optional educational presentations. In order to optimally evaluate the effectiveness of this presentation, a larger sample size would be ideal. Further research is needed to explore the effectiveness of group healthy eating classes on preoperative weight loss as well as postoperative weight loss and maintenance. iii List of Tables Page Table 1: Morbidity outcomes 1 year after Bariatric surgery5 Table 2: Individual and mean pre and post-test score, and percent improvement.24 Table 3: Individual and mean pre and post-test confidence scores, and percent improvement.26 iv List of Figures Page Figure 1: Correct answers – Results by question.25 1 Chapter 1

Problem, Purpose and Hypothesis Introduction Statement of the Research Problem Bariatric Surgery has been shown to be an effective long term solution for patients needing significant weight loss. Weight loss surgery is, however, only a tool: in order for the patient to be successful losing weight and keeping it off, they need to adopt a healthy eating pattern. A return to preoperative unhealthy eating contributes to weight regain after weight loss surgery. To achieve weight loss and maintenance, nutrition and meal planning guidance should be provided to patients both before and after surgery (Mechanick, et al. 2009) Surgical programs often recommend or even require preoperative weight loss as evidence of a patient’s ability to adopt a healthy eating pattern in order to be considered an acceptable candidate for surgery. Many insurance companies dictate that patients participate in a six month, medically supervised weight loss program in order to qualify for surgery. However, insurance

companies do not specify the need for weight loss, or even for evidence of a change in knowledge or behavior. Weight loss is difficult without meaningful behavioral change, based on knowledge of behavioral practices that the patient perceives he or she can reasonably and realistically adapt into his or her life. A recent systematic review of 29 studies examined the relationship between preoperative weight loss and post-operative weight loss outcome. Authors reported an overall inconsistency with regard to success of mandatory preoperative weight loss in the clinic setting, attributing this to inconsistencies among clinic protocol. They observed that nutritional counseling and a clear weight loss prescription tended to influence preoperative weight loss success. They also 2 concluded that although studies were limited and inconsistent, a majority indicated that preoperative weight loss may lead to greater postoperative weight loss success as well as reduction in surgical

complications (Ochner, Dambkowski, Yeomans, Teixeira & Pi-Sunyer, 2012). Temple Bariatric Surgery Program serves patients in the Philadelphia, Pennsylvania area, at both Temple University Hospital and Jeanes Hospital. The adult obesity rate (Body Mass Index, a measure of the ratio of weight to height, >30) in Philadelphia in 2012 was 29% (Breneman & Beaulieu, 2014) and in 2013 an estimated 68% of adults in Philadelphia were considered overweight or obese (BMI <25) (Centers for Disease Control and Prevention (CDC), 2013). At Temple Bariatric Surgery Program, patients are introduced to the practice at a Seminar, designed to introduce basic surgical procedures and outcomes. Their next step is a clinic appointment with both the Surgeon and the practice Dietitian. The Dietitian currently conducts a Nutritional Assessment and works with the patient to design a goal-oriented weight loss plan based on individual needs. The Dietitian works with the patient during monthly visits to

assess accomplishment of these weight loss goals, and fine tune the healthy eating plan as needed. During the initial assessment it is often discovered that the patient has limited knowledge of basic nutrition concepts and healthy food preparation skills, as well as ingrained unhealthy eating patterns. Access to healthy foods or food preparation methods is also limited An estimated 30% of Philadelphia adults consume less than or equal to one serving of fruits or vegetables each day (CDC, 2013). Group education has long been shown to be an effective method of promoting lifestyle change. A recent prospective randomized-controlled trial demonstrated the benefit of group healthy eating classes on postoperative weight loss after Gastric Bypass surgery (Nijamkin, Campa, Sosa, Baum, Himburg & Johnson, 2012). Temple Bariatric Surgery Program does not currently utilize this strategy. For this study, a lesson plan 3 was created focusing on teaching patients how to select and prepare a

healthy diet designed to induce weight loss, both before and after surgery. Tools were given to the patient, including strategies for obtaining healthier foods and instruction on how to prepare them. This study asked the question: Can an interactive lesson on healthy eating habits for weight loss, given early in the preoperative process, improve knowledge of how to plan a healthy meal designed to induce weight loss? Purpose of the Study The purpose of this study was to develop, implement, and evaluate an interactive lesson for patients in the Temple Bariatric Surgery Program on healthy eating habits for weight loss, intended to increase their ability to plan and fix healthy meals both before and after surgery with the ultimate goal of weight loss and maintenance. Hypothesis After participating in an interactive lesson on healthy eating habits for weight loss, patients of Temple Bariatric Surgery Program were expected to demonstrate increased knowledge of how to plan and fix healthy

meals, designed with weight loss in mind, as measured by a change in their scores on a pre and post-test. Patients were also expected to demonstrate an increased confidence in their ability to plan and fix healthy meals, designed with weight loss in mind, as indicated by an increase in confidence score. 4 Chapter 2 Review of Literature Prevalence and Impact of Obesity Rates of obesity in the United States continue to increase. More than one third of adults in 2009-2010 were considered obese, as defined by body mass index (BMI), a measure of the ratio of weight to height, ≥ 30 kg/m² (Mechanick et al., 2013) Twenty nine percent of adult Philadelphians were considered obese in 2012 (Breneman & Beaulieu, 2014). Obesity has been recognized as a medical disease state, increasing risk for overall morbidity and mortality. Obesity has been shown to directly increase risk of insulin resistance, metabolic syndrome, type two diabetes, stroke, dyslipidemia, hypertension, coronary artery

disease, cancer, chronic kidney disease, osteoarthritis, sleep apnea, nonalcoholic fatty liver, cholelithiasis, arthritis, and infertility. These are costly diseases to manage An estimated total of 180 billion dollars was spent each year in the United States over the last decade on medical costs attributable to obesity. BMI has been shown to correlate positively with mortality, and negatively with quality of life (Wimalawansa, 2013). Obesity Surgery Severely obese individuals are able to successfully lose 5-10% of body weight through behavioral changes or pharmacologic treatments, but bariatric surgery has been shown to be the most successful sustainable treatment for obesity. Bariatric surgery has been shown to resolve or diminish obesity-related comorbidities such as diabetes and cardiovascular disease, leading to the recent designation of bariatric surgery as “metabolic surgery”. Individuals undergoing Roux-enY gastric bypass (RYGB) are estimated to have a seven year increase in

life expectancy, based on improvements in comorbidities. Longitudinal data summarizing the impact of bariatric 5 surgery on improvement or remission of comorbidities collected from 28,616 patients at 109 hospitals is summarized in Table 1 (Cummings & Isom, 2015). The two most commonly performed bariatric surgeries at Temple Bariatric Surgery Program are Roux-en-Y gastric bypass (RYGB), and Sleeve Gastrectomy. In RYGB a small gastric pouch is created, and a new anastomosis joins this small pouch with the intestine at the level of the proximal jejunum. In Sleeve Gastrectomy (SG) the greater fundus of the stomach is excised, leaving a sleeve-shaped, smaller stomach. Both procedures restrict the amount of food that can be ingested at one time, and both have been implicated in manipulation of gut hormones in a way that diminishes hunger. RYGB further decreases the caloric impact of food, as ingested nutrients bypasses a majority of the intestine, where they are normally absorbed

(Cummings & Isom, 2015; Mechanick et al., 2013) Table 1 Morbidity outcomes 1 year after Bariatric surgery % Patients Achieving Remission or Significant Improvement Comorbidity RYGB SG Type 2 diabetes 83 55 Hypertension 79 68 Hyperlipidemia 66 35 Sleep apnea 66 62 Gastroesophageal reflux 70 55 Adapted from Cummings & Isom, Pocket Guide to Bariatric Surgery: second edition, 2015 6 Success of Weight Loss and Maintenance after Bariatric Surgery It has been well documented that patients often struggle to maintain long term weight loss after surgery, as patients may fail to comply with healthy eating habits. Weight loss after bariatric surgery can be measured as a percentage of the patient’s initial body weight. In a systematic review of studies, it was found that weight loss at two to three years after bariatric surgery varies from a mean of 20-35% of initial weight. Mean weight loss at ten years post-op is approximately 16% of initial weight, representing

a mean weight regain of 7% (Jensen et al., 2014). Weight loss success after bariatric surgery can more accurately be measured by percentage loss of excess weight loss (initial weight – ideal weight) (EWL) (Livhits et al., 2010) Loss of ≥ 50% EWL is considered by some as weight loss success, and loss of < 50% EWL is considered weight loss failure. An estimated 20% of patients fail to achieve this goal In their retrospective study of 148 patients one year after RYGB, Livhits at al. (2010) found that 53% of patients lost ≥ 50% EWL and 47% of patients lost < 50% EWL. The Eating Inventory was used to assess eating habits. They found significantly favorable disinhibition scores on The Eating Inventory among “weight loss success” patients, when compared to “weight loss failure” patients, indicating that a change in eating behavior enhanced overall weight loss. The behaviors that most strongly predicted success were keeping follow up appointments, attending support group

meetings, and participating in physical activity. They concluded that these behaviors should be encouraged before surgery, in order to enhance postoperative weight loss and maintenance (Livhits, 2010). Since successful weight loss and maintenance are the ultimate goals of bariatric surgery, it is imperative to examine and implement clinic protocols designed to enhance these aims. 7 Obstacles to Healthy Eating Adopting healthy eating habits conducive to weight loss and maintenance is a challenge for patients, both before and after bariatric surgery. Excessive caloric intake can be influenced by many factors, such as food addiction, maladaptive eating patterns, and food culture. Lowincome, urban patients face the additional challenges of lack of nutrition knowledge and physical or financial difficulty accessing healthy food. In a recent examination of fruit and vegetable and fast food consumption by low income African Americans, culture, personal upbringing, and environmental and

economic factors were shown to strongly influence food choice. The plethora of fast food establishments and paucity of fresh produce in urban environments has resulted in diminished shopping and cooking skills. Nutrition education programs are recommended to address the particular needs of these individuals: instruction on how to plan and prepare healthy, quick, affordable meals made from items available locally (Dollahite, Pijai, Scott-Pierce, Parker, & Trochim, 2014; Lucan, Barg, Karasz, Palmer, & Long, 2012). Residents of North Philadelphia face obstacles to healthy eating every day. An estimated 235 million Americans live in lowincome areas more than one mile from a supermarket They rely on convenience, or corner stores located within walking distance to purchase food. Philadelphia is home to 1989 such stores Cavanaugh, Mallya, Brensinger, Tierney, and Glanz (2013) randomly examined the availability, price, and quality of healthy foods available at 200 of an estimated 630

corner stores in Philadelphia enrolled in the Philadelphia Healthy Corner Store Initiative (HCSI). Foods and beverages identified as healthier options were carried less frequently and at a higher price point than their higher fat, higher sugar counterparts. A scant variety of fruits and vegetables were found to be offered for sale. Given these findings it is not surprising that an estimated 30% of Philadelphians consume less than one serving of fruits and vegetables each day (CDC, 2013). 8 This analysis enabled authors to identify interventions anticipated to further improve healthy food selection and affordability. A nutrition education piece designed to provide information on the location of corner stores participating in the HCSI would likely enable Philadelphians to choose healthier foods. The Impact of Nutrition Counseling on Healthy Eating Behaviors after Bariatric Surgery The Registered Dietitian (RD) plays a very influential part in the patient’s overall success after

bariatric surgery – a role that should begin early in the pre-surgical process. Nutrition education covering healthy behaviors such as meal selection and planning, portion size awareness, mindful eating techniques, hunger awareness, self-monitoring, and physical activity can help give patients tools for success. Nutrition counseling, including motivational interviewing and goal setting, can help patients put healthy habits into place in order to enhance post-operative weight loss and maintenance (Cummings & Isom, 2015; Mechanick et al., 2009; Mechanick et al., 2013) In a systematic review of studies, authors observed that nutrition counseling and a clear weight loss prescription led to preoperative weight loss (Ochner, Dambkowski, Yeomans, Teixeira, & Pi-Sunyer, 2012). In a rigorous systematic review of clinical trials, Jensen et al. (2014) sought to determine the efficacy of lifestyle and behavioral counseling on weight loss and maintenance, as well as to determine which

dietary intervention strategies are effective for weight loss and maintenance in obese patients. They found strong evidence to recommend the following strategies to induce weight loss: 9 -referral to a nutrition professional for counseling -participation in a comprehensive lifestyle program, using behavioral change strategies for at least 6 months -on-site, comprehensive weight loss interventions (≥14 sessions in 6 months) led by a trained interventionist, either in group or individual form -instruction on a calorie deficit of ≥500 kcal/day to induce weight loss (1,2001,500/day for women) Based on their extensive review of the evidence, they recommended that comprehensive lifestyle intervention by a nutrition professional (RD) is so fundamentally helpful that it should be the foundation of treatment even when medications or Bariatric surgery are provided to augment weight loss. A recent randomized, controlled trial examined the effect of an evidence-based lifestyle

intervention on preoperative weight loss among a group of 240 patients awaiting Bariatric surgery. The intervention consisted of weekly face to face or telephone counseling, instruction on healthy eating behaviors, a goal of heathy weight loss (one-two pounds per week), goal setting, and self-monitoring. The intervention group lost more weight (measured in kilograms, and as a percentage of usual body weight [UBW]), and had a greater chance of having achieved five or ten percent UBW loss. The group who experienced the healthy eating intervention also showed a significantly higher incidence of practicing eating behaviors conducive to weight loss, as measured by improvement in Eating Behavior Inventory (EBI) score compared to the control group (Kalarchian, Marcus, Courcoulas, Cheng, & Levine, 2013). The importance of the RD’s role in weight loss success after surgery was outlined in a recent audit of sixty eight Bariatric Surgery patients in the United Kingdom. A majority reported

that they felt they would have lost and maintained weight more optimally if they had more support from the 10 RD (Harbottle, 2011). Nutrition counseling by a RD not only helps patients to meet pre-operative but also post-operative weight loss goals as well. In their recent randomized, controlled trial, Sarwer, Moore and Spitzer (2012) showed that regular counseling by a RD after bariatric surgery was associated with greater weight loss at four and twenty four months after bariatric surgery, and that this counseling was also associated with improvements in eating behavior, when compared to a control group. Preoperative Weight Loss as a Predictor of Postoperative Weight Loss Success Several studies have attempted to determine whether losing weight before surgery leads to greater success with post-operative weight loss. Solomon, Liu, Alami, Morton, and Curet (2009) studied sixty-one Gastric Bypass patients, randomly assigned to “weight-loss” and “non weight-loss” groups. All

“weight loss” groups were counseled by the Bariatric RD and told to lose 10% of their body weight. They lost an average of 82% of UBW The “non weight-loss” group gained one percent of UBW. The patients were reevaluated at one year after surgery At first glance of the data they found no statistical difference in weight loss between the groups, which they attributed to “outliers” – patients who were not told to lose weight but did so on their own, or patients in the “weight-loss” group who gained weight. On reanalysis of the data, authors found that those who lost more than five percent of EBW before surgery had greater weight loss one year after surgery (measured by percentage of BMI change and EBW) than those who lost less than five percent EWL before surgery, regardless of whether they were in the “weight-loss” or “non weight-loss” groups. The small size of this study may have been the cause of inconsistent results. A meta-analysis of studies examining the

effect of preoperative weight loss on post-operative success by Livhits et al. (2009) concluded that patients who lost weight preoperatively lost five per cent greater EBW at one year post-op than those who did not lose 11 weight before surgery. In a more recent meta-analysis, Ochner, Dambkowski, Yeomans, Teixeira, and Pi-Sunyer (2012) examined the same phenomenon. They found inconsistent results, which they attributed to lack of consistency among treatment protocol regarding both preoperative weight loss requirements and counseling. They concluded that preoperative weight loss may indeed lead to greater overall weight loss as well as reduction in comorbidities and surgical complications, and that responsibility for fostering dietary change lies in the hands of the health care team. They also suggested that more research needs to be done in this area, in order to determine and establish standards of practice for pre-Bariatric surgery requirements. Use of Pre-test/Post-test in

Educational Research In a recent review article, Boyas, Bryan, and Lee (2012) examined the usefulness of pretests and post-tests in conducting educational research. Using this method, a pre-test is given before the educational presentation to determine level of knowledge of predetermined learning objectives. After an educational presentation, an identical assessment (post-test) is given Ideally, one would see improvement from pre-test to post-test scores, demonstrating a mastery of educational program objectives. They suggested including both “basic knowledge” questions that require students to remember and recall information given, and “application and analysis” questions, which require students to problem-solve using information given during the presentation. They concluded that the pre-and post-test method can be a useful tool not only to assess acquisition of knowledge, but to pinpoint areas for improvement of educational program materials. Levy et al (2011) stressed the

need to design pre-test/ post-test questions after conducting a careful needs assessment of the intervention population, and suggested that survey questions can also be used to identify change in comfort level, or confidence level of putting newly attained skills into practice. Pre-test and post-test surveys were used in their recent study 12 of the effectiveness of a nutrition education piece given to healthcare workers. Comparison between pre- and post-test questions indicated a significant increase in both knowledge of, and confidence to put into practice, the lessons taught in the nutrition intervention. The Expanded Food and Nutrition Education Program (EFNEP) is a well-established evidence-based program designed to give targeted nutrition education to low income families. In a recent study designed to evaluate EFNEP’s effectiveness, pre- and post-test design was implemented to assess knowledge gained, as well as self-reported behavior change attributed to the educational

program (Dollahite et al., 2014) Appropriate Educational Methods for Counseling and Teaching Adults Cognitive Behavioral Therapy (CBT) has long been recommended to facilitate change in destructive eating habits in overweight patients. In a recent review of literature Spahn et al (2010) examined nutrition counseling strategies that have been linked to positive behavior change. In CBT, a person is taught to explore actions and beliefs that contribute to undesired results, and to explore alternate ways of establishing and functioning within a healthy environment. By introducing the skills of problem-solving, goal setting, stimulus control, and self-monitoring, the RD can help patients to take charge of their actions in a way that produces desirable health outcomes. CBT given for six months or less has been associated with sustained weight loss and maintenance for at least eighteen months. In the Look Ahead trial, nutrition counseling utilizing CBT resulted in improved measures of blood

sugar control and reduced weight. James Prochaska’s transtheoretical model describes individuals as existing at sequential stages of readiness to change behavior. Counseling is most effective when designed to approach patients at the appropriate level, with the goal of helping patients to see benefits of change and improving desire and confidence in ability to carry out necessary steps. In one study, the 13 transtheoretical model was used to design a nutrition education piece for 1,029 individuals with Diabetes. Compared to those in the control group, those in the intervention group advanced to a subsequent stage of change, decreased energy consumption from fat, increased consumption of fruits and vegetables, and improved measures of blood sugar control. RDs are recommended to use the aforementioned behavior change theories and models to optimize counseling effectiveness by designing nutrition education programs that facilitate the ability to create a healthy eating environment,

enhance healthy choices within that environment, and increase individuals’ self-efficacy (Spahn et al., 2010) In the mid- 1960s Malcolm Knowles pioneered the concept that adults learn quite differently than their younger counterparts. Knowles defined Andragogy as the science of understanding and supporting adults as learners. He stated that adults are problem centered, selfdirected, internally motivated, and learn best in a social context where they can apply prior knowledge. They also learn best when they can see the benefit of putting acquired knowledge into practice in order to enhance their lives. The term “lifelong learning” is a goal that can be applied to adult learners whether they are in a classroom or a lecture, as individuals are never finished attaining knowledge that can help them thrive. According to his theory, adults learn best when they are able to take in new information, assimilate the new information into personal experience, and possibly adopt a new point of

view (Bass, 2012). When participating in nutrition education, adults should be given the chance to analyze preconceived views and attitudes about their own challenges to healthy eating. When provided with knowledge and tools for success, they will benefit from seeking to understand how realistically they might be able to put newly acquired knowledge into place, and by considering how they might benefit from these changes. 14 Optimally, they would learn more about healthy eating by experience, such as by planning a meal, or participating in a grocery store tour. In a recent article, Freedman et al. (2012) stressed the importance of using Cognitive Psychology and adult learning theories to design effective health behavior change programs. They recommended designing interventions in environments conducive to learning and using strategies that promote retention of information, placing information in context that is valuable to learners. They stressed the importance of allowing

learners to take an active role in applying new information, and using strategies to increase motivation to apply new knowledge. They designed the Better Education and iNnovation (BEAN) model to design effective health education modules based on the aforementioned goals. Using qualitative analysis and interviews, they analyzed the effects of implementing their strategies while giving a series of health education lessons. Learners gave positive feedback, and reported change in health behaviors Hand et al (2014) recently evaluated the effectiveness of the RD Parent Empowerment Program (RD PEP) to promote healthy eating behaviors in participants. The RD PEP is a series of four evidencebased interactive group workshops led by nutrition professionals, given to parents in an urban environment, designed to promote heathy family diet environments and behaviors. Family food and exercise habits were assessed using the validated Family Nutrition and Physical Activity (FNPA) survey, measured pre-

and post-intervention. The intervention utilized the aforementioned adult education strategies: interactive learning, facilitating communication, and tailoring of information for relevancy to participants. Analysis of focus group-attained data revealed that participants valued an open, friendly learning environment, and attendance was positively influenced by a perceived value of the program information. Participants attributed behavior change to attendance at the workshop. FNPA scores significantly improved among 15 participants from baseline to completion of the workshop. In their analysis of the EFNEP program, Dollahite et al. (2014) used a switching replications randomized experimental design to show that their eight session group workshop educational intervention format had an immediate and lasting impact on participants’ knowledge of and participation in healthy eating behaviors. Education to control group participants was delayed, not denied, while the retention of

education by the intervention group was assessed, in order to control for secular trends and more accurately assess retention and application. Lessons were based on adult learning theory using principles such as respect for and engagement of participants, conveying information in a way that could be immediately applied to their day to day lives, and allowing participants to discover new information themselves. The moderator facilitated behavior change by motivating participants – helping them to see the benefits of making healthy eating choices. Those who attended at least six of the eight sessions reported improved eating behaviors, even eight weeks after the intervention. The demonstrated success of these studies can be helpful for designing a healthy eating intervention for patients undergoing Bariatric surgery. A U-shaped room would foster communication, and a warm, safe, open learning environment where questions and comments are encouraged would make learners comfortable. Deeper

levels of understanding could be gained by providing opportunities for practical application. Instead of simply teaching about healthy lunch options, the facilitator might begin with “imagine you are choosing something for lunch” Individuals learn by modeling. After discussing healthy eating options, the facilitator might ask volunteers to share some healthy eating options with the class. 16 Multimedia Presentations In a recent review article, Penciner (2013) summarized research on the effectiveness of multimedia presentations such as PowerPoint (Microsoft Corp, Redmond, WA) on learning and information processing. Educational psychologists favor learning tools that engage learners in verbal and visuospatial thinking, in order to increase acquisition, retention and transfer of information. According to the multimedia principle, students learn better when visuals supplement verbal presentations. Using a multimedia presentation style would be a predicted asset to a healthy eating

intervention for Bariatric surgery patients. The Benefit of Group Instruction Nutrition education interventions based on evidence-based adult counseling and educational strategies have been shown to be particularly effective when conducted in the group setting. Dollahite et al (2014) Freedman et al (2012) and Hand et al (2104) all found that group healthy eating interventions facilitated an increase in knowledge and behavior change. In a systematic review of three randomized controlled trials, group counseling was shown to be significantly more effective than individual counseling in middle aged subjects to improve weight loss and diabetes management (Spahn et al., 2010) The Effect of Nutrition Counseling on Healthy Eating Behavior and Weight Loss after Bariatric Surgery In a rigorous systematic review of clinical trials Jensen et al. (2014) sought to determine the efficacy and safety of Bariatric surgery procedures and which procedural protocol factors tended to increase patient

outcomes. They stated that Bariatric surgery should be considered an adjunct to lifestyle modification: behavior therapy, dietary change, and physical activity. The RD has an important role in using evidence-based counseling and education techniques in order to optimize 17 patient outcomes after Bariatric surgery. A healthy eating group education class, designed with the adult learner in mind, would be anticipated to induce improved weight loss and maintenance after surgery. Nijamkin et al (2012) demonstrated this hypothesis to be supported in their prospective, randomized-controlled trial examining the effect of a comprehensive nutrition education and behavior modification intervention on weight loss and physical activity after RYGB surgery. One hundred and forty four Hispanic Americans were randomly placed into two groups six months after surgery. The comprehensive nutrition intervention took place from six to twelve months after surgery. It consisted of group education classes,

utilizing a PowerPoint (Microsoft Corp, Redmond, WA) presentation method and encouragement of group discussion, given every other week for six months. Teaching points included selection of a reduced calorie meal plan, the importance of physical activity, strategies for behavior change, management of stress, and overcoming obstacles. After each educational group session, participants were asked to complete a pre- and post-session quiz to evaluate knowledge acquired. Both groups had lost the same amount of weight at the time of the intervention. However participants of the comprehensive nutrition and lifestyle education sessions lost significantly greater excess body weight than the control group after the intervention at one year after surgery (25% vs 13%). In their recent randomized, controlled trial Kalarchian et al. (2013) found that an evidence-based lifestyle intervention improved preoperative weight loss and healthy eating behaviors among a group of patients awaiting Bariatric

surgery. Postoperative weight loss success would be anticipated to be even more enhanced if the RD were to begin conducting group healthy eating interventions early in the pre-surgical process. 18 Chapter 3 Methods Research Design This quasi-experimental research pilot study was designed to present and evaluate an interactive lesson for patients of Temple Bariatric Surgery Program on healthy eating habits for weight loss. The study utilized a pre-test/post-test design to evaluate the impact of the interactive lesson. Subjects were a convenience population recruited from initial seminars Subjects The study population included patients scheduled to have Bariatric Surgery – either Sleeve Gastrectomy or Gastric Bypass at Temple Bariatric Surgery Program, including patients seeking surgery at Temple University Hospital and Jeanes Hospital. They were recruited by a flyer distributed at initial seminars- one at Jeanes Hospital and one at Temple University Hospital. The flyer can be

found in Appendix A The flyer included details about two Healthy Eating classes during which the two interventions took place. Additional recruiting was conducted via phone call by a representative of Temple Bariatric Surgery program, Rosenie Balde LPN. Patients were reminded of the upcoming optional Healthy Eating classes, and encouraged to attend, in order to improve their success with preoperative weight loss. The script for this conversation can be found in Appendix B. Two Healthy Eating classes/interventions were held within 10 days of the Seminars. Incentives to participate in the intervention included assistance with weight loss, a healthy snack, a toolkit for healthy eating, and a chance to win raffle prizes. The researcher had access to this population because she is employed as a Registered Dietitian at Temple Bariatric Surgery Program, specifically at Temple University Hospital. The researcher did not have clinical contact with the patients prior to the intervention 19

From initial recruitment until the completion of both interventions, patients were seen by another Dietitian in the Temple University Hospital or Jeanes Hospital clinic. Although attendance at the Healthy Eating class was encouraged, participation in the intervention and research were both voluntary. The participants were expected to be primarily female, from the ages of 25 – 65 They were expected to be African-American, Caucasian, and Hispanic in fairly equal proportions, predicted by the patient mix usually seen at Temple Bariatric Surgery Program. Educational level was expected to vary from General Educational Development certificate or High School Diploma to College Graduate. Participants were expected to be of lower to middle socioeconomic class It was estimated that around forty patients would be recruited from the two seminars, with the anticipation that around ten to fifteen potential subjects would attend the two Healthy Eating classes. Instrumentation The data collection

instrument was a 10 question pre-test and post-test, with primarily true/false or multiple choice questions. The test was designed by the researcher, with questions chosen to ascertain knowledge of concepts taught during the educational intervention: calorie awareness, meal preparation and selection, and knowledge of proper portion sizes. One additional question was added by the researcher to assess degree of confidence in ability to follow a healthy diet, with weight loss in mind. This question, also written by the researcher, utilized a Likert scale. The pre-test can be found in Appendix C and the post-test in Appendix D A copy of the lesson plan can be found in Appendix E. The researcher developed the educational piece based on concepts identified from clinical experience and from the professional literature as being important for Bariatric patients to understand when embarking on a weight loss program. 20 Procedure The researcher completed the Collaborative Institutional

Training Initiative (CITI) Human Research Curriculum. Her Certificate of Completion can be found in Appendix F The Proctor, Steven Clarke, MS RD LDN CNSD, and Rosenie Balde LPN also completed the CITI Human Research Curriculum. Their Certificates of Completion can be found in Appendix G and Appendix H, respectively. Authorization to conduct this research study was granted by Michael Edwards, MD FACS, Director of the Temple Bariatric Surgery Program and Chief of General and Minimally Invasive Surgery at Temple University Hospital. The Letter of Authorization can be found in Appendix I. This research was approved by Immaculata University Educational Review Board. The Letter of Approval can be found in Appendix J Temple University Institutional Review Board (IRB) signed an Institutional Authorization Agreement, allowing Immaculata to serve as the IRB of record, permitting the research to proceed. The approval document and a letter from Temple University IRB can be found in Appendix K and

L, respectively. Study participants gathered for the advertised Healthy Eating class either in the Meetinghouse conference room on the campus of Jeanes Hospital or in an education classroom at Temple University Hospital. After all participants had gathered and taken their seats the researcher closed the door, distributed the consent document, and read it aloud to the participants. She then asked participants to keep the consent document, but to refrain from writing their name on it, and she explained that their consent to participate in the study could be indicated by checking off the consent box found at the top of the pre-test. A copy of the consent document can be found in Appendix M. The researcher gave participants the opportunity to ask any questions, and answered them to their satisfaction before exiting the room. After the 21 researcher left the room, the proctor randomly distributed self-seal manila envelopes and pens to each participant. Each envelope was labeled with a

letter of the alphabet Each manila envelope contained a blue pre-test (with consent box on the top) and a green post-test, each previously labeled with the same letter of the alphabet as on the outside of the manila envelope. The participants were told to refrain from writing their name or any identifying information on any of the papers or the envelope, in order to maintain anonymity. They were then instructed to remove the blue paper marked “Healthy Eating Habits for Weight Loss” from the manila envelope. They were asked to check the box on the top of the form if they agreed with the consent document and wished to participate in the study, and were instructed to complete the pre-test to the best of their knowledge, refraining from speaking aloud during the test or discussing answers. They were given 10 minutes to complete the pre-test. After all of the participants completed the pre-test they were asked to return it to the envelopes, after which the proctor summoned the

researcher into the room in order to begin the educational session. The educational session followed a Power Point presentation, written by the researcher. It lasted approximately 30 minutes, during which participants learned about calorie counting, identifying high calorie and low calorie foods and beverages, and choosing and preparing healthy meals using the Healthy Plate format formulated by the United States Department of Agriculture. Participants were offered a light yogurt and a bottle of water at the start of the presentation in order to demonstrate the palatability of low calorie snacks and beverages. Participants were given a handout designed to follow along with the presentation, including a list of resources for healthy eating, pictures demonstrating proper portion sizes, and visual representations of high calorie and low calorie meals. They were also given a raffle ticket to possibly win a small prize, chosen with weight loss in mind. A list of small raffle prizes can be

found in the lesson plan in 22 Appendix E. At the end of the presentation, participants were encouraged to ask questions of the researcher, which were answered to everyone’s satisfaction. Next, the researcher left the room, and the proctor instructed the participants to take out the post-test from their manila envelope, a green paper labeled “Healthy Eating Habits for Weight Loss”. They were instructed to complete the post-test to the best of their ability, again refraining from writing identifying information on the paper, speaking aloud, or discussing answers with one another. Ten minutes were allotted for the completion of the post-test Participants were then instructed to place the completed post-test into the manila envelope along with their pre-test, seal the envelope, and hand it to the proctor. The proctor placed all manila envelopes into a portable file box, closed the box, and called the researcher into the room. Participants were again thanked for attending, and

given the chance to ask further questions of the researcher. At this time, a raffle was held, and attendees were randomly selected to win weight loss–friendly prizes. This intervention was given twice, using the above procedures. Pre-tests and post-tests are being stored in a locked box in the researcher’s home for a period of five years, when they will be destroyed. No one except the researcher will have access to them Data Analysis Only completed tests were used for data analysis. The mean score on pre-tests were compared with mean scores on post-tests, in order to determine the overall effectiveness of the intervention. Examination of each test question, compared pre-test vs. post-test, determined the individual impact of certain portions of the presentation. Each individual’s improvement in score was also noted, in order to determine the number of subjects who benefitted from the educational intervention. The test question designed to measure confidence was also compared

pre-test and 23 post-test, by individual and overall, to determine whether the intervention had an impact on confidence to follow a healthy diet. 24 Chapter 4 Results One participant attended each Healthy Eating class- one male and one female. Both were over the age of 50, and Caucasian. Both attendees chose to participate in the study intervention In order to maintain anonymity, sealed envelopes were not analyzed until the completion of both interventions. Individual scores on pre and post-tests, as well as mean scores on pre and posttests are summarized in Table 2, along with percentage improvement by individual and overall Pre and post- tests were scored by analyzing the number of correct answers to the ten knowledge-oriented questions. Participant W demonstrated a decrease in score by 11% after the intervention, and Participant K’s score increased by 43%. Overall, this represents a mean increase of 13%. Table 2 Individual and mean pre and post-test score, and percent

improvement Pre-test score Post-test score Percent change Participant W 9 8 -11 Participant K 7 10 +43 Mean 8 9 +13 Answers to pre and post-test questions were analyzed individually, to determine which aspects of the educational presentation impacted knowledge most effectively. Figure 1 illustrates the number of participants answering each question correctly, comparing pre and post-test results. Participant K answered questions three, seven, and eight incorrectly on the pre-test and correctly on the post-test. Participant W answered questions three and eight correctly on the pre-test but 25 answered them incorrectly on the post-test. This participant answered question seven incorrectly on the pre-test and correctly on the post-test. Question three assessed knowledge of appropriate portion size of protein when planning a healthy meal according to the Healthy Plate guidelines. Question seven assessed knowledge of the calorie deficit needed to lose one to two pounds

per week, and question eight ascertained knowledge of calorie amounts of various foods. Figure 1 Correct Answer Results By Question Participants 2 1 Pre-Test Post-Test 0 1 2 3 4 5 6 7 8 9 10 Question Number Participants’ degree of confidence in ability to lose weight before surgery was assessed using a Likert scale in question 11, where “1” represented the patient strongly disagreeing with the statement “I have the ability to lose weight before I have Bariatric surgery” and “5” represented strongly agreeing with the same statement. Table 3 depicts confidence score and percentage change in confidence score, both by participant, and by mean. After the presentation, Participant W increased in confidence by 25%, and participant K did not increase in confidence, having scored the highest possible score on pre-test. Mean increase in confidence was 11% 26 Table 3 Individual and mean pre and post-test confidence scores, and percent improvement Pre-test

confidence Post-test confidence Percent change score score Participant W 4 5 25 Participant K 5 5 0 Mean 4.5 5 11 27 Chapter 5 Discussion Interpretation of Results This study was conducted to evaluate the impact of a nutrition education intervention delivered to Bariatric patients early in the pre surgical process. The educational presentation was designed using adult learning theories and Cognitive Psychology strategies, after conducting a needs assessment for this particular population. A multimedia presentation style was utilized, and participants were frequently encouraged to apply and verbalize how they might fit newly attained eating practices into their daily routine. Knowledge of healthy eating habits for weight loss, and degree of self-efficacy to lose weight were assessed using a pre-test and post-test questionnaire. It was hypothesized that post education test scores would improve from baseline scores, and that self-assessed confidence would improve from

before to after the intervention. Overall, the results supported the hypothesis: mean knowledge scores improved by 13% and degree of confidence increased by 11%. Upon analysis of answers to individual test questions, participants appeared to already understand concepts investigated by questions 1, 2, 4-6, 9 and 10, indicated by correct answers by both participants on the pre-test. This may be attributable to good knowledge of healthy eating concepts prior to the education session. Attendance at the Healthy Eating class was optional. Perhaps patients who care about following a healthy diet in order to lose weight before having Bariatric surgery would tend to go out of their way to attend a nutrition class. This may have influenced results. Questions 3, 7, and 8 were more difficult for attendants, with one participant answering all incorrectly before the intervention and all correctly after the intervention. This indicates that the intervention served to teach this participant the

concepts covered in the intervention assessed by these questions- namely optimal portion size of protein 28 (3), calorie deficit needed to induce weight loss (7), and calorie amounts of various foods (8). One participant answered questions 3 and 8 correctly before the intervention and incorrectly after the intervention, indicating that the intervention may have served to confuse this participant regarding portion size of protein and calorie deficit needed to induce weight loss. This same participant answered question 7 incorrectly before the intervention and correctly after the intervention, indicating they retained the information given during the presentation on calorie amounts of various foods. Self-efficacy improved overall among participants: an important predictor of weight loss success. Limitations Small sample size (N=2) limited the reliability of the data. Although results were encouraging, it is not possible to accurately assess the effectiveness of an educational

session based on the results of two subjects’ pre-test and post-test results. The generalizability of this study is limited due to small sample size, and also because subjects were both Caucasian, and over the age of fifty. This does not adequately reflect the population of patients of Temple Bariatric Surgery Program: African American, Caucasian, and Hispanic in fairly equal proportions, and from 20-60 years of age. Validity of data was limited by the fact that patients were not entirely anonymous. Although protocol was designed to protect identity and confidentiality, only one participant attended each Healthy Eating class. Although they were informed that their unidentified envelopes would be mingled with those of other class participants, subjects’ performance on pre-test and post-tests may have been affected both positively and negatively- by a desire to succeed or by nerves. Data was additionally limited by the fact that the validity and reliability of our pre-test/post-test

as an assessment tool were not tested prior to their use in this study. Further study of a larger sample size would be needed to 29 ascertain whether questions were representative of knowledge needed by this population and successfully communicated in the educational session. Comparison of Results with Recent Literature No recent studies were found that mirror this study design: the effect of early healthy eating education on knowledge and self-efficacy. However recent studies have indeed shown that group healthy eating instruction, designed using evidence-based adult counseling and educational strategies, have produced not only an increase in knowledge but behavior change as well (Dollahite et al., 2014; Freedman et al, 2012; Hand et al, 2104) Additionally, Nijamkin et al. (2012) found that group healthy eating classes delivered after RGYB surgery increased knowledge of healthy eating behaviors, and led to subsequent greater excess body weight loss than seen in a control group.

This study showed similar results: group healthy eating education increased both knowledge and self-efficacy in the study sample. Hopefully knowledge gained and increase in confidence will also translate into greater preoperative and postoperative weight loss. Procedural Issues The benefit of the group was observed during both Healthy Eating classes. Both patients brought a spouse, and questions and discussions about program topics were encouraged. The camaraderie created among the group, although it was small, can be anticipated to increase commitment to success. Talking points were highlighted by visual props – a vegetable steamer, measuring cups/spoons, a calorie counting book, a water bottle, and a recipe book. These were given out as raffle prizes as an incentive for participants to attend the class. Although they did not serve as a sufficient incentive to attendance, having the items in class stimulated productive conversation regarding their use. A handout was given to each

participant, containing visual 30 representation of portion sizes, recipes, lists of items in each food group, visual representations of food with calories listed for all, and local resources for obtaining fruits and vegetables. All were reported as being helpful for participants except the local resources, as these patients had no issue with food access. Both participants commented that they felt that the class would contribute to their overall success, and they felt it was worth the effort they made to attend. Small sample size was likely due to the Healthy Eating class and intervention being optional for patients. Patients had to take time out of their daily routine, pay for parking and travel, and face weather obstacles to attend. The intervention given at Temple University Hospital was rescheduled seven days after its original date, due to a significant snow storm. Individuals seeking weight loss surgery may not initially see the benefit of attending a healthy eating class,

as they have likely tried many diet interventions to no avail in the past. For future studies, strategies should be utilized to maximize sample size. Evaluating an educational presentation on an already-assembled group is extremely preferable to recruiting members anew. Application of Results Although it is not currently mandatory to attend a Healthy Eating class before having surgery at Temple Bariatric Surgery Program, this practice is being considered for the future. Many Bariatric surgery practices utilize this protocol, in order to ensure all patients benefit from the increased support to weight loss a group class can provide. This will provide an opportunity to study the effectiveness of the educational intervention on a larger group of patients and could serve as a follow up to this study, with the anticipation that preoperative and postoperative weight loss could be measured as well. 31 Suggestions for Future Research Further research is needed in this area. Practice

protocol is not consistent regarding the requirement of preoperative weight loss. Therefore, controlled studies investigating the effect of preoperative weight loss on postoperative weight loss and maintenance are limited and inconsistent. Bariatric surgery has the potential to reduce chronic disease and mortality, but only if patients are successful at keeping weight off. Bariatric surgery is only a tool: patients must utilize this tool to its maximum capacity in order to be successful, by changing destructive eating habits. Factors that can increase postoperative success such as preoperative behavior change and weight loss should be studied, and optimized. Summary Study results indicated that a Healthy Eating class delivered early in the preoperative process to patients at Temple Bariatric Surgery Program improved knowledge of healthy eating behaviors and increased self-efficacy for weight loss. Although sample size was small, results indicate that early group nutrition education can

positively influence knowledge, confidence, and possibly weight loss. Many Bariatric patients fail to successfully lose and maintain weight after surgery, because of a return to unhealthy eating habits. If patients can begin working on restructuring behavior before surgery, healthy habits will more likely persist. The Registered Dietitian working with Bariatric patients has a unique opportunity to influence patients’ success by designing and implementing evidence-based group nutrition education programs well before the patient’s surgical date. 32 References Bass, C. (2012) Learning theories and their application to science instruction for adults The American Biology Teacher, 74(6), 387-390. Boyas, E., Bryan, LD, & Lee, T (2012) Conditions affecting the usefulness of pre-and posttests for assessment purposes Assessment & Evaluation in Higher Education, 37(4), 427437 Breneman, V., & Beaulieu, E(2014) Food environment atlas Retrieved from

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health literacy case study in “how to teach so learners can learn”. Health Promotion Practice, 13(5), 648-656 Hand, R.K, Birnbaum, AS, Carter, BJ, Medrow, L, Stern, E, & Brown K (2014) The RD parent empowerment program creates measurable change in the behaviors of lowincome families and children: An intervention description and evaluation. Journal of the Academy of Nutrition and Dietetics, 114, 1923-1931. Harbottle, L. (2011) Audit of nutritional and dietary outcomes of bariatric surgery patients Obesity reviews, 12, 198-204. Jensen, M.D, Ryan, DH, Apovian, CM, Ard, JD, Comuzzie, AD, Donato, KA, & Yanovski, S.Z (2014) 2013 AHA/ACC/TOS Guideline for the management of overweight and obesity in adults: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and The Obesity Society. Circulation, 129 (25) (s2), S102-S138 Kalarchian, M.A, Marcus, MD, Courcoulas, AP, Cheng, Y, & Levine, MD (2013) Preoperative lifestyle

intervention in Bariatric Surgery: Initial results from a randomized, controlled trial. Obesity, 21(2), 254-260 Levy, J., Harris, J, Darby, P, Sacks, R,Dumanovsky T, & Silver, L (2011) The primary care nutrition training program: An approach to communication on behavior change. Heath Promotion Practice, 12(5), 761-768. Livhits, M., Mercado, C, Yermilov, I, Parikh, J, Dutson, E, Mehran, A, & Gibbons, MM (2009). Does weight loss immediately before bariatric surgery improve outcomes: a systematic review. Surgery for obesity and related diseases, 5(6), 713-721 Livhits, M., Mercado, C, Yermilov, I, Parikh, JA, Dutson, E,Mehran, A, & 34 Gibbons, M.M (2010) Behavioral factors associated with successful weight loss after gastric bypass. The American Surgeon, 76, 1139-1142 Lucan, S.C, Barg, FK, Karasz, A, Palmer, CS, & Long, JA (2012) Perceived influences on diet among urban, low-income African Americans. American Journal of Health Behavior, 36(5), 700-710. Mechanick, J.I,

Kushner, RF, Sugerman, HJ, Gonzalez-Campoy, JM, Collazo-Clavell, ML, Spitz, A.F, & Dixon, J (2009) American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric patient. Obesity, 17 (S1), S1-S69 Mechanick, J.I, Youdim, A, Jones, DB, Garvey, WT, Hurley, DL, McMahon, MM, & Brethauer, S. (2013) Clinical practice guidelines for the perioperative nutritional, metabolic and nonsurgical support of the bariatric surgery patient – 2013 update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery. Surgery for Obesity and Related Diseases, 9, 159-191. Nijamkin, M., Campa, A, Sosa, J, Baum M, Himburg, S, & Johnson, P (2012) Comprehensive nutrition and lifestyle education improves weight loss and

physical activity in Hispanic Americans following gastric bypass surgery: A randomized controlled trial. Journal of the Academy of Nutrition & Dietetics, 112 (3), 382-390 Ochner, C.N, Dambkowski, CL, Yeomans, BL, Teixeira, J, & Pi-Sunyer, FX (2012) Prebariatric surgery weight loss requirements and the effect of preoperative weight loss on postoperative outcome. International Journal of Obesity, 36, 1380-1387 35 Penciner, R. (2013) Does PowerPoint enhance learning? Canadian Journal of Emergency Medicine, 15(2), 109-112. Sarwer, D.B, Moore, RH, &Spitzer, JC (2012) A pilot study investigating the efficacy of postoperative dietary counseling to improve outcomes after bariatric surgery. Surgery for Obesity and Related Diseases, 8, 561-568. Solomon, H., Liu, GY, Alami, R, Morton, J, &Curet, MJ (2009) Benefits to patients choosing preoperative weight loss in gastric bypass surgery: New results of a randomized trial. Journal of the American College of Surgeons, 208,

241-245 Spahn, J.M, Reeves, RS, Keim, KS, LaQuatra, I, Kellogg, M, Jortberg, B, & Clark, NA (2010). State of the evidence regarding behavior change theories and strategies in nutrition counseling to facilitate health and food behavior change. Journal of the American Dietetic Association, 110 (6), 879-888. Wimalawansa, S.J (2013) Visceral adiposity and cardiometabolic risks: epidemic of abdominal obesity in North America. Research and Reports in Endocrine Disorders, 3, 17-30 36 Appendix A: Recruitment Flyer 37 38 Appendix B: Recruitment Phone Call Script “This is Rosie Balde calling from Temple Bariatrics. I would like to remind you of two upcoming classes on healthy eating for weight loss. Although attendance at the class is optional, we encourage you to go to one of these classes because they are designed to help you lose the weight you need to lose before the surgery. There is a class at Temple Hospital in the 2nd floor Boyer building classroom at (insert date

and time of class here) and there is a class at Jeanes Hospital Meetinghouse classroom at (insert date and time of class here).” “We will look forward to seeing you then.” 39 Appendix C: Pre-Test 40 Healthy Eating Habits For Weight Loss Please check off this box if you understand the research and you voluntarily consent to participate in this study: the effect of a Healthy Eating class on knowledge of a healthy diet for weight loss. Please circle the best answer to each question 1. Juice can be part of a healthy weight loss program, as long as it is labeled “100% natural” a. True b. False 2. The appropriate portion size for protein when planning a healthy meal according to the Healthy Plate guidelines is: a. 1 Cup b. 10 ounces c. 6 ounces d. 3 ounces 3. The appropriate portion size for starch when planning a healthy meal according to the healthy plate guidelines is: a. 1/3 Cup b. 1 Cup c. The size of my fist d. 2 Cups 4. The following meal preparation is NOT

considered low-fat: a. Steaming b. Frying c. Boiling d. Baking 5. To lose weight, it is helpful to skip meals in order to eat less a. True b. False 41 6. As long as I stay under a certain number of calories each day, it is okay to eat fried chicken 4 months after bariatric surgery. a. True b. False 7. In order to lose 1-2 pounds each week, about how many calories would someone need to remove from their diet each day? a. 1000 b. 1500 c. 500 d. 100 8. All of the following foods have about 150-170 calories: 1 snack bag of Doritos 10 ounces of Fruit Punch One apple plus one sugar free fat free chocolate pudding cup 2 tablespoons of Caesar salad dressing a. True b. False 9. Which has the most calories: a. A take-out Grilled Chicken Caesar salad b. Ham and cheese sandwich on white bread with regular mayo c. Ham and cheese sandwich on lite bread with lite mayo 10. A meal containing 1 fried chicken breast, 1 cup macaroni and cheese, ½ Cup corn with 1 pat of butter has: a. About 500

calories b. More than 500 calories c. Less than 500 calories 11. Circle the number of the phrase that shows your belief of the following statement: “I have the ability to lose weight before I have bariatric surgery” 1 Strongly Disagree 2 Disagree 3 Neither Agree Or Disagree 4 Agree 5 Strongly Agree 42 Appendix D: Post-Test 43 Healthy Eating Habits For Weight Loss Please circle the best answer to each question 12. Juice can be part of a healthy weight loss program, as long as it is labeled “100% natural” a. True b. False 13. The appropriate portion size for protein when planning a healthy meal according to the Healthy Plate guidelines is: a. 1 Cup b. 10 ounces c. 6 ounces d. 3 ounces 14. The appropriate portion size for starch when planning a healthy meal according to the healthy plate guidelines is: a. 1/3 Cup b. 1 Cup c. The size of my fist d. 2 Cups 15. The following meal preparation is NOT considered low-fat: a. Steaming b. Frying c. Boiling d. Baking 16. To

lose weight, it is helpful to skip meals in order to eat less a. True b. False 44 17. As long as I stay under a certain number of calories each day, it is okay to eat fried chicken 4 months after bariatric surgery. a. True b. False 18. In order to lose 1-2 pounds each week, about how many calories would someone need to remove from their diet each day? a. 1000 b. 1500 c. 500 d. 100 19. All of the following foods have about 150-170 calories: 1 snack bag of Doritos 10 ounces of Fruit Punch One apple plus one sugar free fat free chocolate pudding cup 2 tablespoons of Caesar salad dressing a. True b. False 20. Which has the most calories: a. A take-out Grilled Chicken Caesar salad b. Ham and cheese sandwich on white bread with regular mayo c. Ham and cheese sandwich on lite bread with lite mayo 21. A meal containing 1 fried chicken breast, 1 cup macaroni and cheese, ½ Cup corn with 1 pat of butter has: d. About 500 calories e. More than 500 calories f. Less than 500 calories 22.

Circle the number of the phrase that shows your belief of the following statement: “I have the ability to lose weight before I have bariatric surgery” 1 Strongly Disagree 2 Disagree 3 Neither Agree Or Disagree 4 Agree 5 Strongly Agree 45 Appendix E: Lesson Plan 46 Lesson Plan I. Objectives Upon completion of the educational intervention the participant should be able to: a. Demonstrate increased knowledge of how to plan and fix healthy meals, designed with weight loss in mind b. Aim for a daily calorie level, chosen with weight loss in mind c. Read calories on a food label d. Identify high and low calorie: a. Foods b. Drinks c. Cooking methods e. Prioritize foods based on calorie level f. Identify an acceptable Healthy Plate-based meal g. Demonstrate increased confidence in their ability to plan and fix healthy meals, designed with weight loss in mind II. III. Content a. Counting calories i. How many do I need each day ii. How many do I need for each meal iii. How

do I read the calories on the food label iv. Identify high calorie foods and drinks v. Prioritize between high calorie vs low calorie foods vi. Identify high calorie or low calorie cooking methods b. Using the Healthy Plate model to plan a meal i. Protein, vegetable, starch ii. Proper portion sizes Materials a. Educational handouts a. Copy of Power Point presentation b. Handout illustrating proper portion sizes c. Food journal d. Sample meal plans e. Resource guide for obtaining healthy food in the Philadelphia area i. Location of food stores ii. Farm to family flyers iii. Food banks 47 b. Items for raffle i. Vegetable steamer ii. Cup measure set iii. Book: Beyond rice and beans iv. Book: Calorie king v. Water bottle c. Sugar free, fat free yogurts for snack (15), water bottles (15) d. Supplies: correspondingly marked pre-tests, post-tests, manila envelopes, box for storage, raffle tickets, bin for raffle IV. Procedure: Pre-test, Power Point Outline Post-test a. Calorie counting

b. Label reading c. Identifying high and low calorie foods and cooking methods, prioritizing when choosing a meal d. Using the USDA Healthy Plate to plan meals e. Portion size awareness V. Evaluation Mean test scores on Pre and posttest will be compared to assess overall increase in knowledge of how to plan and fix healthy meals. Individual question scores will be compared pre and posttest to assess knowledge of individual concepts. Confidence score will be compared pre and posttest to assess confidence in ability to plan and fix healthy meals. 48 Appendix F: Ethics Training Certificate – Ruth Christner 49 50 51 Appendix G: Ethics Training Certificate – Steven Clarke 52 53 54 Appendix H: Ethics Training Certificate – Rosenie Balde 55 56 57 Appendix I: Letter of Authorization, Temple Bariatric Surgery Program Director 58 59 Appendix J: Letter of Approval, Immaculata University Educational Review Board 60 61 Appendix

K: Approval Document: Temple University IRB 62 63 Appendix L: Letter from Temple University Institutional Review Board 64 65 Appendix M: Consent Document 66