Gaining Control: Work the Plan and the Plan Will Work

He was due for a knee replacement surgery at the Baltimore VA Medical Center, when his surgeon, Dr. Sumon Nandi, told him that the procedure was being canceled. The pre-operation examination indicated that the surgery would be dangerous given his weight and blood sugar levels, both too high. “My A1C had hit 8.5 and I weighed 255 pounds,” Onorato said.

A normal A1C is (hemoglobin A1C) is considered to be less than 5.7 percent whereas A1C levels 6.5 percent or higher indicate diabetes and between 5.7 percent and 6.4 percent indicate prediabetes. These ranges may vary slightly depending on factor like age, overall health, and medications. 

“I was mad. I was mad that the surgery got canceled, but mostly I was mad at myself,” Onorato said.

“As a hip and knee replacement surgeon, I have the daily privilege of relieving chronic pain that limits patients’ ability to enjoy life.  However, for some patients, their poor health makes the surgery too risky to perform,” said Dr. Nandi.

Undaunted and determined to have the much-needed knee replacement surgery, Onorato decided to take control of his health. He wanted the surgery and to get it, he had to stop ignoring his diabetes and lose weight. “I knew I was going to do whatever it took to reach my goal of having that knee replacement,” he said.

He asked Dr. Nandi’s team what he needed to do to get ready for surgery, and the team asked if Onorator wanted to speak to a nutritionist to help him lose weight and lower his A1C. 

“We know that patients with uncontrolled diabetes, those with a hemoglobin A1C greater than 8.0%, have a much higher risk of getting an infection after a joint replacement,” said Dr. Nandi.  “A joint replacement infection is to be avoided at all costs, as it requires repeat surgery and can even result in death.  Together with their medical doctors, patients can decrease their hemoglobin A1C so that they are eligible to have joint replacement surgery safely.”

Onorato was onboard with the surgical team’s recommendation, and he was connected to VA Licensed Dietitian Kerri Kimbrell-Silva. After he and Kimbrell-Silva met, his journey toward having a knee replacement surgery began with the first goal of getting his diabetes under control. But before meeting with Kimbrell-Silva, Onorato immediately eliminated all sugars out of his diet. “I also told everyone that my surgery was canceled due to my weight and sugar numbers, and my friends and family ended up being my greatest support.” 

Due to his sore knee, Onorato couldn’t exercise. “I met with the dietitian, and we came up with a plan that worked for me, a plan for weight loss that included the fact that I couldn’t exercise,” he said.

For Kimbrell-Silva, working with Onorato proved to inspirational because his dedication and motivation to completing his goal made things easier.  Together they created a nutrition plan, and Kimbrell-Silva provided him with handouts about portion control, meal planning, and plating foods with the goal of reducing his glucose levels. “He himself is an inspiration,” said Kimbrell-Silva, noting that Onorato would often find information and share it with her as well, remarking that wanting the knee replacement motivated him more than anything else.

“We work with each Veteran individually so that the nutrition plan is something that they want to follow,” said Kimbrell-Silva, adding that for Veterans with limited mobility, chair exercises, water aerobics, and modified versions of traditional exercises can be recommended. “For individuals with limited mobility, the focus is on building strength, improving flexibility, and increasing cardio health without straining joints.”

Onorato’s motivation to reach his goal and qualify for the surgery kept him going. It took a little over a year for him to reverse his diabetes, reducing his A1C to normal levels and losing 56 pounds, to date.  “I’m not done yet. I haven’t yet reached my goal weight, which is 185 pounds. I plan to keep going. I went from size 44 pants to a size 38, which was what I was wearing five years ago. If I were able to exercise, I would have lost more weight faster,” he said. “Portion control is a big factor.”

With help from the Kimbrell-Silva and his entire team, including the VA telehealth program, and his primary care provider, Dr. Olivette-Angela Guedon, coupled with Onorato's own desire to lose weight and take control of his diabetes, he kept a positive attitude and educated himself about healthy eating and portion control. 

 “I found an app that allows me to scan products in the supermarket to show me what’s in them,” he said. “If the app doesn’t recommend the food, I don’t buy it.”

Weight and A1C aside, for Onorato, the real goal looms ahead. His surgery is set for this month. “Patients like Veteran Onorato are shining examples of what can be achieved with dedication and persistence, the same qualities that make us proud of our Veterans every day,” Dr. Nandi said.

For Onorato, being healthy makes a huge difference in his quality of life.  “I look totally different now. I tell anyone who asks, ‘work the plan and the plan will work.’”