a guide to bariatric surgery - st. peter's hospital

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bariatric

surgery

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Table of ContentsIntroduction ............................................................................................1

Diet Progression Overview .....................................................................2

Vitamin/Mineral Supplementation .......................................................3

Stage #1: Clear Liquids .........................................................................3

Stage #2: Full Liquids ............................................................................4

The Protein Challenge After Bariatric Surgery ......................................5

Protein Supplements .............................................................................6

Stage #3: High Protein Liquid and Soft or Blenderized Solids ............6

Stage #4: “For Life .................................................................................9

Survival Skills After Bariatric Surgery ...................................................12

Special Considerations for Lap Band Patients (LAGB) ........................13

Special Considerations for Biliopancreatic Diversion with Duodenal Switch Patients (BPD/DS) .....................................................................14

Pre-Surgery Shopping Ideas ..................................................................14

Trouble Shooting ....................................................................................15

Staying Healthy .......................................................................................16

Weight Loss Surgery Resources and Helpful Links .............................16

What Can I Do To Get Ready Before My Surgery ..................................17

Measurement Equivalents and Abbreviations .....................................17

Post-op Vitamin And Mineral Supplements – For Life .........................18

Body Measurement Record ...................................................................18

Food Journal ...........................................................................................19

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IntroductionWhether you are considering or have had bariatric surgery, you need to know the nutritional implications ahead. Bariatric surgery limits the amount of food you can eat at any one time, helps control hunger, and is a method used to help obese persons lose weight. Initial weight loss is often rapid, but should slow to a rate of 2-4 pounds per week. Bariatric surgery cannot and should not be viewed as a foolproof method of weight loss, but as a tool.

For bariatric surgery to be truly successful, eating and physical activity habits must be modified. It is necessary to eat healthful, nutritious foods in order to maintain good nutrition. Make “Every Bite Count” toward your nutritional goals. By making proper choices, you can prevent or minimize potential complications. Recommendations for post-op nutrition vary slightly depending on the procedure. These differences will be noted in this book. Your surgeon will help you decide which type of surgery is right for you.

The SurgeriesRoux-en-Y (RGB): The Roux-en-Y gastric bypass procedure is the most commonly performed procedure. In this procedure, a small portion of your stomach, about ½ to 1 ounce, is separated from the remain-der of the stomach. The volume of the new stomach pouch is about equal to the size of a ping pong ball. The pouch is then joined to the middle section of your small intestine. The remainder of the stomach may be removed or stay in the body. The procedure may be done “open” (larger incision) or laparoscopically (LGB or laparoscopic gastric bypass with small slits allowing instruments to be inserted).

Vertical Sleeve Gastrectomy (Sleeve): In this pro-cedure, a large portion on the stomach is removed, leaving the stomach with a volume of 5-8 ounces. The smaller stomach volume limits food intake, and may decrease production of the hormone ghrelin. Reduc-ing ghrelin helps reduce hunger, possibly more than a purely restrictive procedure.

Biliopancreatic diversion with duodenal switch (BPD/DS): This procedure combines a gastric sleeve with re-routing food to pass through only a small portion of the small intestine. This re-routing reduces the amount of food digested due to less contact with digestive juices and reduces absorption because food spends less time in contact with the surface of the intestine. Ad-ditional protein and vitamin and mineral supplements are required to reduce risk of malnutrition with this procedure.

Laparoscopic Adjustable Gastric Band (LAGB or lap band): This procedure reduces food intake by placing a small band around the top of the stomach, creating a pouch with a ½ to 1 ounce volume. A circular balloon inside the band can be inflated or deflated with fluid to provide the correct feeling of fullness for the patient. This procedure requires frequent follow up with the surgery clinic for band fills.

The Mental Aspect Of Bariatric SurgerySome patients report that the importance of food decreases after surgery. Other patients become more preoccupied with food. Psychological responses such as these are normal as your eating habits change dra-matically after surgery. If you find that you are over-whelmed with thoughts of food, or have used eating to deal with emotions in the past and now cannot, you may choose to seek help in dealing with them.

A bariatric support group meets monthly at St. Peter’s Hospital. Contact 495-6967 for more information about the support group or other services available to you.

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Post Bariatric Surgery DietDay of surgery: Nothing by mouth

Post-OP Day #1, 2 & 3:Stage #1: Clear Liquid Diet

•Clearliquidsservedin1ouncemedicinecups•Firststepsinretraininghowyoueat•Drink1ounceofliquid(1medicinecup)every15-30min.•Sipslowlyandstopsippingwhenyouarefull•Avoidusingastraw•Avoidcarbonation,sugar,caffeine,alcoholicbeverages•Allfruitjuicemustbediluted50:50withwater

Post-OP Day #4:Stage#2:HighProteinFullLiquidDiet(liquidsonly)

•Highproteinpowder/liquidsupplementsand/ormilkorsoymilkbasedliquids•Goal:Worktowards60+gramsofproteinperday•Sipslowly…allow15-30minutesperounce•Avoidusingastraw•Sipwaterorothernoncarbonated/decaffeinatedbeveragesbetweensupplements(Goal: 48oz/day)•Duration-2weeks

Post-OP Day #17:Stage#3:BlenderizedorSoftDiet

•Continuehighproteinpowder/liquidsupplements•Blenderizedproteinfoodsorstage1or2babyfoodmeat,or

chopped or ground moist meats chewed to pureed consistency •Addsoftcookedvegetablesandsoftfruits,eitherfreshand

peeled or canned in juice or light syrup•Eat6-8timesperday•Useababyspoontoencouragesmallbites•Sipwaterorothersugar-free,noncarbonated/decaffeinatedbeveragesbetweenmeals(GOAL48-64oz/day)•Duration-2weeks

Post-Op Day #31:Stage #4: Post Bariatric ‘Soft’ Diet Guidelines

•6minimealsperday•Listentoyourbodyforfullnesssignals-stopeatingwhen

satisfied•Emphasizegoodsourcesofprotein•Chewfooduntilitispureedconsistency•Donotdrinkfluidswithmeals•Sipsugar-free,noncarbonated,decaffeinatedfluidsbetweenmeals(GOAL48-64oz/day)•Recordanyfoodintolerance•Continuewithyourproteinsupplements(Maynotbenecessaryforlapband/sleeveafterhealing)•Don’tforgetyourvitaminandmineralsupplements•Avoidexcessfatandsugar•Duration---ForLife!!

Goals of early diet:• Hydration• Nutrition• Promote Healing• Avoid vomiting• Weight loss

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Vitamin/Mineral SupplementationVitamin and mineral supplementation is “For Life!” Before surgery you could get enough vitamins and minerals from your foods, but now that you are eat-ing much smaller portions, you will not be able to get enough nutrition from the foods you eat. In addition, due to the nature of the surgery, you may not absorb the nutrients from food as before. Vitamin and mineral supplementation is “For Life,” to avoid serious nutrient deficiencies.

The amounts and types of supplements needed de-pendonthetypeofsurgeryyouhave.Usethecharton page 18 to find recommended supplements for your type of surgery. Sometimes, additional supplementa-tion of one or more nutrient will be needed based on your particular situation. Your physician or registered dietitian will let you know if additional supplementa-tion is needed. Bear in mind that more is not always better, as most nutrients can be toxic if taken in exces-sive doses. Be sure to read the manufacturer’s direc-tions and the serving size under “supplement facts” on the label.

A vitamin B-complex supplement, available in liquid form, may be added to the recommended supplements if desired, for any type of surgery. Do not use B-com-plex in place of vitamin B12 because it contains less B12 than recommended.

Another optional supplement is probiotics, which some studies show improved results in patients after bariat-ric surgery. Probiotics are helpful bacteria that help keep a good balance of organisms in the intestines. One study found increased early weight loss and better Vitamin B 12 levels in patients with daily use of lacto-bacillus supplements after Roux-en-Y gastric bypass. Probotics are not recommended in immune compro-mised patients.

For best absorption, take calcium supplements at least 2 hours before or after multivitamin and iron supplements and take only 500-600 mg calcium per dose, with doses at least 2 hours apart. Also, calcium citrate is preferred after bariatric surgery due to better absorption than other forms of calcium.

Stage #1: Clear Liquids

When To Begin? Your doctor will order sugar-free liq-uids usually the first or second day after your surgery.

How long?3days.

Goal: To practice sipping on very small amounts of flu-ids throughout the day and to provide adequate hydra-tion. (Goal: 48-64 oz/day)

What foods can be included? A Clear Liquid diet typically consists of liquids, hot or cold, that one can see through.•Water • Sugar-FreeJell-O•Clear broth or Bouillon•Crystal Light•Coffee/Tea(decaffeinated)•Clear liquid protein supplement•Low calorie Cranberry juice•Popsicle (sugar free)•Applejuice(dilute50:50withwater)•Grapejuice(dilute50:50withwater)

Fruit juices, even when “unsweetened” have high sugar content. Although we include them here, they should be limited and not remain a constant part of your diet.

Important Tips:•Measureallliquidsin1ouncemedicinecups•Drink1ounceofliquid(1medicinecup)every20

minutes. (You may receive usual size portions on your tray in the hospital, yet you should not drink all of the items on the tray at once. The tray is to giveyouavariety.Usethemedicinecupsforpor-tion control.)

• Sipslowly!!Stopsippingassoonasyoufeelfull.•NO straws as they may cause air to enter your

stomach, causing gas and bloating.•NO gum, as it may cause you to swallow air.•Avoid caffeine, sugar, alcohol and carbonated

beverages.• Starttakingyourmultivitaminsatpostopday#3.

REMEMBER: Not everyone advances at the same rate. How quickly you move from one stage to the next will depend on how well you tolerate your diet. If you have trouble after advancing to the next stage, go back to the previous stage for a few days.

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Stage #2: Full Liquids

When To Begin?The‘FullLiquidDiet’maybestartedwhile you are in the hospital or started at discharge and is ordered at the discretion of your doctor, usually 4 days post surgery. Items should be low sugar or sugar free/lowfatbeverageandcreamsoupchoices.Inthehospital, this will consist of a high protein supplement designed for bariatric patients.

How Long? 2 weeks as tolerated.

Goals: 1.Adequatefluidintake(48-64ml/d).Werecom-mend24-32oz.ormoreofclearliquidsduringthisdietstage,plus24-32ozofanycombinationoffullliquids.

2.Todrink60-90gramsproteinforRGB/SLEEVE/LapBandand90-120gramsofproteinforBPD/DS to promote proper healing of your incisions and new stomach pouch. You may not be able to get this much protein in at first. Protein is also important for maintaining muscle mass during weight loss. Therefore, it is important to choose liquids high in protein, or ones to which you have added a protein supplement. Add flavored or unflavored protein powder to milk, liquids and semi-soft foods as ap-propriate.Evensmallamountsofproteinpowderadded to many foods can add up over the day and really boost protein intake. Choose items with less than15gsugarandlessthan3gfatperserving.

What Foods Can Be Included?•All foods from Stage #1 •Soy milk (unsweetened)• Skim/Nonfatmilk/1%milk• LactaidMilk• *Low-fat strained cream soup • *Sugar-free pudding• *Sugar-free cocoa • *No sugar added Carnation Instant Breakfast•Powdered or liquid protein supplements•Greek yogurt•Nonfat yogurt, “light”, plain, or no sugar added (no

fruit chunks or seeds)

*Make with enriched milk or add plain or flavored protein powder, as desired.

EnrichedMilkRecipeOne way to get adequate protein is to ‘enrich’ all the milkyouuse.Usethisenrichedmilktodrinkorwhenyou use milk in cooking. To 1 qt of fluid nonfat milk: Add 1 cup nonfat milk

powder

To 1 cup of fluid nonfat milk: Add ¼ cup nonfat milk powder

Mixwellandrefrigerate

Stage #2 Diet: Full Liquid Example Menu

Breakfast 2-4 oz. No Sugar Added Instant Breakfast made with ‘enriched’ nonfat milkSippedover30-60min. Mid-Morning 2-4 oz. Nonfat, sugar-free yogurtEatenover30min.

Lunch 2-4 oz. strained low fat cream soup made with ‘en-riched’ nonfat milk Sippedover30-60min.

Mid-Afternoon 2-4 oz. protein powder shake

Dinner 2-4 oz. strained low fat cream soup made with ‘en-riched’ nonfat milkSippedover30min.

Evening 2-4 oz. sugar-free pudding made with ‘enriched’ nonfat milkEatenover30min.

Between Meals: Drink2-4oz.(1/4-1/2cup)waterperhour

Portions are general guidelines; listen to your stomach and stop eating/drinking when full/satisfied.

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The Protein Challenge After Bariatric SurgeryProtein intake is extremely important after bariatric surgery because protein has many functions in the body. We don’t store it, so we need to consume it every day. Adequate protein without supplementation is difficult in the early post-op period due to the small size of your newstomach.Yourproteinintakegoalis60–90gramsdailyforRGB,SleeveorLapbandand90to120gramsdailyforBPD/DStopromoteadequatehealingandprevent the loss of lean muscle tissue while you are los-ing weight. Your protein may come from a combination

of regular foods and protein supplements. As time goes on post-op, it is preferred to decrease supplement use and get your protein from real foods as much as pos-sible. Lap band and sleeve patients may not need pro-tein supplements after the first 6 weeks. Choose from the following high protein foods plus supplements as needed to help you reach your protein goal. Keep track of protein you consume, being sure to adjust protein amount to portion you actually consume.

Food Sources of Protein

Food Item Portion Size Average ProteinSkim/Nonfat Milk 1 cup (8 oz.) 8 gramsLight Yogurt (low-fat) 1 cup (8 oz.) 8 gramsGreek yogurt (low-fat -check label- brands vary) ½ cup Up to 10 gramsSugar-free pudding ½ cup 4 gramsInstant Breakfast Powder 1 pkt. (20 g) 5 gramsLow-fat cottage cheese ½ cup 13 gramsLow-fat cheese 1 oz 7 gramsEgg 1 Whole 6 grams

Chicken/Turkey/Beef/Pork 1 oz 7 gramsFish 1 oz 7 gramsTurkey Jerky 1 oz 13 gramsNote: 3 oz. of meat is the size of a deck of cards; 1 oz meat is 1/3 the size of deck of cards.

Beans: pinto, black. Kidney, lentils, lima, etc. ½ cup (4 oz.) 5-7 gramsChili (meat and beans) ½ cup (4 oz.) 8 gramsBean soup ½ cup (4 oz.) 3-5 gramsPeanut butter 1 Tbsp 4 gramsNuts 2 Tbsp 3-4 gramsRefried beans (fat free) ½ cup (4 oz.) 7 grams

Soy milk 1 cup (8 oz.) 6 gramsTofu ¼ cup (2 oz.) 5 gramsGreen soybeans (edamame) ½ cup 8 gramsTextured vegetable protein 1/3 cup 5 gramsVeggie/ Soy burger 1 Patty 10-15 grams

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Protein SupplementsSources, Hints, Suggestions, and RecipesDifferent brands and types of protein supplements have different textures and flavors. We recommend trying several varieties before and after surgery to determine which suits your taste. Some brands are available in single serving packets. Try to buy the small-est amount possible in the beginning while determining acceptability. Also, ask the store about return policies.

Some places to buy them:www.bariatriceating.comwww.NestleNutritionStore.comGNC HealthFoodStoresCostcoGrocery StoresDrug storesAmazon.com

Choosing a Protein Supplement•Buy sample sizes, if available, before surgery

so that you can try different types before buy-ing bulk. Supplements may taste different to you after surgery.

•Appropriate supplements are made from whey, soy, casein, milk protein or egg. Avoid collagen, gelatin, and rice-based supplements. Check the list of ingredients to see what the supplement is made from.

•Readthenutritionfactsonthelabel.Chooseasupplementwith15-30gprotein,<15gsugarand<3gfatperserving.

•Considerservingsizesofproteinbasedonnumber of meals per day. Include protein every time you eat.

Flavors of Protein Powders and TipsMostproteinpowderscomein3flavors:plain,choco-late, and vanilla. Some brands offer strawberry, peanut butter, and other fruit favors

•Plain Powder: Good to add to soups, broth, hot ce-reals, flavored yogurt, sugar-free pudding, mashed potatoes, and vegetable juice

•Chocolate and Vanilla: Good for shakes and when added to plain or flavored yogurt, pudding, juice, and cocoa

•Strawberry and Fruit: Good added to juice, plain andberryyogurt,orsugar-freeJell-Opowder

•Addsugar-freecoffeesyrups(1/2to1ounceper8oz serving) for more flavor variety

•Tominimizelumping,addproteinpowdertocoldor warm liquid before mixing with a hot liquid

Recipe SuggestionsEachrecipemakesapproximately2servings

•Dreamsicle:8oz50:50water/OJ(pulpfree)+vanilla powder

•MandarinChocolate:8oz50:50water/OJ(pulpfree)+chocolatepowder

•Mocha:8oz(hotorcold)decafcoffee+chocolate powder

•VeryBerry:8ozdietBerrySnapple+strawberry powder

•TropicalBlast:8oz50:50water/pineapple,papaya,ormangojuice+tropicalfruitpowder

•ChocolateBanana:8oznonfatmilk+½banana+chocolate powder

•Blendotherfruitswithproteinpowderanddilutedjuice, milk or yogurt

•Mixproteinpowdersorliquidswithsugarfreefruitflavored drinks like Crystal Light or Diet Snapple

•Highproteincreamsoup.Mix1/3cnonfatdrymilkpowder,3TBSPunflavoredproteinpowder,1 TSP chicken or beef bouillon and enough hot watertoequal1cup.Mixwell.Eatsoupwhenitislukewarm.

Stage #3: High Protein Liquid and Soft or Blenderized Solids

When to Begin?Usually2-3weeksaftersurgery.

This stage consists of blenderized, ground, chopped or flaked protein sources plus soft vegetables, fruits and starches. All food must be chewed to the consistency of baby food!Moistureisveryhelpfulinimprovingtoler-ance of foods. You can add moisture with broth, fat free gravy and fat free mayonnaise or plain yogurt as appropriate. Listen to your body for signs of fullness as you eat. Total amount eaten per meal is usually about 1/4cupto1/2cup.Portions are general guidelines; eat slowly, listen to your stomach for signs of fullness and stop eating when satisfied/full.

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How Long? 2 weeks or as long as necessary.

Goals:

1. Adequate fluids, 48-64 oz daily.

2.Consume60-120gramsofproteinperday,depend-ing on surgery type, to promote healing, maintain muscle mass during weight loss.

3.Addotherhealthyfoodssuchassoftvegetables,fruits, grains.

Tips:Continue to sip and eat slowly. It should take approxi-mately 15 minutes to consume 1 ounce of food. Listen to your body’s signs that you have eaten enough. Drink sugarfreefluidsbetweenmeals.Holdliquids30min-utesbeforemealsandwaitfor30minutesafteramealbefore you begin sipping on liquids.

What Foods Can Be Included?

•AllfoodsfromStage#1and#2

Protein foods:

•Eggsoreggsubstitutes:scrambledorsoftcooked

•Cottagecheese,Ricottacheese(lowfat)

•Meats:blenderizedandflavoredwithfat-freegravy

•Cannedchicken,shredded;flakyfish(tuna,tilapia)

•Choppedorgroundleanmeat(moist),mild,lowfat chili

•Beans,soybeans,fat-freerefriedbeans,beansoups,lentil soup

•Tofu:Soft

•Lowfatsoup(chunkymeatorlowfatcreamsoups)

•Proteindrinks

•Tuna,eggorchickensaladmadewithlowfatmay-onnaise

Vegetables:

•Wellcookedvegetables:pureed,mashedand/orchewed to pureed consistency. Avoid gas- forming vegetables such as cauliflower, cabbage, Brussels sprouts, broccoli. Avoid tough, stringy veggies such as corn, celery and asparagus.

Fruits:

•Softfruitscannedinwaterorjuice,orsoft,peeledfreshorfrozenfruits.Fruitsshouldbeunsweetenedand pureed or mashed or chewed to baby food consistency. Avoid skins and seeds.

Starches. These should be limited. Protein, vegetables and fruits are more important for nutrition and weight loss:

•Cookedcereals,coldcereals,lowfatcrackers(<3gfat/svg.)

•Potatoes,sweetpotatoes:wellcookedandmashed

•Toastedbread(nountoastedbread)-nobreadforlap band

•Noodles:wellcookedandmashed-nonoodlesforlap band

Notes:

•Ifyouchoosebabyfoods,selectsingle-itemfoodssuch as chicken, meat or carrots, not combination dinners or desserts. You may add seasonings to improve taste.

•Ifyoudonottoleratewholefoods,tryasofterform such as ground, finely chopped or blenderized foods. If these are still a problem, go back to high protein liquids.

Guidelines For Blenderizing Food

1. Cut food into very small pieces, about the size of your thumbnail.

2. Place food into blender or food processor.

3. Addenoughliquidtocovertheblades.Usefat-freegravyorbrothwithmeatsand/orvegetablesfor more flavor and palatability.

4. Blend or puree until smooth consistency: no lumps, chunks, or pieces.

5. Your food should resemble the consistency of applesauce.

6. Usespicesfreely,withtheexceptionofhotsea-sonings such as cayenne pepper, white pepper, and Tabasco.

7. Add protein powder to increase the nutrient density. You may not wish to add a full scoop, but any amount is recommended.

8. Strain foods that do not blend completely.

9. Whenitcomestopureeingfood,yourcreativityis your only limitation.

10. Pourpureedfoodintoicecubetraysandfreezeforfutureuse.Mosticecubetraysholdabout1 oz per cube and work well for storing pureed portions.

11. When ready, re-heat in your microwave and enjoy.

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Blenderized/Soft Diet Stage #3 MenusuggestionsafteryourbariatricsurgeryYouwilllikelytolerateabout1/4-1/2cuptotalvolumepermeal

Sunday Monday Tuesday Wednesday Thursday Friday SaturdayBREAKFAST

Cream of Wheat made w/ milk

oatmeal made w/ milk

Farina made w/ milk

Scrambled egg and applesauce

Cream of Rice made w/ milk

Cottage cheese and peach slice

Scrambled egg and yogurt

SNACKProtein supplement, milk or soy milk

Protein supplement, Milk or soy milk

Protein supplement, milk or soy milk





LUNCHTuna and peas

Cream of Mushroom soup and yogurt

Cottage cheese and peaches

Chicken with ff gravy and carrots

Cream of celery soup and pears

Tuna with ff mayo and yogurt

Cheese stick and melon








DINNERChicken, cottage cheese and applesauce

Lean ground beef and mashed sweet potatoes

ham and green beans

fish, squash and beets

Meatloaf, cottage cheese and carrots

Chicken, yogurt, and creamed corn

Pork, mashed sweet potatoes and applesauce








Notes:

•Allmilkusedinfoodpreparationshouldbelowfatorfatfree,enrichedorhaveproteinpowderadded

•Chooselowfatcreamsoups

•FF=fatfree

•Fatfreegravycanbeusedtomoistenfoods

•48oz.-64oz.noncaffeinated/noncarbonated,lowsugarfluidperday

•Chewwell.EatSlowly.

•Listentoyourbodyforsignsoffullness.Stopwhensatisfied.

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Stage #4: “For Life”

When to Start? 4-5 weeks after surgery. Time frame is very independent.

How Long?“FORLIFE!!!”Start experimenting with a variety of nutrient-dense solid foods.

IMPORTANT:

•DO NOT drink liquids with meals. DO NOT drinkfor30minutesbeforeandaftermeals.

•Sip water between meals and snacks to reach a daily goal of 48-64 ounces fluids.

•Portions: about 1 cup total volume per meal, the amount tolerated varies from person to person. Listen to your body for signs of fullness.

•Eat3-6“mini-meals”perday.

• Eatveryslowly,takingsmallbites:Itshouldtakeatleast30minutestoeatameal.Stopeating when you feel you are satisfied.

• Focusontheproteincomponentofyourmealfirst, as protein remains the most important nutrient to consume other than water. Vegetables and fruits should come next.

•Always chew solids to a pureed consistency.

•Avoid high fat and high sugar foods and beverages.

•Continue to add foods one at a time and assess your individual tolerance. If a food does not agree with you at first, try it again at a later time.

•Keep a record of any food intolerances.

•Continue to take your vitamin and mineral supplements as recommended for your type of surgery.

Sample Menu for Beginning Bariatric Regular Diet

Breakfast 1-2 soft cooked eggs OR 1/4 cup cottage cheese ¼ cup oatmeal made with enriched milk Snack 4 oz. nonfat milk (enriched)

Lunch ¼ cup water packed tuna ¼ cup light canned peaches ¼ cup well-cooked green beans

Snack 4 oz. nonfat vanilla yogurt

Dinner 2 oz. tender chicken breast ¼ cup steamed carrots

Snack 4 oz. Diet Instant Breakfast made with enriched nonfat milk

Plus 4-8 oz. low calorie fluids each hour Snacks between meals and Snacks snacks

Portions are a general guide. Listen to your stomach for signs of fullness, stop eating when satisfied.

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Guidelines for Life

Food Group Recommended Foods Foods To Avoid

Meats and High Protein Foods

Eat this food first in your meal as it is important to your health at this time!

Include about 2 oz. at each meal, listen to your stomach, don’t overeat.

• Lean and well-trimmed beef, pork & lamb

• Chicken & turkey

• Fish and shellfish

• Cold cuts with <3 grams of fat per oz.

• Turkey jerky

• Eggs or egg substitute

• Cottage cheese- 1% or nonfat

• Cheese with <3 grams fat per oz.

• Beans, tofu, soybeans

• Peanut butter, *nuts of all kinds (watch portions)

• High fat and fried meats, fish, or poultry

• Skin of poultry

• Bacon, hot dogs, sausage

• Eggs or omelets cooked with any added fat

• Regular cheese

• *Dry meat, *shrimp

Milk and Milk Products

Include 2 cups per day as a beverage or in cooking

• Nonfat or 1% milk

• Light yogurt

• Sugar-free cocoa

• Diet instant breakfast made with nonfat milk

• Greek yogurt – low fat

• Whole milk, cream, and high fat dairy food

Starches

2-3 servings/day

1 serving = ¼ cup or ½ slice bread

• *Toasted bread, low fat crackers, rice cakes, pretzels

• Plain breadsticks, *nonfat pop-corn

• Hot or cold cereal, oatmeal

• Potatoes,* rice,* noodles, cous-cous, quinoa

• Corn, peas, lima beans, winter squash, lentils

• Pastries, croissants, muffins

• Donuts, cookies, cake, bis-cuits, buttery crackers

• Popcorn with added fat

• Granola (check fat content)

• Macaroni and cheese, fettuc-cini Alfredo, au gratin or fried potatoes

• Any starch with cheese, cream, or butter added

Vegetables

2 servings /day

1 serving = ¼ cup

• Any well-cooked, soft plain veg-etable

• Re-introduce raw vegetables and salad VERY slowly!!

• Chew all vegetables well

• Lettuce may be tolerated at 4 weeks post-op

• Vegetables with fat, cream, or cheese sauce. Any fried vegetables

• Celery strings

• Tough, raw veggies, seeds

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Food Group Recommended Foods Foods To Avoid

Fruits

2-3 servings/day

1 serving = ¼ cup or ¼ of a whole piece of fruit

• Start with bananas, applesauce, melon, soft fruits canned in juice or water.

• Re-introduce raw fruits, berries, & uncooked *dried fruits VERY slowly

• Fruits canned in heavy syrup

• Coconut

• Fruit skins

• Citrus membranes

• Pineapple

Soups

1 serving = ¼ cup

• Vegetable or broth-based soups.

• Low fat soups (i.e. Campbell’s Healthy Request) made with nonfat milk

• Cream soups or chowders made with whole milk, but-ter, or cream

Beverages

Drink these 30 minutes before or after meals

Do not drink with meals

• Water, tea, decaf coffee, unsweetened fruit juice (dilute 50:50 water)

• Broth or bouillon

• Sugar-free drinks (i.e. Crystal Light)

• Regular pop, Kool-aid, fruit drinks, fruit punch, sweetened juices, lemonade, alcoholic beverages

• Be aware of juicing! You can easily get more calories than desired!

Fats

1 tsp. fat or oil= 45 calories.

Watch portions carefully. Limit to 2-3 tsp. daily.

• Small amounts of canola oil, olive oil, olives, avocados

• Reduced fat or fat free salad dressings, mayo, cream cheese, sour cream, gravy

• Butter buds or Molly McButter

• Cooking sprays

• Trans fat free tub margarines

• Regular salad dressings or mayo

• Butter, stick margarine

• Regular cream cheese, sour cream

Sweets • Sugar-free Jell-O

• Sugar-free popsicles

• Sugar-free, nonfat yogurt, pudding, or custard

• Regular gelatin and popsicles

• Ice cream, ice milk, sherbet, sorbet, pie, cake, cookies, pastries, candy

Foodstoavoidincludehighsugarandhighfatfoodsormaybedifficulttodigest.

*Notwithlapband.Maybepoorlytoleratedwithothersurgeriesaswell.

** Name brands are provided for clarity only and do not indicate an endorsement.

Portions are general guidelines. Obey your stomach for amounts to consume!

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Survival Skills After Bariatric SurgeryRemember:1. At first, your new stomach can only hold 1-2 oz. (1/8-1/4c)atatime.Therefore,theamountyouconsume at any one time must be less than 2 ounces. As time goes on, you should be able to eat larger amounts. Listen to your body for signs of fullness.

2. Alwaysallow15-30minutespereachounceoffood. GO SLOW!Chewthoroughly.Useasmallplate, baby spoons and timer to help you slow down. This is a period of adjustment for your new stomach. Pay attention to signs of fullness.

3. Stopeating/drinkingassoonasyoufeelsatisfied.

4. Forstage3and4,donotdrinkfluidswithmeals.Allow30minutesbeforeorafteramealtostartsippingcalorie-free/caffeinefree/noncarbonated beverages.

5. Focusonhighproteinfoods.Eatthemateverymealandsnack.Useproteinsupplements,powder,or liquid as needed to meet protein goals. (Lap band and sleeve patients often do not need protein supplementsafterthefirst5-6weeks.)

6. Avoidfoods/beverageswithexcessfatandsugar.ParticularlyinRGB/LGBpatients,thesecancause‘Dumping Syndrome’. Weight regain can also occur with these foods, regardless of surgery type. This is a lifestyle change YOU have chosen for improved health.

7. Supplemental vitamins and minerals are a must, “FOR LIFE.”

8. Carbonated beverages and using a straw will en-courage swallowing air into your smaller stomach. In addition to being painful, this could also cause nausea and vomiting.

9. Gumchewingmaycauseanincreaseinswallowedair. Avoid chewing gum.

10.Noteveryoneadvancestheirdietatthesamerate.Listentoyourbody!Gobacktothepreviousstageif you do not tolerate your diet.

11.Recordallfoodsandliquidsfor2-3dayspriortoyour individual appointment with the dietitian. Formsareprovidedinyourbook.

Special Considerations for RGB/LGB1. Drink adequate fluids. Sip 48-64 oz. no-calorie,

non-carbonated beverages between meals. Stay-ing hydrated is your first priority. Don’t drink with mealoruntil30minutesafterameal.

2. Eatthepropertypesandamountsoffoods.

a.Followthedietprogressionforthefirst4-5weeks after surgery.

b.Onceyouareeatingstage4,eat3-6minimealsdaily.Eatproteinfoodsfirst,thenvegetablesand fruits, then starches. Start with 1-2 ounces per meal, gradually increasing volume you eat as you tolerate larger amounts, with a max of about 1 cup per meal total volume.

c. Avoid beverages with calories other than milk orsoymilk.Avoidhighsugar/highfatfoodsandbeverages. This includes juices (even those you make with a juicer), regular vitamin water, sug-ary sports drinks and energy drinks. These can interfere with weight loss and may cause dump-ing syndrome (diarrhea, nausea, sweating, rapid heartbeat, dizziness.)

d.Avoidcaffeine(irritates/stimulatestheGItract),carbonation, gum chewing and straws (bring air into stomach).

e.Foodswhichcanhelpwithweightloss:leanpro-teinfoods,veggies,fruits,wholegrains.Foodswhich may prevent weight loss include sweets, refined carbs, fruit juices, fried foods, fatty sauces (like Alfredo sauce) and alcohol.

3. Don’tdrinkwithmeals!Thiscanoverfillyoursmaller stomach, leading to discomfort and nausea. Avoidbeveragesfor30minutesaftermeals.

4. Avoid nausea and vomiting. Sip beverages slowly. Eatsmallmeals.Takesmallbitesoffoods.Chewthoroughlyandwaitbetweenbites.Eatslowly,taking30minutestoeatameal.Stopeatingwhenno longer hungry. Avoid using a straw which may bringairintothestomach.Followtherecom-mended diet progression.

5. Successful weight loss with RNY gastric bypass depends on:

a. Eatingtherightfoods.

b. Listening to and obeying your stomach for signs of fullness.

c. Increased activity and exercise- ask your sur-geon when to start.

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Special Considerations for Sleeve Gastrectomy 1. Drinkadequatefluids. Sip 48-64 oz. low calorie,

non-carbonated beverages between meals. Staying hydrated is your first priority.

2. Eat the proper types and amounts of foods.

a. Only liquids or soft and well chewed foods should be consumed for the first 4-5 weeks, per the diet progression.

b. Onceyouaretoleratingstage4,eat3-6healthy,balancedminimealsdaily.Eatproteinfoodsfirst, then vegetables and fruits. Avoid bever-ages with calories (other than milk) and soft foods (pudding consistency) because these may prevent desired weight loss.

c. Track your protein intake. Real foods are the preferred source of protein, but supplements may be used if needed to reach your protein intakegoalof60-80gramsdaily.

d. Common problem foods are beef, breads, rice, carbonated beverages, pineapple, celery, fibrous foodsandfattyfoods.Fibrousandstringyfoodsmay cause an obstruction in the 1st few months after surgery.

e. Foodswhichhelpwithweightlossincludeleanprotein,veggies,fruits,wholegrains.Foodswhich may prevent weight loss include sweets, refined carbs, fruit juices, fatty sauces, fried foods and alcohol.

3. Don’tdrinkwithmeals! This can overfill your small-er stomach leading to discomfort and nausea. Avoid beveragesfor30minutesbeforeandaftermeals.

4. Avoid nausea and vomiting. Sip beverages slowly. Eatsmallmeals.Takesmallbitesoffood.Chewslowlyandthoroughlyandwaitbetweenbites.Eatslowly,taking30minutestoeatameal.Stopeatingwhen no longer hungry. Avoid using a straw which maybringairintothestomach.Followtherecom-mended diet progression.

5. Successful weight loss with sleeve gastrectomy de-pends on:

a. Eatingtherightfoods.

b. Listening to and obeying your stomach for signs of fullness.

c. Increased activity and exercise- ask your surgeon when to start.

6. Vitamin and mineral supplements are needed for life! See the chart on page 18 for recommendations.

Special Considerations for Lap Band Patients (LAGB)1. Drinkadequatefluids. Sip 64 oz. low calorie, non-

carbonated beverages between meals.

2. Eat the proper types and amounts of foods.

a. Only liquids or soft and well chewed foods should be consumed for the first 4-5 weeks. Keep the volume of calorie-containing foods andliquidsunder3cupsdaily.Thevolumeyoucan consume may not feel less than usual until after the band is filled for the first time. Your stomach should hold 1-2 TBSP at first and later 1/3-1/2cup.

b. Onceyouaretoleratingstage4,eat3-6healthy,balancedminimealsdaily.Eatproteinfoodsfirst, then vegetables and fruits. Avoid bever-ages with calories and pureed foods (pudding consistency) because these may prevent desired weightloss!

c. Common problems foods are beef, breads, rice, carbonated beverages, pineapple, celery, fibrous foods and fatty foods. Tolerance to some of these may improve over time.

d. Foodswhichhelpwithweightlossincludeleanprotein,veggies,fruits,wholegrains.Foodswhich may prevent weight loss include sweets, refined carbs, fruit juices, fried foods, fatty sauces, chips and alcohol.

3. Don’tdrinkwithmeals! This causes foods to pass too quickly through the band, leading to increased hunger and preventing desired weight loss. Avoid beveragesfor30minutesbeforeandaftermeals.

4. Avoid vomiting.Sipbeveragesslowly.Eatsmallmeals. Take small bites of food. Chew slowly and thoroughlyandwaitbetweenbites.Take15-30minutes to eat a meal. Stop eating when no longer hungry. Avoid using a straw which may bring air into the stomach.

5. Get your band adjusted as recommended by surgery. Proper adjustment is important for adequate weight loss. After an adjustment, consume only soft foods for2days,resumeahealthysolidfooddietonday3.Your band should be adjusted if you have excessive hunger, increased intake or slowed weight loss.

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6. Successful weight loss with lap band depends on:

a. Proper band adjustment

b. Eatingtherightfoods

c. Listening to your band for signs of fullness

d. Increased activity and exercise- ask your sur-geon when to start.

7. Vitamin and mineral supplements are needed for life! See page 18 for recommendations. Protein supplements are usually not needed long term after lap band and can interfere with adequate weight loss.

Special Considerations for Biliopancreatic Diversion with Duodenal Switch1. AlthoughtheBPD/DSreducesabsorptionoffat

and protein, you will still be able to absorb sugars and starches. (Carbohydrates.) Watch your sugar andstarchintaketopreventweightre-gain!

2. Thegoalistoeat3healthymealsdaily.Besuretogetenoughprotein,55-60gdailyatfirst,increasingto90-120gdailyasyouareabletoconsumemore.

3. Avoidcarbonation,caffeine,highcarbohy-drate liquids.

4. This procedure increases risk of lactose intoler-ance. Be aware of an increase in gas and diarrhea with dairy products, particularly milk. Try soy milk, lactaid (enzyme drops or treated milk) or yogurt and low fat cheese.

5. Post-op problems:

a. Nausea. This can be related to acid in the stomach, sensitivity to odors, pain medications, not eating enough, vitamin supplements and dehydration. Take antacid as prescribed, stay hydrated. Try taking vitamins at bedtime.

b. Vomiting: Often due to overeating.

c. Loose stools: Stools will be softer after this surgery.Excessfatandpossiblylactoseintoler-ance can cause loose stools.

6. Fatsolublevitamins(ADEK)arepoorlyabsorbedafter this procedure. As a result, lifelong supple-mentation with these vitamins is required. You must take a fat soluble vitamin supplement for life in addition to your multivitamin in order to avoid deficiencies.

Pre-Surgery Shopping IdeasThe following is a list of ideas to help you prepare your kitchen and ultimately, prepare yourself for maintain-ing good nutrition after bariatric surgery.

Drinks:•Sugarfreedrinkmixes(powder),lowsodiumbroth•Decafteaorcoffee,sugar-freepopsicles,clear

protein drinks•Noncarbonatedflavoredwater,sugar-freegelatin•Sugarfreepopsicles•Sugarfreecoffeesyrupsforproteinsupplements

Protein:•Stage1and2babyfoods(plainmeats)•Lowfatcottagecheese•Nonfatdrymilkpowder•Lightyogurt/Greekyogurt,nosugaradded•Eggs/eggsubstitute•Highproteinsupplementbeverages/protein

powders•Lowfatcreamsoups•Sugar-freepuddingmix•Peanutbutterand/orpowderedpeanutbutter

Fruit:•Unsweetenedapplesauce•Stage1and2babyfood(unsweetened)•Cannedfruitspackedinwaterorjuice

Vegetables:•Stage1and2babyvegetables•Cannedcarrots,peas,beets,greenbeans

Starch:•Instant‘plain’hotcereals•Sweetpotatoes,potatoes•Noodlesandrice(well-cookedandmashed),not

for lap band•Quinoa•Couscous

Fat and flavorings•Flavoredcookingsprays•Cannedfatfreechicken,vegetable,orbeefbrothforflavoring/blenderizing,fatfreegravy

•Oliveoil,canolaoil,saffloweroil,transfatfreetubmargarine

Tools: •Blenderorfoodprocessor •Timerorwatch •Babyspoon •Smallplates •Waterpitcher •1oz.medicinecups•Shaker •Waterbottle (for protein supplements)

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Trouble Shooting

Nausea, Vomiting, Abdominal Pain, Bloating

• Can be caused by eating too quickly or eating too much, not chewing enough, drinking beverages with meals, lying down after eating

• Also caused by drinking cold liquids, using a straw, eating high fat or high sugar foods, eating gas-producing foods, or drinking carbonated beverages

Dumping Syndrome (Most common with RGB/LGB)

• Caused by rapid emptying of food into small intestine

• Symptoms include abdominal cramping, nausea, lightheadedness, flushing, rapid heartbeat, and diarrhea

• Typically occurs after eating simple sugars and high fat foods

• Include protein at each meal to reduce chance of dumping

Dehydration • Often occurs because you cannot take large sips of fluids

• Best course of action is to carry a water bottle at all times and sip frequently

• Sip slowly between meals, 6-8 cups per day

• Avoid carbonated beverages, as they cause gas

Nutrient Deficiencies

• Due to the reduced food intake and/or reduced absorption

• Choose nutrient dense healthy foods regularly

• May occur years after surgery, therefore, vitamin and mineral supplements are for life

• You may also need other supplements recommended by your health care providers based on laboratory results

Food Intolerances • Some foods are less tolerated after surgery. This occurs for several reasons and varies from patient to patient

• If you have difficulty tolerating certain foods, remove them from your diet and try again 1 to 2 weeks later

• Sometimes your body will reject a food that is normally tolerated well. This is normal.

• Food intolerances vary from person to person. This will be evaluated on a case by case basis

• Microwave cooking can change the texture of foods. Moist cooking methods, like a slow cooker, may work better.

Unsuccessful Weight Loss

• If your stomach is repeatedly challenged with larger quantities of food than recommended, it will stretch and you will regain the lost weight

• Eating high fat and high sugar foods can contribute to weight regain.

• Frequent “grazing” on low-nutrient foods is also likely to cause weight regain.

• Recommended portions let you know what is typical. Allow yourself to recognize when you are satisfied, and stop eating.

• Signs of fullness include a feeling of pressure, possibly nausea, and on occasion, pain.

• Stop eating before you feel full

• Eat healthy foods for a lifetime of good living

• Lack of exercise can lead to regain.

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Staying HealthyThe following are tips to help you stay healthy long term.

1. Weigh weekly. This can help you adjust if you start to gain weight back.

2. Monitoryourintake.Trackproteinintakestartingonemonthpostop.Usefoodlabelsandthecharton page 5 to help you determine protein intake. Anexamplefoodjournalcanbefoundonpage19.Keeping food and activity records can help keep you on track with your eating and exercise program andimproveslongtermsuccess!

3. Havelabsdoneasrecommendedbyyoursurgeonfor the first year, then yearly for the rest of your life. Nutrient deficiencies can occur years after bariatricsurgery!

The following labs are recommended: •VitaminB12/folatepanel• Iron panel•Lipid panel•parathyroid hormone•Vitamin A•Serum 25OH vitamin D•Albumin•prealbumin•CRP• chem 7 plus calcium• thiamin

4. Continuetoexerciseregularly!

5. Continuetodrinkwaterregularly!

6. Continuetochooseanutrientrichdiet!

7. Keeptakingyourvitaminandmineralsupple-ments for life!

8. Attend a support group whenever possible. Sup-port group participants have been shown to be more successful at maintaining their lost weight.

9. Follow up with your Registered Dietitian at the 4-6 weekspost-opclassandindividuallyat3months,6months, and 12 months post-op.

Weight Loss Surgery (WLS) Resources and HelpfulLinks

American Society for Metabolic and Bariatric Surgeryhttp://www.asbs.org/The official website of the ASBS provides informa-tion regarding the various techniques and the history behind WLS.

Association for Morbid Obesity Support (AMOS)http://www.obesityhelp.com/intro.html This site is a national online support group as well as a resource for information.

CalorieKing.comhttp://www.calorieking.com/This site is a very helpful website with an extensive food database with the nutritional values of foods. It can be used as a way to monitor daily intake, exercise patterns, and weight loss goals.

Nutrient analysis programs/online food journalswww.mypyramidtracker.gov or choosemyplate.govwww.fitday.com, myfitnesspal.com, sparkpeople.com

Professionalreferencesforthishandbook:Mechanick,JIetal.AmericanAssociationofClinicalEndocrinologists,TheObesitySociety,andAmericanSocietyforMetabolicandBariatricSurgeryMedicalGuidelines for Clinical Practice for the Perioperative Nutritional,Metabolic,andNonsurgicalSupportofthe Bariatric Surgery Patient. Surgery for Obesity and Related Diseases.4(2008)S109-S184.

Allis,LS,etal.ASMBSAlliedhealthNutritionalGuidelines for the Surgical Weight Loss Patient. Sur-gery for Obesity and Related Diseases4(2008)S73-S108

Woodard, GA, et al. Probiotics improve outcomes after Roux-en-Y gastric bypass surgery: a prospec-tive randomized trial. JGastrointestSurg.(2009)Jul;13(7):1198-204.

Snyder-Marlow,etal.Nutritioncareforpatientsundergoing laparoscopic sleeve gastrectomy for weight loss.JoftheAmericanDieteticAssociation(2010)April;110:600-607.

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Pre-op Bariatric Surgery Action Plan

Go shopping!

•Vitamin, mineral supplements□ chewable or liquid□ See chart page 18

•Protein supplements□ See pages 5

• Foodsyouwillneedpost-op□ See page 12

•Tools (baby spoon, small plate, timer, sippy cup, shaker, blender or food processor)

Get ready!

•Practice drinking 48-64 oz. water daily

•Practice eating slowly, chewing thoroughly□Take15-30minutestoeatone

ounce of food□ Listen for signs of fullness

•Wean yourself off of caffeine

•Keepthisbook-youwillneeditpost-op!

•Take your measurements and record on the chart at appendix 1. Also take a picture pre-op. Patients find that taking pictures and measurements monthly for the first year post op can help them see their progress better. The scale does not tell the whole story, so those measurements can help you avoid being discouraged when your weight loss slows temporarily.

Plan to see your Registered Dietitian

•Post op class, 4-8 weeks after surgery (callclinictoschedule)andat3,6and12months after surgery.

•Call for an appointment if you have prob-lems,ClinicalNutrition444-2189

•Attendmonthlysupportgroup.Call495-6967for times and location.

Measurement Equivalents and Abbreviations

Liquid Measures1 teaspoon 1/16 fluid oz.1 tablespoon ½ fluid oz. 3 teaspoons 1/16 pint1/8 cup 1 fluid oz. 2 teaspoons 1/8 pint¼ cup 2 fluid oz 4 teaspoons ¼ pint½ cup 4 fluid oz. 8 teaspoons ½ pint1 cup 8 fluid oz. 16 teaspoons 1 pint2 cups 16 fluid oz. 32 teaspoons 1 quart4 cups 32 fluid oz. 34 teaspoons6 cups 48 fluid oz. <<Your minimum daily goal!!

Dry Measures1 tablespoon 3 teaspoons ½ ounce2 tablespoons 1/8 cup 1 ounce4 tablespoons ¼ cup 2 ounces8 tablespoons ½ cup 4 ounces

Additional Measurement Equivalents30cc 2 tablespoons 1/8 cup60cc 4 tablespoons ¼ cup90cc 6 tablespoons 1/3 cup120cc 8 tablespoons 1/2 cup

Abbreviation Definitionscc unit of measure for liquidsc cupTsp teaspoonTBS or Tbsp tablespoonoz ounce

What can I do to get ready before my surgery?

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Post-OP Vitamin and Mineral Supplements – For LifeRGB Sleeve BPD/DS LAGB

MultivitaminLiquid or chewable, with minerals(iron, zinc, copper)

2 adult doses daily 1-2 adult doses daily, start with 2.

2 adult doses daily 1 adult dose daily

Calcium Citrate** w/ Vitamin DLiquid or chewableDivide into 2-3 doses

1500-2000 mg/d 1500 mg/d 1800-2400 mg/d 1500 mg/d

Vitamin D400-800 IU minimum

Check Amount in multivitamin and calcium supplement

Check amount in multivitamin and calcium supplement

Provided in ADEK Check amount in multivitamin and calcium supplement

Vitamin B-12Liquid, chewable, or sublingual

350 mcg/d orally or -1000 mcg/mo intramuscularly or500 mcg weekly intranasally




Iron with Vitamin C 40-65 mg/d may be needed for menstruating women

40-65 mg/d may be needed for menstruating women

40-65 mg/d Recommended

40-65 mg/d may be needed for menstruating women

ADEK(special water soluble, fat soluble vitamin supplement)

n/a n/a 2 tablets daily to provide:Vit A:5,000-10,000 IU/dVit D:600-50,000 IU/dVit E:400 IU/dVit K:1 mg/d

n/a

Body Measurement Chart

Date

HeadLeft ArmRight ArmBustChestWaistHipsLeft thighRight ThighLeft calfRight CalfTotal InchesTotal Inches Lost

Current WeightWeight Gain/LossTotal Weight Loss

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Food Journal - Post Bariatic SurgeryDay & Date Time Food/Beverage

How Much Notes

Protein Grams

Fluid Ounces

Sat

11/1/11 8 a.m. SF Instant Breakfast 4 oz Used enriched milk 9-11 4

9:10 a.m. Light cranberry Juice 3 oz Very full after 3 oz 0 3

10 a.m. SF Vanilla Pudding 4 oz Instant-Use enriched milk 9 4

Food Journal - Post Bariatic SurgeryDay & Date Time Food/Beverage

How Much Notes

Protein Grams

Fluid Ounces

Notes for Dietitian

a guide to bariatric surgery - st. peter's hospital

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