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Bariatric Surgery Program
Roux en Y Gastric Bypass
Sleeve Gastrectomy
CEAC 1285
May 2017
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Bariatric Surgery
This book provides information to help you prepare for surgery as well as long term
success after surgery. The information in this book is to be used for informational
purposes only. It is not intended to replace professional medical advice, diagnosis, or
treatment. Always consult your health care professional regarding specific treatment
or advice.
Remember to bring this book with you to all of your visits including
pre-surgical program visits, pre-admission visit, hospital stay, and all
follow up appointments after surgery.
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Bariatric Program
The program is based in Regina, Saskatchewan. Currently, we are the only
provincially funded Bariatric Surgery Program in the province.
Our team includes general surgeons qualified in bariatric surgery for obesity
treatment, a registered dietitian, registered nurse, exercise therapist, and psychology
team.
The Bariatric Program works with patients who have been referred by their attending
doctor or nurse practitioner to prepare for weight loss surgery.
Currently, we are the only provincially funded bariatric surgery program in
Saskatchewan.
Bariatric Program
Surgical Assessment Centre
#102 - 1621 Albert Street
Regina, Saskatchewan
Phone: (306) 766-0398
Fax: (306) 766-7551
Email: BariatricProgramRQHR@rqhealth.ca
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Table of Contents Page
Contact Information 2
Health Care Team 4
Types of Surgeries Performed 5
The Digestive System 6
Roux en Y Gastric Bypass Surgery 7
Sleeve Gastrectomy Surgery 8
How the Surgery is Done 9
Risks of Surgery 10
Program Goal 15
Patient Roles and Responsibility 15
Smoking 15
What to Expect 16
Stages of the Program
Initial visit 16
Approval for Surgery 16
Additional Visits 16
Psychology 17
Mindful Eating 18
Unhealthy Eating Habits 19
Strategies for Change 19
Exercise 21
Preparing for your appointment 22
Benefits of Physical Activity 22
Exercise Journals 23
Success with Physical Activity 24
Nutrition 25
Food Journals 25
Steps to Prepare 26
Eating Techniques and Guidelines 27
Preparing for Surgery and Planning Ahead 28
Managing Blood Sugars 29
Pre-Surgery Diet 30
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Bariatric Program Team
Considering bariatric surgery can be a very difficult decision. Our knowledgeable and
supportive team is here to guide and support you on this journey We provide
information about the surgery, what to expect in hospital, pre and post-surgery
nutrition, exercise recommendations, counselling, and support.
Our team supports you in every step of the way, focusing on your emotional, physical,
and nutritional needs while you are in the program.
Surgeons - are specially trained in bariatric surgery. They provide you with
information about bariatric surgery and help guide you in the direction of which
surgery is right for you. They provide follow up care related to bariatric surgery while
you are in the Bariatric Program.
Registered Nurse (RN) – is there to educate patients to help guide optimal treatment
strategies.
Registered Dietitian (RD) - assesses, monitors, and guides you towards the
nutritional changes you need to make to prepare for surgery. The RD is there to help
you achieve optimal nutrition and successful weight loss both before and after
surgery.
Psychology Team - completes a psychological assessment of your emotional
readiness for bariatric surgery and preparation for long term success. It may be
recommended that some clients obtain additional counselling in the community.
Exercise Therapist (ET) - guides clients toward safe and achievable activity goals.
Physical activity is an important part of any weight loss program.
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Types of Surgery Performed We offer both the Roux en Y Gastric Bypass and the Sleeve Gastrectomy procedures.
Both procedures performed in the Regina and are covered by Saskatchewan Health if
you are a resident of Saskatchewan.
We encourage you do to your own research and be well informed about both types of
procedures. Ultimately, it will be a discussion between you and your surgeon as to
which procedure is best for you based on factors such as medications and medical
conditions.
The following pages will discuss the normal digestive process; how this is altered
with surgery; how it is performed and the potential risks associated with surgery.
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Digestive System
Esophagus (food pipe) - the “pipe” that carries the food that you eat and drink from
your mouth to your stomach.
Stomach - where food is broken down into smaller pieces to be used for energy by
your body. Food then moves from the stomach to the small intestine.
Small Intestine - also called the “small bowel”. It is where much of the digestion and
absorption occurs. Two parts of the small intestine that are involved are the duodenum
and the jejunum.
Duodenum - the first and the shortest part of the small intestine Jejunum - the second part of the small intestine
Figure 2: Normal Digestive System
Anatomic regions of the stomach. [Reproduced with permission from Mercer DW, Liu TH, Castaneda A: Anatomy
and physiology of the stomach, in Zuidema GD, Yeo CJ (eds): Shackelford’s Surgery of the Alimentary Tract, 5th
ed., Vol. II. Philadelphia: Saunders, 2002, p 3. Copyright Elsevier.]
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Roux en Y Gastric Bypass Surgery This surgery is both a restrictive and a malabsorptive procedure. It restricts or limits
the amount of food you can eat and you absorb less calories and nutrients.
Your surgeon creates a new, smaller stomach pouch at the end of the esophagus by
stapling the top portion of the stomach. The larger “old stomach” is stapled closed.
This makes it “restrictive” - the new smaller stomach pouch limits the amount of food
you can eat.
The surgeon then cuts the small intestine at the jejunum and attaches it to the new
stomach. This process bypasses most of the stomach as well as the duodenum.
Bypassing the duodenum means less calories and nutrients are absorbed. This makes
it “malabsorptive” and therefore you absorb less calories and nutrients.
The larger or “old stomach” is still functioning and continues to secrete digestive
juices needed to help digest food when the duodenum and jejunum are rejoined lower
in the small intestine.
Figure 3: Roux en Y Gastric Bypass
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Sleeve Gastrectomy Surgery This is a restrictive procedure where most of the stomach is permanently removed.
The stomach is cut, creating a long “sleeve-like” stomach pouch. The stomach is then
stapled and the remaining portion of the stomach is removed. There is no change to
the small intestine, as compared to the Roux en Y Gastric Bypass.
This surgery often results in less feelings of hunger as it may decrease the amount of
“grehlin” which is produced. Grehlin is known as one of the “hunger hormones”.
The new “sleeve” stomach has a greatly reduced capacity, much less than the amount
the stomach can hold before surgery. Therefore, you feel full much quicker. As this is
a restrictive procedure, the stomach pouch is smaller, but functions much the same.
Note: This procedure cannot be reversed.
Figure 4: Sleeve Gastrectomy
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How the Surgery is Done
Both Roux en Y Gastric Bypass and Sleeve Gastrectomy procedures are
“laparoscopic”. Laparoscopic surgery is a minimally invasive surgery performed
using 5 to 6 small incisions. Each incision is about 5 mm to 14 mm long.
One incision is used to insert a small camera while the other incisions are used to
insert instruments needed to perform the surgery. The incisions are then closed using dissolvable sutures or staples.
Figure 1: Example of Port Placement for Laparoscopic Surgery
Diagram courtesy: From Schauer PR, et al,
eds. Minimally Invasive Bariatric Surgery,
1st ed. New York: Springer; 2007.
Reprinted with permission, Cleveland
Clinic Center for Medical Art &
Photography © 2005-2009. All rights
reserved.
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Risks of Surgery
Although laparoscopic gastric bypass and sleeve gastrectomy are relatively safe, as
with any surgery, there are important and potentially serious complications known to
be associated with this operation. This may include, but are not limited to:
Risks related to general anesthesia. Although infrequent, difficulty in placement of
the breathing tube is the most common problem and potentially the most serious, if it
resulted in significant oxygen deprivation that could result in brain or heart injury. To
avoid this, the placement of the tube (intubation) might need to be performed under
local anesthesia while you are awake. When the tube is securely in place, it allows the
anesthesiologist to safely put you to sleep before the operation begins. As a result of
intubation you may experience a sore throat for 3 to 5 days.
Vomiting and aspiration. Due to intubation there is always a risk of vomiting
and aspiration of stomach contents which can lead to pneumonia and is
potentially life threatening. It is extremely important that you do not eat or
drink anything after midnight the night before surgery unless specifically
advised to take sips of water.
Chipped, broken, or loose teeth. This may occur as a result of intubation. It is
important to tell your anesthesiologist if you have loose teeth or dental
problems. Remove your false teeth before surgery.
Stroke or heart attack. Although infrequent, it is possible, especially in older
patients with a history of heart disease.
Nerve injuries to the arms and legs resulting in some loss of use can occur. These are related to the positioning on the operating table and are almost
always temporary. Great efforts are made to avoid this.
Bleeding and injury to vital organs. Laparoscopic surgery uses punctures to enter
the abdomen and can lead to injury to your internal blood vessels, stomach, liver,
colon, intestine, or spleen during surgery. Hematoma (pooling of blood under the skin
similar to a bruise) and internal bleeding can be minor or much more serious and may
lead to the need for emergency surgery, transfusion, or death.
Blood transfusions. The risk of needing a transfusion is small.
Leaks, abscess, and infection. An anastomosis is the connection when the surgeon
fastens bowel to bowel or bowel to stomach. If an anastomosis does not form a
complete seal, an anastomotic leak occurs which is the leakage of fluid from within
the bowel (anastamotic leak). Fluid from the gastrointestinal tract, containing at least
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some bacteria, leaks out into the abdomen where it does not belong and can cause a
serious infection along with swelling, a rapid pulse rate, and sometimes the formation
of an abscess.
This is always a very serious complication. Diagnosis and treatment are made much
more difficult by severe obesity and this is one of the many reasons why it is best to
lose as much weight as you can before surgery.
Fistulas. This is an abnormal connection from one hollow organ to another.
Gastrogastric fistulas are a possible complication of Roux en Y Gastric Bypass.
Sometimes, surgery is needed to separate the new small pouch from the “old” stomach
pouch. Symptoms of ulcer, intestinal bleeding, esophageal stricture (narrowing), and
increase in volume of meals that can be tolerated at one time are signs a fistula may be
present.
Atelectasis. This condition happens when part of the lung collapses caused by lack of
motion of the chest wall. Atelectasis can cause a fever after surgery and leads to
developing pneumonia. This is prevented by lung exercise through deep breathing.
Pneumonia. This is an infection in the lungs after surgery and can be serious. It is
prevented using good anesthesia and respiratory treatment and preventing atelectasis.
Pulmonary embolism. This affects the lungs and the heart but usually starts in the
legs with formation of blood clots. Although blood clots can occur at any time, and
are more likely in overweight patients, these are especially likely at the time of and
soon after surgery due to decrease in movement or activity.
If blood becomes still due to lack of movement or activity it clots in the vein. A
pulmonary embolism is when a clot breaks off and floats through the veins to the
lungs. The blood clot blocks the arteries in the lung and can cause a part of the lung to
lose circulation. If the circulation to a large part of the lung is affected, the heart is
then placed under a lot of strain as it cannot receive oxygen from your lungs. This
may cause the heart to fail suddenly, which can be fatal.
Pulmonary embolism is prevented with elastic stockings to compress the legs and
keep the blood flowing faster in the veins, by administering heparin (blood thinner)
before and after surgery, operating efficiently, and by getting up to walk as soon as
possible after surgery.
Bowel obstruction. After any abdominal surgery, scars called “adhesions” can form
in the abdomen. Even many years after the original operation, the bowel can be
obstructed at the site of the adhesion. This usually occurs because the bowel twists or
kinks at the site of the adhesion and the obstruction must be relieved before the bowel
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loses its blood supply and dies. Usually, an emergency surgery is needed to correct
this. Most bowel obstructions occur within a few days after surgery. If so, the
adhesions are much softer and often come apart on their own.
Obstruction of the stomach outlet. During surgery, the opening from the stomach to
the intestine is made small in order to slow the flow of food out of the small stomach
pouch. Immediately after surgery there is swelling which can make it difficult to
swallow liquids, but this usually gets better in a day or two. All healing occurs by scar
formation and because scars always contract, the opening between the stomach and
bowel can become too small so that food cannot get through. This obstruction causes
nausea and vomiting and must be corrected usually by balloon dilation through an
endoscope passed through the mouth.
Nausea and vomiting. These are the most common complications occurring in the
first few months after bariatric surgery. They may occur after eating too fast, drinking
liquids while eating, not chewing enough, or eating more than the pouch can
comfortably hold. It is critical to eat very slowly and chew foods very well.
Sometimes nausea and vomiting can be triggered after trying a new food. Wait a few
days before trying a new food again. Tell your doctor if frequent vomiting occurs
despite using proper eating techniques.
Diarrhea/constipation. Diarrhea is uncommon long term, but not unusual in the first
few weeks after surgery. Constipation is more common early after surgery. It is not
necessary to take a laxative unless you have not had a bowel movement within 5 days
after surgery. Ask your bariatric team what is best to take.
Overeating. Eating more than the new pouch can hold may cause vomiting,
expansion of the pouch, weight gain, or even rupture of the stomach. Almost all
patients undergoing weight loss surgery have had problems with overeating. The
causes for this are complex. Surgery does not change this. Education, counselling, and
ongoing follow up are important.
Dehydration. This can occur especially if there is frequent vomiting or diarrhea.
Prevent dehydration by sipping on water or other low calorie beverages in between
meals, keeping in mind that the stomach can only hold 3 to 4 oz (.09 to .12 L) at a
time.
Dumping syndrome. This occurs when food passes too quickly from the stomach to
the small intestine. Symptoms may include a combination of nausea, dizziness,
uncomfortable fullness, cramping, diarrhea, weakness, sweating, and rapid heart rate.
Eating very sweet or high sugar foods can cause dumping. Your RD discusses foods
to avoid.
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Food intolerances. Intolerance to red meats, bread, rice, pasta, high fibre foods, and
milk are common. However, food intolerance varies with each individual.
Hair loss. Thinning hair or loss is common during rapid weight loss. This commonly
occurs between 3 and 6 months post surgery. It usually resolves when nutrient intake
and weight stabilize. Take the recommended supplements every day and achieve the
recommended amount of protein every day to minimize hair loss.
Bile acid reflux. This occurs when bile flows back into the stomach. Symptoms can
be resolved with treatment with antacids.
Inability to perform upper gastrointestinal endoscopy after surgery. Endoscopy is
a visual examination that allows for examination of the inside of the stomach and
duodenum by using an instrument called an endoscope. The endoscope is passed
through your mouth, down to your esophagus, stomach, and small intestines.
Endoscopy is performed to detect abnormalities (e.g. ulcer or tumor). Since your
gastric anatomy is altered during surgery, endoscopy to detect stomach problems in
your bypassed stomach is very difficult. Gastric cancer in the bypassed stomach is
rare but early diagnosis of gastric cancer by endoscopy cannot be performed because
of the inability of the endoscope to pass through the roux-en-y limb into the
duodenum and stomach. This prevents endoscopic access (Endoscopic Retrograde
Cholangio-Pancreatography Procedure or ERCP, Endoscopic sphincterotomy) to the
pancreatic duct and bile duct. However, magnetic resonance imaging (MRI) can
visualize those structures and the bile duct can be accessed percutaneously through the
abdominal wall and the liver in the rare instances it is required.
Symptomatic gallstones. Abdominal pain due to gallstones has been known to
develop in a small number of patients who have previously undergone gastric bypass
where the gallbladder is intact. Laparoscopic cholecystectomy (removal of the
gallbladder) may be required.
Adhesions. These are scar tissues caused by healing after surgery and are much less
common after laproscopy.
Headache from caffeine withdrawal. This can occur in patients who frequently
consume coffee, tea, or soda and can sometimes be quite severe. Stop all caffeine
intake well before the time of surgery.
Stomach pain and ulcers. These are complications which may require medical
attention. Tell your doctor if frequent stomach pain becomes a problem.
Malnutrition, vitamin and mineral deficiencies. Rapid weight loss may result in
symptoms of malnutrition and anemia. Decreases in iron, vitamin B12, and/or folate
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may occur after undergoing Roux en Y gastric bypass. Vitamin B12 is absorbed in the
stomach and duodenum which is largely bypassed with the Roux en Y surgery. With
either Roux en Y or Sleeve Gastrectomy surgery, you may require additional vitamin
B12. Taking the prescribed oral multi-vitamins regularly is useful in preventing folate,
iron and B12 deficiency after surgery.
Peripheral neuropathy. Disorders resulting from injury to the peripheral nerves have
been reported after bariatric surgery where protein and vitamin malnutrition has
occurred.
Osteoporosis and bone loss. Due to low stomach acid and bypass of the duodenum
after Roux en Y Gastric Bypass, calcium absorption is decreased. Both reduced
absorption and reduced dietary intake of calcium and vitamin D are factors that
contribute to bone loss after bariatric surgery.
Gastrointestinal bleeding. Bleeding from a duodenal ulcer after undergoing weight
loss surgery for obesity has been reported.
Abdominal wall hernia. Weakening of the abdominal wall due to surgical incision
although unlikely, is a risk in any surgical procedure. Hernia is very uncommon after
laparoscopic bariatric surgery.
Changes to your body image and depression. This is common after weight loss
surgery. It has been reported that divorce rates may increase in patients who have
undergone bariatric surgery.
Reproductive risks. It is well documented that obese patients are often unable to
become pregnant. Studies have shown that women who have undergone bariatric
surgery and lose weight are usually able to become pregnant, have normal
pregnancies and deliveries, and healthy babies. However, if you become pregnant
during the first 2 years after surgery, the effect that rapid weight loss has on the
unborn child is unknown. You must use one or more of the medically acceptable
methods of birth control during the period of active weight loss. If you can become
pregnant and are not presently using a reliable method of birth control, talk to your
doctor before surgery about which method is right for you.
Pregnancy should not occur during the first 2 years after surgery and patients must be
certain not to miss any of their vitamin supplements when they decide to become
pregnant later.
Death. Although all measures are taken to assure optimal surgical care, death is a
potential risk of any surgery
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Bariatric Program Goal
Our goal is to help you along your journey in preparation for surgery as well as post-
surgical care while in the Bariatric Surgical Program.
Benefits for you while in the program: increased knowledge of healthy foods and consultation with a registered
dietitian
psychological support to help you learn strategies to deal with unhealthy
eating patterns such as emotional eating or mindless eating
fitness assessment and exercise goals that are right for you
registered nurse support.
Patient Roles and Responsibilities
While enrolled in the program, you are agreeing to:
Attend all program appointments
Note: Missed appointments may result in dismissal from the program.
Attend education classes
Lose or maintain weight during the pre-surgical program. Depending on your
BMI, you may be required to lose a certain amount of weight
Keep accurate food and beverage and activity records every day and bring them
to every appointment
Work on eating techniques to prepare for life after surgery such as: eating
slowly, chewing your food very well, and not drinking with meals
Demonstrate that you have made lifestyle changes and are mentally prepared
for surgery, and continued success after surgery.
Be smoke free before starting the program. This is a requirement of the
program. You are also agreeing to remain smoke free lifelong
Not be pregnant at the time of acceptance into the program or during the
duration of the program.
Smoking
You are required to be smoke free before entrance into the program. Smoking can
increase your risk of complications such as anesthetic complications, blood clot
formation in the legs or lungs. Patients who smoke are at risk for pneumonia and
infection. Smoking stimulates stomach acid production which may lead to ulcer
formation. You must agree to permanently stop smoking after surgery.
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What to Expect
Before Your First Visit You are required to have specific blood work done before your first clinic visit.
Stages of the Program Before approval for surgery, you must successfully complete the pre-surgical
program. The purpose of the program is to help you to succeed after surgery. You
will attend multiple visits at the clinic where we discuss topics such as emotional and
mindless eating, healthy eating and exercise. Before surgery is the time to focus on
creating lifelong changes for success. The habits you go into surgery with, are the
same habits you come out with.
Initial Visit Plan to spend 2 consecutive days at the clinic. Feel free to bring a bagged lunch
and water. There are limited food venues on site.
On the first day, you meet with the RN and a surgeon.
On the second day, you meet with the RD, psychology team member, and ET
individually.
You may be at the clinic for the majority of the days.
You will attend multiple visits at the clinic between your initial visit and your
approval for surgery.
Approval for Surgery Your progress in the pre-surgical program is reviewed by the team, including the
surgeon. All aspects are taken into consideration, including your general health.
Depending on your progress in the pre-surgical program and your health status, you
will be approved for surgery and placed on a surgical wait list.
Additional Visits
We want you to have the best possible success after surgery. Sometimes, additional
time in the pre-surgical program is needed to help you prepare for surgery. The team
determines if additional time in the pre-surgical program would be beneficial.
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Psychology
Why is Psychology Part of the Pre-Surgical Program
The decision to have bariatric surgery is a very important one. Making major lifestyle
changes that are recommended for best outcomes following surgery can be stressful.
The Bariatric Team wants to ensure that patients are able to make these changes and
have successful outcomes, both physically and emotionally. The psychology team will
discuss any emotional or psychological factors that might interfere with maintaining
healthy eating patterns and lifestyle changes.
What is Discussed with Psychology
How a person is able to change their eating behaviour before surgery has a lot to do
with how successful he/she will be at changing their eating habits after surgery and
lifelong. Aspects of your life that may affect your weight loss journey may include:
Your understanding of lifelong changes necessary for success
Stress management
Support networks
Ability to follow a treatment regime (nutrition, exercise)
Body image before and after surgery
Emotional or mindless eating.
Challenges with Emotional Eating
It is common for people to cope with overwhelming emotions of stress by overeating
or under eating. Examples of overwhelming emotions are: sadness, depression,
anxiety, loneliness, anger, frustration, and envy.
Boredom, mindless eating, or binge eating often play a role in the development of
unhealthy eating patterns. When we are bored, we might eat for something to do
rather than eat because we are hungry. Eating a large amount of food within a short
period of time and feeling a loss of control. It is often a means to escape our emotions
in the short term and is typically followed by the feeling of guilt or shame after.
Mindless eating is not paying attention while you are eating such as in the car, in front
of the TV or computer, or always eating on the run.
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Mindful Eating
Do you ever eat on-the-go? While driving? While at work? In front of the television?
Many of us eat while multi-tasking. Often, we are not fully aware of what we are
eating because we are distracted. This is called mindless eating. When we eat
mindlessly, we are more likely to overeat and feel less satisfied with what we have
eaten.
Mindful eating is the opposite of mindless eating. It involves being in the present
moment and paying attention to why we are eating, what we are eating, and how we
are eating. Mindful eating is a way to develop healthy eating patterns. Eating
mindfully allows us to enjoy what we are eating, notice feelings of fullness, and
prevent overeating.
An important aspect of mindful eating is that it allows us to become aware of the
thoughts and feelings that arise around food, and to notice any impulses to soothe or
comfort ourselves with food.
The following are some examples of what you can do to begin practicing mindful
eating:
Stop and check-in with yourself. Take time to ask yourself, “How am I feeling
right now? Am I actually hungry?”
Eliminate distractions. For example, sit at your kitchen table and turn off the
television and other distractions. This will help you stay in the moment and bring
your awareness to what you are eating.
Slow down. Focus on chewing more slowly, taking breaths between bites, or even
setting your utensils down between bites.
Use all your senses. While you are eating, pay attention to the smell, texture, and
different flavours of the food. This will help you stay in the moment.
Notice your thoughts. You might find that your thoughts wonder while you eat -
that is okay! Every time your mind wonders, bring your attention back to your
senses and the experience of eating.
Awareness of bodily cues. Notice how your body feels while you eat. Bring
awareness to feelings of fullness that may arise during or after the meal.
It is important to remember that, like any new skill, mindful eating takes practice!
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Other Unhealthy Eating Habits
Skipping meals
Snacking/grazing all day
Habitual evening snacking
Eating out most of the time
Eating unhealthy food or fast food regularly
Drinking your calories
Eating for celebration or reward
Overeating
Eating in the middle of the night
Sometimes these unhealthy eating habits are so ingrained in our lives we are not even
aware of them. To change these habits it is important to increase your awareness of
your unhealthy eating patterns, including what might trigger them, so you can start to
make change. Our psychology team can provide direction about how to cope more
effectively with thoughts and emotions that may derail a person’s best efforts to
develop healthy eating patterns and other lifestyle changes such as exercise.
Part of the process of creating better eating habits is to take notice of when and why
we are eating. A useful strategy in gaining insight into unhealthy eating patterns is to
record the circumstances in which you eat, as well as any thoughts or emotions you
experience prior to and while you eat. This type of journaling can help identify when
you engage in unhealthy eating patterns such as emotional or mindless eating. Once
you develop the awareness of when you might use food to manage your emotions, you
can start to develop alternative coping strategies. For example, a helpful strategy
when bored is to practice distraction techniques. Placing notes on the fridge or pantry
is one idea to remind yourself to slow down and consider whether you are actually
feeling hungry, or using food to manage emotions.
Strategies to Manage Challenging Eating Patterns
Distract yourself:
Clean
Knit/crochet/craft
Play a game on your cell phone or computer
Do a puzzle with lots of pieces
Play solitaire
Get outside of your house, even if you just sit outside.
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Find alternatives to comfort yourself:
Take a hot bath or shower
Light candles
Drink hot herbal tea
Play or cuddle with your pet
Exercise
Engage in a favorite hobby such as gardening
Read a good book
Listen to soothing music.
Use your social supports:
Spend time with or reach out to supportive family members, exercise buddies,
friends, co-workers or counsellors when trying to overcome challenging eating
patterns.
Be aware of anyone that may attempt to derail your weight loss efforts and
consider their influence on your efforts.
For strategies to overcome challenging eating patterns (e.g. emotional eating), there
are helpful workbooks and general reading references provided in the Additional
Resources Section.
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Exercise
What to Expect From an Exercise Therapist
Many patients find it difficult to exercise before surgery due to health conditions such
as increased shortness of breath, joint pain, or heart conditions. While in the program,
a Certified Exercise Physiologist (CEP) or Exercise Therapist (ET) works with you
and your doctor to develop a physical activity plan that is safe and appropriate for you
and your current abilities.
A healthy lifestyle includes a combination of proper diet and exercise which can
improve your overall physical and mental health. Therefore, demonstrating the ability
to make and sustain these lifestyle changes before surgery is an important component
of the program. Keeping consistent, accurate activity logs is required. You need to
bring these to each appointment to be reviewed.
If you are physically able, you may be asked to perform a short fitness evaluation
during your exercise therapy appointment. This may include:
6 minute walk test (cardiovascular exercise)
Sit to stand from a chair (functional lower extremity strength/endurance)
Sit and reach test (hamstring and low back flexibility)
The ET will assist you in developing and maintaining a healthier lifestyle through
physical activity. You may be prescribed individually tailored exercises and receive
educational material about many common questions related to physical activity.
Medical Clearance
Based on your health history, you may be asked to see your family doctor regarding
medical clearance.
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Preparing for your Exercise Therapy Appointment
Medications/Inhalers Please have any inhalers that may be needed during your fitness testing.
Appropriate Clothing and Footwear Wear comfortable clothing and footwear suitable for participating in physical activity
(e.g. t-shirt, comfortable pants, and running shoes/good supportive shoes). Relaxed
fitting clothing that does not limit your movement is best.
Food and Beverages To ensure the most accurate physical activity assessment results, it is important to
follow these instructions as they can affect your heart rate, blood pressure, and
physical movement.
Do not eat a large meal within 2 hours of your appointment.
Do not drink alcohol at least 6 hours before your appointment.
Do not drink caffeinated beverages at least 2 hours before your appointment.
Bring a water bottle with you.
Benefits of Physical Activity
Engaging in and maintaining a regular exercise routine is essential to staying healthy.
Combined with healthy nutrition, regular physical activity is the most efficient way to
lose weight. Once you reach your goal, it is part of maintaining a healthy weight.
Additional Benefits Maintains and increases muscle strength and flexibility
Improves balance, co-ordination, and mobility
Increases your energy level
Improves mood, self-esteem and confidence
Helps control high blood pressure, cholesterol, and diabetes
Improves overall quality of life.
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Exercise Journals
Keeping an exercise journal during the pre-surgical program is required and you need
to have these at each appointment to be reviewed. Journaling brings awareness to how
much and what type of activity you are doing.
After surgery, continue journaling your activity. This helps you to stay on track and
continue bringing awareness into your activity routine.
How to keep an exercise journal
You can start by downloading an app for exercise journaling onto your computer,
tablet or mobile device. There are many options available. See the Resource section
of this book or ask your ET for options. Keeping an exercise journal on a calendar or
in a notebook is also acceptable.
Record all of the activity you are doing that is over and above your daily living
routine. Record your walks at work, walking on the treadmill, swimming,
strengthening activities, etc. Make sure you are recording the type of activity
and the amount of time you did this activity for.
It is the awareness that you get from exercise journaling, that helps create behavior
change.
Sample Exercise Plan See Resource section of this book.
25
Success with Physical Activity Have fun. Always choose activities you enjoy.
Recruit others. Exercise with a partner, family, or friends.
Warm up and cool down. Start your activity with a gradual warm up of 5 to 10
minutes to help prevent injury. At the end of each workout make sure you gradually
cool down with a minimum of 5 minutes to minimize dizziness and risk of fainting.
Begin slowly. Water aerobics, swimming, elliptical, cycling, and rowing are great low
impact exercise options. When your body is ready, gradually increase the amount of
time you spend exercising from 20 to 60 minutes. Then over time, increase the
intensity.
Gradually progress. Slow and steady progressions are extremely important.
Advancing exercises too quickly (duration or intensity) places you at significant risk
for injury, setbacks to achieving your goals, muscle soreness, and loss of motivation.
Set realistic goals. Set small, weekly goals that are realistic and attainable. Keep a log
of the type of activity and the time spent doing that activity on a daily basis. At the
end of the week check to see if you have met your desired goals.
Drink water. It is important to stay hydrated before, during, and after exercise. You
need to replenish the fluids you have lost through sweat. Do not wait until you are
thirsty. By the time you are thirsty, you are most likely already dehydrated.
Stay safe. Check with your doctor before starting an exercise program. Listen to your
body. If something does not feel right, slow down or stop, and consult your doctor if
necessary.
26
Nutrition The best time to make changes in your food choices and lifestyle is before surgery.
The changes you make need to be sustainable lifelong. Surgery alone does not make
you successful with losing and maintaining your weight loss. Keeping a food journal
and making changes in your food choices and eating patterns is an effective way to
help lose weight and prepare for surgery. It is part of the lifelong commitment.
Food Journaling
Keeping a food journal during the pre-surgical program is required. You need to
bring these to each appointment. Food journals act as an awareness tool. The first step
in any behaviour change is awareness. It is not just the actual act of recording the food
you eat, but rather what you learn from keeping food records and the changes that you
make based on this. Many studies have shown that those who keep food records
consistently lose twice as much weight as those who do not keep food records and are
more successful at maintaining weight loss long term.
After surgery you must continue to keep food records to ensure you are meeting your
protein and fluid needs.
How to keep a food journal
You can start by downloading an app for food journaling onto your computer, tablet
or mobile device. There are many options available. See the Resource section of this
book or ask your RD. Keeping a food journal in a notebook is also acceptable.
Record everything you eat and drink. Be specific. Remember to record
condiments as well as this can contribute calories.
Be as accurate as you can be. Weigh and measure food portions. Avoid
“eye-balling” as we often tend to underestimate portion sizes.
It is a good idea to record the places where you eat and the times. This helps
you gain awareness into the pattern of your eating and why you are eating at
certain times.
It is the awareness that we get from food journaling, that helps create behavior
change.
27
Steps you can take to prepare:
Stop caffeine
Stop alcohol
Stop drinking carbonated beverages
Avoid foods and beverages high in sugar
Eat 3 meals a day to avoid skipping meals
Start practicing eating techniques that will help you after surgery.
Caffeine Caffeine can irritate your stomach lining especially with your new, small stomach.
Caffeine should be avoided at least initially after surgery. It can take time to wean off
caffeine so you should be starting to do this during the pre-surgery program.
Alcohol We recommend that you do not drink alcohol for 1 year after surgery. Alcohol can be
an irritant to the new stomach pouch and you may find that you feel the effects of
alcohol from even a very small quantity. Alcoholic beverages are high in calories and
may cause dumping syndrome.
Carbonated Beverages Carbonated beverages produce gas in your new, small pouch. This can be quite
painful. Continuing to consume carbonated beverages can create unnecessary stress
on your pouch and has the potential to expand your new pouch over time. You need to
eliminate all carbonated beverages both before and after surgery.
High Sugar Beverages and Foods Beverages such as fruit juices, iced drinks, specialty coffees, or added cream and
sugar are often very low in nutritional value and contribute a significant amount of
calories. This is the same with high sugar desserts and baked goods. Eating these
types of foods regularly can dramatically slow down weight loss.
Avoid Skipping Meals Skipping meals often leaves us too hungry at the end of the day. When this happens,
we tend to overeat. It is important to focus on 3 meals per day.
Practice Eating Techniques This is something you will need to practice well before surgery. This includes taking
30 minutes to eat a meal, chewing food very well, and not drinking fluids with your
meal. These are often some of the most difficult things for patients to practice.
28
Eating Techniques and Guidelines Always eat or drink very slowly. Pace eating your meals to last 30 minutes even
when the amount of food is very small. Eating too quickly can cause nausea and
vomiting.
Keep foods moist. This makes swallowing and digestion easier. Do not eat dry, over
cooked meats.
Chew food thoroughly. All food should be chewed to a liquid consistency while in
the mouth. Food that is not thoroughly chewed can cause nausea and vomiting or may
cause blockages in outlets.
Eat foods or beverages only in the amounts suggested. Eating larger amounts may
cause vomiting, weight gain, expansion and even rupture of the stomach.
Do not consume carbonated beverages.
Do not drink fluids with meals, 30 minutes before or 30 minutes after eating meals. This may overload the stomach causing nausea or vomiting, and may cause
expansion and rupture of the stomach.
Drink plenty of fluids. Without adequate fluids, the body becomes dehydrated. To
prevent dehydration, drink 3 to 4 oz (90 to 120 mL) of water or other acceptable low
calorie beverages between meals.
Note foods that are not well tolerated. Every individual has their own food
intolerances. Sometimes after surgery people can develop lactose intolerance. These
people can try lactose reduced milk. If a food is not tolerated, eliminate it and try it
again in a small amount a week later. Try only 1 new food at a time.
Use a baby spoon to get the bite size right. This can help teach you the correct
amount of food to eat at one time.
Stop eating as soon as you are full. Listen to what your body is telling you. One
extra ounce or mouthful can be enough to make you vomit. Eating beyond being full
can lead to stretching of your pouch.
Choose nutrition and quality. When you can consume so little, it needs to be the
best it can be.
29
Preparing for Surgery and Planning Ahead Return to work or school When you return to your regular activities depends on what you do and how you feel.
Six weeks is the recommended time to be off work or school. Discuss this with your
doctor at scheduled follow up visits.
Surgery Date You will receive a call with a surgery date approximately 4 to 5 weeks before surgery.
Preadmission Clinic You will need to be seen in Regina at the Preadmission Clinic prior to surgery. The
clinic prepares patients for elective surgeries. A medical history and teaching about
the surgery is done over the phone or in person at the clinic. The surgeon may ask you
to have further investigation completed before the surgery and this may include being
seen by other specialists or an anesthesiologist. Further testing such as laboratory, X-
rays, etc. may also be done prior to surgery.
Medications Your surgeon will review your current medications and may recommend follow up
with your family doctor regarding any changes needed.
Blood work You will be given any necessary laboratory requisitions at your approval appointment.
This can be done at your nearest outpatient laboratory.
Additional Information Please refer to “My Surgery Planning in Advance” that was provided to you upon
approval for surgery.
30
Managing Your Blood Sugars
The pre-surgical diet is a low carbohydrate diet. You need to closely manage your
diabetes while on the pre-surgical diet. It is important to talk with your diabetes health
care team before starting your liquid diet as your diabetes medications may need to be
adjusted.
If you do have a low blood sugar while on the liquid pre-surgical diet, it is important
to treat it right away. This is the one time you can “break away” from the pre-
surgical liquid diet.
If your blood sugar is less than 4.0 mmol/L, take 15 g of fast acting sugar right away.
Choose 1 of the following:
1 tablespoon (15 mL) sugar or 3 sugar cubes, dissolved in water
¾ cup (200 mL) juice
6 Life Savers® (must be chewed)
1 tablespoon (15 mL) honey
Wait 15 minutes. Check your blood sugar. Repeat treatment if still less than 4.0
mmol/L or if symptoms persist.
31
Pre-Surgery Diet - 14 Days Before Surgery
For 14 days before your surgery you must follow a liquid, high protein diet. The pre-
surgery diet helps shrink the liver and makes it easier for the surgeon to perform the
surgery. After surgery, you transition through a liquid to a pureed and then a regular
diet. This transition is designed to help you heal and to meet your fluid and nutritional
needs.
There are many variations in both the pre-surgery and post-surgery diet progression
for bariatric surgery. Follow the diet instructions given to you at the Bariatric
Program.
High Protein Drink Recipe
Purchase ISOFLEX™ nutrition supplement. It can be purchased at various locations.
Ask your Dietitian. This supplement comes in different flavours, all of which are
acceptable.
Make up a full day’s batch and refrigerate!
Take your high protein drink supplement as directed (300 mL or 1 ¼ cups at
breakfast, lunch, supper, and before bed).
Eliminate all other meals and snacks.
Drink adequate water to prevent dehydration.
You can also have sugar free, low fat, clear fluids
Take 1 standard adult multivitamin each day while on the pre-operative diet.
Allowed Sugar Free Fluids: Crystal Lite™, MIO™, or any other similar, sugar free clear fluid
Broth (clear beef, chicken or vegetable broth)
Sugar Free JELLO™
Sugar Free Popsicles (less than 5g carbohydrate per popsicle and limit to 1
to 2 per day)
Decaffeinated coffee or tea - black without milk or sugar added
Note: The day before surgery, consume only low calorie, low fat, sugar free clear
fluids (water, broth, tea, or sugar free JELLO™). Do not consume the high protein
drink the day before your surgery.
Note: Do not eat or drink anything after midnight the day before your surgery.
Recipe:
80 grams ISOFLEX™
1200 mL (5 cups) of 2% milk
Combine protein powder with the milk. Store prepared drink in the refrigerator. This
recipe makes 4 servings of 300 mL (1 ¼ cups). Take one serving 4 times per day
(breakfast, lunch, supper, and before bed).
32
After Surgery
33
After Surgery Page
What to expect in hospital
Stage 1 to 3 34
Stage 3 meal plan to follow for 2 weeks after surgery 35
“Leak” test 36
Post Surgery Follow up Appointments 36
Recovery 36
Stage 4: Pureed/Soft Foods (2 weeks after surgery) 39
Protein and Fluid Goals 39
High Protein Foods 41
Sample Meal Plans 42
Foods Included and Not Included 45
Stage 5: Low Fat Solid Foods (6 weeks after surgery) 46
Protein and Fluid Goals 46
Sample Meal Plan 47
Foods to Include, Avoid and Less Tolerated 48
Protein 50
Vitamin/Mineral Supplements Lifelong 51
Potential Nutrition Related Complications after Surgery 53
Exercise After Surgery 56
Recommendations 56
Long term Exercise Goals 57
Psychological Considerations After Surgery 58
Body Image 58
Unhealthy Eating Habits 58
Social Supports 58
Weight Loss Expectations 58
Weight Plateaus 59
Weight Regain 59
Reminders 60
Additional Resources 61
34
What to Expect in Hospital: Nutrition After Surgery
Stage 1: Water Typically, you progress to Stage 1 within a day after surgery.
Allowed: 30 mL (1 fluid oz) water per hour.
Reminders: Use the 30 mL (1 oz) medicine cup provided to you in hospital
Write down the amount of all the water that you drink on the fluid record
sheet that is provided.
Stage 2: Sugar Free Clear Fluids Usually 24 hours after Stage 1
Allowed: 30 to 90 mL (1 to 3 oz) of regular clear broth, water, sugar free JELLO™
Fluid Goal: 1500 mL (6 cups per day)
Reminders: Stop sipping as soon as you feel full. Never force yourself to finish.
Once you reach your fluid goal, your IV fluids may be discontinued.
Feel free to bring your own Crystal Lite™, MIO™, or other sugar free
clear fluid.
Typically, you will be seen by the unit RD on this day. Your home diet will be
reviewed and you will be given your follow up clinic appointments.
35
Stage 3: Low Sugar High Protein Liquids Usually 24 hours after Stage 2
Duration: You must follow the Stage 3 liquid diet for 2 to 3 weeks after
surgery or until follow up with RD.
No solid food during the Stage 3 diet.
Foods Allowed: 120 mL (1/2 cup) of your high protein drink every 2 hours,
8 times per day.
120 to 240 mL (1/2 to 1 cup) of sugar free fluid taken between the
high protein drink
Allowed fluids: water
sugar free drinks such as Crystal Lite™, MIO™
black decaffeinated coffee or tea
clear broth
tomato or V8® juice
sugar free popsicles less than 20 calories each, no more than 2 per
day
sugar free JELLO™
Powerade Zero™ or G2™ (low sugar Gatorade)
Other sugar free/low calorie fluids
Fluid Goal: At least 1500 mL (6 cups) daily. Includes high protein drink
and allowed fluids. Sip all fluids slowly. Stop drinking
immediately if you feel discomfort.
Protein Goal: At least 60 to 80 grams of protein per day. Track your protein intake.
Vitamin/Mineral Supplements:
Take 2 chewable adult multivitamins per day such as Jamieson Multi 100%
Complete™ if you have had Roux en Y Gastric Bypass surgery.
Take 1 chewable adult multivitamin per day such as Jamieson Multi 100%
Complete™ if you have had Sleeve Gastrectomy Surgery.
Take 1 tbsp liquid Calcium Citrate with vitamin D, 2 to 3 times per day.
Calcium doses should be divided over the day to maximize absorption.
36
*Make 14 copies of this page to use at home for the first 2 weeks after surgery.
It is important to follow the schedule below and the times outlined
to ensure adequate hydration and protein intake.
Stage 3: Meal Plan
Time Nutrition Supplement
8:00 a.m. 120 mL (1/2 cup) high protein drink
9:00 a.m. 120 to 240 mL (1/2 to 1 cup) allowed fluids
10:00 a.m. 120 mL (1/2 cup) high protein drink
11:00 a.m. 120 to 240 mL (1/2 to 1 cup) allowed fluids
12:00 p.m. 120 mL (1/2 cup) high protein drink
1:00 p.m. 120 to 240 mL (1/2 to 1 cup) allowed fluids
2:00 p.m. 120 mL (1/2 cup) high protein drink
3:00 p.m. 120 to 240 mL (1/2 to 1 cup) allowed fluids
4:00 p.m. 120 mL (1/2 cup) high protein drink
5:00 p.m. 120 to 240 mL (1/2 to 1 cup) allowed fluids
6:00 p.m. 120 mL (1/2 cup) high protein drink
7:00 p.m. 120 to 240 mL (1/2 to 1 cup) allowed fluids
8:00 p.m. 120 mL (1/2 cup) high protein drink
9:00 p.m. 120 to 240 mL (1/2 to 1 cup) allowed fluids
10:00 p.m. 120 mL (1/2 cup) high protein drink
37
X-Ray Test
Your surgeon may decide to perform an X-ray test, often referred to as a “leak test”
following your surgery. For this exam, you are required to swallow X-Ray dye and
have X-Ray’s performed to ensure your surgery is “water tight” and there are no
leaks.
Post-Surgery Follow Up
Follow up appointments are extremely important after having bariatric surgery.
It is expected that you attend all appointments.
You will be seen at 2 weeks and 6 weeks after surgery. The clinic will notify you of
further follow up appointments.
It is important to keep all appointments so that your progress can be monitored and if
you have any problems, these can be addressed sooner rather than later.
Recovery
Do not sit or stand for a long period of time. It is important to change positions and
walk around to help avoid formation of blood clots.
It is recommended that you plan to take 6 weeks off to recover after surgery. Most
patients feel very tired and less energetic after surgery. Do not lift heavy objects 10
lbs (4.5kg). Do not do pushing and pulling motions such as vacuuming. Do not do
any strenuous exercise for 4 to 6 weeks unless directed by your doctor.
You can start walking after you get home from the hospital in bouts of 5 to 10 minutes
at a time, repeated 2 or 3 times throughout your day at a leisurely pace until you have
regained your energy. You can then start to increase the duration.
Pain Control
You may feel some pain at your incision sites or due to the position your body was in
during surgery. Some patients experience neck and shoulder pain. If you have pain,
take the pain control medication as prescribed by your doctor. If your pain does not
lessen, or becomes worse, contact your doctor.
38
Incision Care
It is normal to have some swelling around the incision sites. If you have severe
swelling, bruising or redness that is spreading, contact your doctor immediately.
Medication
You may be given a prescription for pain medication at the time of discharge. If you
are on several medications, a pharmacist may review your medication list before
discharge to decide what you should be taking at home.
With either surgery, tablets need to be crushed to a “tic tac” size or be in liquid form
for the first 6 weeks after surgery. This helps with the absorption of medication and
helps allow the medication to pass through the stomach more easily.
Since your stomach is much smaller, it produces less acid and therefore certain
medications need to be avoided. Always discuss this with your health care provider
and tell your doctors, specialists, pharmacists, and dentists that you have had bariatric
surgery so they can make the best decisions for you.
Non-Steroidal Anti-Inflammatory Medication (NSAIDs)
NSAIDs such as Ibuprofen (Advil®, Motrin®), Naproxen (Aleeve®) or ASA
(Aspirin®) increase exposure of the stomach lining to acid. This in combination with
Gastric Bypass surgery put patients at greater risk of developing stomach ulcers.
NSAIDs should not be taken after gastric bypass surgery.
Ulcer Prevention Medication
Your surgeon prescribed medication to prevent stomach ulcers for at least 6 weeks.
Smoking, alcohol, and using NSAIDs puts you at risk of bleeding and perforated
(ruptured) ulcers requiring emergency surgery.
Blood Sugars and Blood Pressure
If your diabetes or blood pressure medications have been stopped or adjusted after
surgery, it is important to continue to monitor your blood sugars and blood pressure
regularly.
39
Pregnancy
Rapid weight loss after surgery can increase your fertility, or how easily you can get
pregnant. It is important that your weight is stable before becoming pregnant as
pregnancy is not a time to focus on weight loss and can affect the development and
growth of the unborn child. We recommend not becoming pregnant for 2 years after
bariatric surgery.
Contact your family doctor if you experience any of the following:
persistent vomiting or nausea
fever (temperature higher than 38° C or 100.4° F)
incisions which are painful, red, swollen, or bleeding
drainage from incision area
worsening or new abdominal pain.
40
2 Week Follow- Up Appointment After Surgery
Stage 4: Pureed/Soft Foods
You progress to this stage at your 2 week follow up appointment.
Stage 4: Pureed/Soft Foods
Duration Until your 6 week follow up appointment.
Foods Allowed Those outlined in this booklet. Small amounts of soft or pureed
foods at each of your 3 meals.
Fluid Goal At least 1500 mL (6 cups) per day.
Protein Goal 60 to 80 grams per day. Excessive protein should be avoided.
Reminders
Eat slowly. Use the guideline of 10 minutes per ounce of food to help you pace
yourself.
Stop eating as soon as you are full. Never force the food or beverage.
Do not drink 30 minutes before or after meals. Do not drink beverages during
meals to prevent overfilling the pouch and/or prevent dumping.
Weigh the food/meat on a digital kitchen scale after it has been cooked so that
you can be sure your protein calculations are correct.
Chewing gum or using straws after surgery is not recommended.
If you have any food intolerances, review the eating techniques you have
learned (small bites, chew well, eat slow).
Record of all food and fluid intake. Keep track of the grams of protein you
eat daily and the total amount of fluids. Bring your food records with you to
each of your follow up appointments.
41
Pureed and Soft Foods
The focus of this stage is to choose foods high in protein that are easy to digest.
Foods that are too dry may not be well tolerated. Moisten food with broth, skim milk,
lemon juice, tomato juice, light or fat free dressing or mayo.
In the beginning, meats such as canned tuna or canned chicken are generally more
tolerated. Meats that are slow cooked are generally more tolerated than dry or tough
meats.
Try 1 new food at a time. If you find that you do not tolerate a certain food, record
that and try it again in a few weeks’ time.
Protein Goal Your protein goal is 60 to 80 grams of protein per day. Focus on getting adequate
protein and limit low protein foods until you can meet your protein goal. You may
need to continue to use the high protein drink at first in order to meet your protein
goal. Below is a recipe for a single serving of your high protein drink along with the
amount of protein per serving.
Recipe:
27 g ISOFLEX™
1 cup skim or 1% milk
Mix the above.
1 cup = 34 grams of protein
1/2 cup = 17 grams of protein
42
Begin with the foods in the chart below. Limit low protein foods until you are able to
meet your protein goal. Go slow and add 1 new food at a time. Record and monitor
protein intake.
Food Portion Size Grams of Protein
Milk - skim or 1% 1 cup (250 mL) 9
Yogurt - low sugar, low fat, no chunky fruit ½ cup (125 g) 4 to 5
Greek Yogurt - low sugar, low fat, no
chunky fruit
½ cup (125 g) 12
1% cottage cheese 1/3 cup (80 g) 10
18% low fat cheddar cheese 1 oz (30g) 7
Babybel light TM Cheese 1 unit (20 g) 6
Laughing Cow light TM Cheese 2 units (33 g) 4
Refried beans with no added fat 1/3 cup (80 g) 5
Lentil soup (pureed) ½ cup (120 mL) 5
Split Pea soup (pureed) ½ cup (120 mL) 6
Pureed soups ½ cup (120 mL) varies
Skim milk powder 1 tablespoon (15g) 3
Cooked thin Cream of Wheat 1/3 cup (35g) 1
Cooked thin Oatmeal 1/3 cup (35g) 1
Unflavored Protein Powder ½ scoop (14g) 15
Note: this can
vary based on
brand and
scoop size
Pureed fruit such as unsweetened
applesauce
½ cup (120 mL) 0
43
Sample Meal Plan
Time Food or Beverage Amount Grams of Protein
7:00 a.m. Water 1 cup (240 mL)
Meal 1 8:00 a.m. Greek Yogurt (smooth,
low sugar, low fat)
½ cup (125 g) 9
9:00 a.m. Decaffeinated Tea 1 cup (240 mL)
Snack 10:00 a.m. High protein drink ½ cup (120 mL) 17
11:00 a.m. Water 1 cup (120 mL)
Meal 2 12:00 p.m. Split pea soup ½ cup (120 mL) 6
1:30 p.m. Sugar free fluid 1 cup (240 mL)
Snack 3:00 p.m. Yogurt (smooth, low
sugar, low fat)
½ cup (125 g) 5
4:00 p.m. Water 1 cup (240 ml)
5:00 p.m. Tomato juice ½ cup (120 mL)
Meal 3 6:00 p.m. Cottage cheese 1/3 cup (80 g) 10
7:00 p.m. Water 1 cup (240 mL)
Snack 8:00 p.m. Low fat cheese 2 oz (50 g) 10
9:00 p.m. High protein drink ½ cup (120 mL) 17
Total Fluid and
Protein
8 cups 74 g
Once you can easily tolerate the foods in the first chart, then you can begin to try
foods in the following chart. These foods have a bit more texture to them. Go
slowly...pushing your diet too fast can result in abdominal pain, nausea, and vomiting.
Note: Record and track protein intake.
44
Food Portion Size Grams of
Protein
Fish – canned tuna or salmon packed in water 2 oz (50g) 14
Imitation seafood ½ cup (67 g) 8
Egg substitute or liquid egg whites 1/3 cup (63 g) 7
Egg - scrambled, hard boiled or poached 1 large egg 6
Chicken - lean ground cooked 2 oz (50 g) 11
Turkey - lean ground cooked 2 oz (50 g) 14
Crab or shrimp - canned ½ cup (56 g) 15
Extra lean deli meats - shaved ham, chicken
or turkey
2 oz (50 g) 10
Tofu 2 ½ oz (75g) 10
Soy proteins - veggie ground round 1/3 cup (50 g) 10
Use nutrition facts tables on the food products and the Nutrient Value of Some
Common Foods booklet to help determine the amount of protein in the foods you eat.
See the Health Canada website: http://www.hc-sc.gc.ca/fn-an/index-eng.php
45
Sample Meal Plan
Time Food or Beverage Amount Grams
of Protein
7:00 a.m. Water 1 cup (240 mL) 0
Meal 1 8:00 a.m. Scrambled egg and
low fat cheese
1 large egg, 1 oz
(30g) of shredded
cheese
13
9:00 a.m. Decaffeinated tea 1 cup (240 mL) 0
Snack 10:00 a.m. High protein drink 1/2 cup (120 mL) 17
11:00 a.m. Water 1 cup (240 mL) 0
Meal 2 12:00 p.m. 1% cottage cheese ½ cup (125 g) 15
1:00 p.m. Water ½ cup (120 ml)
2:00 p.m. Sugar free fluid 1 cup (240 mL) 0
Snack 3:00 p.m. Greek Yogurt (smooth,
low sugar, low fat)
1/2 cup (125 g) 12
4:00 p.m. Sugar free fluid 1 cup (240 mL) 0
5:00 p.m. Tomato juice 1/2 cup (120 mL) 0
Meal 3 6:00 p.m. Canned tuna with light
mayonnaise
2 oz (60 g) canned
chicken, 1 tsp mayo
14
7:00 p.m. Water ½ cup (120 ml)
Snack 8:00 p.m. Low fat cheese 1 oz (30 g) 7
9:00 p.m. Water 1 cup (240 mL) 0
Total fluid and
protein
8 cups 78g
46
Follow these guidelines for foods included and not included on the Stage 4 diet until
you come for your 6 week follow up visit.
Foods Included
Foods Not Included
Fruit and Vegetables Pureed fruit and
vegetables, unsweetened
applesauce, tomato juice
Fruits and vegetables
with skins, raw
vegetables, dried fruit
and all others not listed
Grains and Starches Cream of wheat, plain
oatmeal thinned
Breads, rice, pasta, hard
crackers and cereals.
Baked goods such as
muffins or pastries
Protein Very soft mashed, or
pureed meats as listed.
Eggs as listed, canned
meats such as water
packed tuna and salmon
Tough, dry meats or
fried meats. Sausages or
wieners. Fish with
bones. Those not listed.
Nuts and seeds
Dairy Soft cheeses as listed,
yogurt (no chunks),
cottage cheese
High fat creams,
homogenized milk, ice
cream
Soup Strained or pureed
soups. Low fat cream
soups prepared with 1%
or skim milk is
acceptable.
Clear beef, chicken or
vegetable broth
All other soups not listed
Beverages Water, sugar free fluids,
decaffeinated coffee/tea
Carbonated beverages,
juices, caffeinated
beverages, alcohol
Desserts/Sweets Sugar free JELLO™,
Sugar free popsicles
All others not listed.
47
6 Week Follow Up Appointment After Surgery
Stage 5: Low Fat Solid Foods You progress to this stage at your 6 week follow up appointment
Stage 5: Low Fat Solid Foods
Duration Forever (for good health and success at weight management)
Foods Allowed Gradual introduce of solid foods.
Eat 3 small meals per day and 2 or 3 planned snacks.
Eat from all food groups.
Do not eat high fat, high sugar foods due to intolerance and high
calorie content.
Fluid Goal Up to 2L (8 cups) of low calorie fluids per day.
Protein Goal 60 to 80 grams total per day.
Reminders
Chewing gum or using straws after surgery is not recommended.
If you have any food intolerances, review the eating techniques that you have
learned (small bites, chew well, eat slowly)
Do not nibble or graze throughout the day. This can lead to weight gain.
Do not eat high fat, high sugar foods due to high calorie content, intolerance,
and the potential for dumping syndrome.
Weigh food on a digital kitchen scale after it has been cooked so that you can
be sure your protein calculations are correct.
Even though your staple line is probably healed, it is still possible to weaken it
or overstretch your new stomach by not being careful about what and how you
eat. Continue to eat or drink slowly and restrict portion sizes. Record all food
and fluids to help monitor your intake.
48
Stage 5: Sample Menu#1
Time Food or Beverage Amount Grams
of Protein
7:00 a.m. Water 1 cup (240 mL) 0
Meal 1 8:00 a.m. Toast and boiled egg ½ slice toast 1 egg 7
9:00 a.m. Tea 1 cup (240 mL) 0
Snack 10:00 a.m. Banana 1/2 0
11:00 a.m. Water 1 cup (240 mL) 0
Meal 2 12:00 p.m. Canned tuna in water
with light mayonnaise
1 piece melba toast
3 oz (90g)can mixed
with 1 TBSP light
mayo
22
1:00 p.m. Sugar free clear fluid 1 cup (240 mL) 0
2:00 p.m.
Snack 3:00 p.m. Shaved turkey with
cheese
2 oz (60g) turkey
with 1 slice low fat
cheese
21
4:00 p.m. Sugar free clear fluid 1 cup (240 mL) 0
5:00 p.m. Tomato juice 1/2 cup (120 mL) 0
Meal 3 6:00 pm Roast chicken breast,
without skin and
butternut squash
2 oz (60g) chicken
and 2 TBSP of
butternut squash
14
7:00 pm Sugar free fluid ½ cup (120 mL) 0
Snack 8:00 pm Low fat cheese 1 oz (30g) 7
9:00 pm Water 1 cup (240 mL) 0
Total fluid and protein 7 cups 71
49
Stage 5: Low Fat Solid Foods
Foods to
Include
Foods to
Avoid
“Go Slow”
Foods
(commonly not
well tolerated)
Fruits and
Vegetables
Fresh or frozen
fruit and
vegetables
Fruit canned with
added sugar or
syrup
Raw vegetables.
Vegetables and
fruits with tough
skins such as
cucumbers, celery
or apples
Grains and
Starches
Cooked potatoes,
toasted breads,
cooked cereals
High fat, high
sugar baked
goods, high sugar
cereals
Breads, rice, and
pasta
Protein
Lean meats with
all skin and
visible fat
removed.
Chicken, fish,
lean pork. Eggs,
low fat cheese,
beans, lentils and
hummus
Breaded and fried
meats, high fat
processed meats
such as bacon,
bologna, wieners,
and sausage
Red meats of any
kind such as
steak, roast beef,
or hamburger
50
Foods to
Include
Foods to Avoid “Go Slow”
Foods
(commonly not
well tolerated)
Dairy Skim or 1% milk,
low fat or Greek
yogurt
Cream, 2% or
homogenized
milk, chocolate
milk, ice cream,
frozen yogurt,
cream cheese
Soups
Low fat cream
soups made with
skim milk, any
other types of
soups, preferably
those with lean
meats
Full fat cream
soups
Beverages
Unsweetened
beverages and
water
Carbonated
beverages, juices,
alcohol, caffeine
Desserts/Sweets
Sugar free
JELLO™ or
popsicles, sugar
free puddings
Candies, pies,
cakes, doughnuts
and pastries. Store
bought muffins
and cookies.
51
Protein
The goal is to meet your protein needs through solid food and good quality protein
sources such as meat, fish, poultry, and eggs. Long term, you should not need extra
protein supplementation. Use of protein powders and supplements are not intended for
long term use. However, in the beginning there may be times when you need to
supplement with a protein drink or protein bar to achieve your minimum required
amount of protein each day.
Suggestions When Choosing a Protein Supplement:
Protein Powders:
Choose a Whey protein.
Whey Protein Isolate is lactose-free. Whey Protein Concentrate contains
lactose.
Look for a protein powder with 20 to 30 grams of protein and less than 5 grams
of carbohydrate.
Pre-Made Protein Drinks:
At least 15 g protein.
Protein Bars:
Look for a protein bar that contains less than 200 calories and at least 15 g of
protein.
52
Vitamin/Mineral Supplements
Why I need to take multivitamin-mineral supplements There are many reasons why, but when your pouch is so small it is difficult get all of
the nutrients you need through food alone. Plus, bariatric surgery makes it difficult for
your body to absorb nutrients.
Why I need to take Calcium with Vitamin D Calcium and vitamin D work together to keep bones healthy. When your pouch is so
small, it can be difficult to get enough and most multivitamins do not contain enough
calcium or vitamin D. After bariatric surgery, calcium citrate is absorbed better than
calcium carbonate.
Roux en Y Gastric Bypass Multivitamin: 2 standard adult multivitamins per day.
Calcium: 1500 to 2000 mg per day (split into 500 to 600 mg doses). Make sure it is
Calcium Citrate. It needs to contain Vitamin D. You may progress from the liquid to
a tablet/capsule form as tolerated, generally 8 weeks after surgery.
Sleeve Gastrectomy Multivitamin: There is limited long term research as to the multivitamin needs of
patients who have undergone sleeve gastrectomy. However, due to overall reduced
dietary intake we recommend that you take 1 standard adult multivitamin daily.
Calcium: 1000 to 1500 mg per day (split into 500 to 600 mg doses). Make sure it is
Calcium Citrate. It needs to contain Vitamin D. You may progress from the liquid to
a tablet/capsule form as tolerated (generally 8 weeks after surgery).
Note: Both types of bariatric surgery make it harder for your body to absorb nutrients.
You need to take your multivitamin and calcium with Vitamin D lifelong.
53
Additional Notes about Vitamin/Mineral Supplements Take your multivitamin regularly on a daily basis as it may help prevent deficiencies
that could occur after bariatric surgery.
If you are taking 2 multivitamins (Roux en Y surgery), both can be taken at the same
time.
Do not take your multivitamin at the same time as your calcium. Calcium needs to be
split into 500 to 600 mg doses as this is the most your body can absorb at one time.
As indicated, you may switch to Calcium Citrate tablets as tolerated. The amount you
need to take depends on how much calcium is in each tablet. Talk with your RD if you
are planning on switching to tablet form.
You may switch to a standard adult multivitamin (not chewable) as indicated above.
It is important to have your blood work done routinely as advised by the Bariatric
Program so that any deficiencies can be detected.
With either surgery, you may need additional Iron, B12 or Vitamin D. Take as
prescribed.
54
Potential Nutrition Related Complications after Surgery Nausea and Vomiting
This is often caused by eating too much food at one time, eating too quickly, or not
chewing food thoroughly and swallowing large chunks of food.
If you are experiencing any vomiting, are you:
eating small portions and using baby spoons to help you take small bites
of food?
chewing your food very well to a liquid consistency?
eating slowly? A good rule of thumb is 10 minutes per ounce of food.
Your meals should take 30 minutes to eat.
avoiding foods that are typically less tolerated after surgery and have the
potential for blockages (bread, rice, pasta, tough meats)
If you are following all of the above diet recommendations and are still vomiting or
experiencing persistent nausea, call the Bariatric Clinic or go to your local Emergency
Department.
Dehydration
After surgery, when the size of your stomach is so much smaller, it can be difficult to
consume all of the fluids your body needs. If you do not drink enough fluids, you can
become dehydrated.
Symptoms of dehydration include thirst, dry mouth, headache, light headedness, and
dark coloured urine.
Even though you cannot drink a large volume of water at one time, it is important to
sip on water throughout the day. Your goal is 6 to 8 cups (1500 to 2000 mL) of
fluid/day.
Tips to Prevent Dehyration
Drink 3 to 4 oz (90 to 120 mL) of water or other acceptable low calorie
beverages between meals.
The goal is 8 cups (2 L) of low calorie fluids each day.
Try to drink out of the same pre-measured container every day to help you
track your fluid intake.
55
Carry a water bottle with you wherever you go and sip on it throughout the day.
Drink water rather than juice, carbonated, sweetened, caffeinated, and alcoholic
beverages.
Flavour your water with fruits or vegetables such as lemon, lime, frozen berries
or cucumber for variety.
Make sure you track the amount of fluid that you consume each day to ensure
you are drinking enough.
Note: Keep track of your fluid intake every day.
Constipation
Often, constipation may occur in the early weeks after surgery. This may be the result
of not eating enough fibre rich foods, especially during the pre-surgical and post-
surgical diet. It is often caused by not drinking enough fluids. Even once you
transition from the liquid diet to a pureed/soft diet, the diet is typically low in fibre as
protein becomes the focus.
If you are experiencing on-going constipation despite adequate fluid intake, talk to
your surgeon about what you can take.
Gas
After surgery, it is not uncommon to experience some gas especially as your bowels
start to move. To help prevent gas, make sure you are eating slowly, chewing food
well, do not chew gum and use straws.
Dumping Syndrome
Avoid foods high in sugar. Eating these foods may cause a condition known as
“ dumping syndrome”. Dumping syndrome occurs when food passes too quickly from
the stomach to the small intestine. Symptoms may include a combination of nausea,
uncomfortable fullness, cramping, diarrhea, weakness, sweating, and fast heart rate.
Reduce your intake of sweets and notify your doctor if these symptoms occur despite
the elimination of sugars. High sugar foods are often high in calories, but contain few
nutrients.
56
Foods that may cause dumping syndrome
Ice cream Chocolate
Frozen yogurt Candies
Sorbet Sweet sauces
Fruit juice Regular JELLO® or regular
puddings
Sweetened iced tea or lemonade Jam
Chocolate milk Honey
Milkshakes Deep-fried foods
Cakes, cookies, pies, pastries and
doughnuts
Specialty coffees
57
Exercise After Surgery
You must be cleared by your surgeon to re-start your exercise program, which is
usually about 6 weeks after surgery.
Excess Skin As you lose weight throughout your journey, you may experience excess skin.
Although strengthening activities are beneficial to maintain lean muscle, it does not
prevent or tone excess skin.
Benefits of Exercise after Bariatric Surgery
Exercise is a key component in weight loss and maintenance. If you do not exercise
after surgery your weight loss may be slower and the chances of regaining weight
are greater.
Exercise Recommendations
Start slowly and work your way up. Go at your own pace.
Within the first few weeks after surgery walking is the only recommended form
of exercise.
Wear good supportive shoes and clothing that are the right fit for you and are
comfortable.
Follow the components of an exercise session:
- Warm-up (5 to 10 minutes), conditioning (20 to 60 minutes), cool
down (5 to 10 minutes), stretching (major muscle groups 5 to 10
minutes).
Gauge your intensity level for what is appropriate for you. Use the Talk Test.
While you are exercising, you want to be able to talk, but would not be able to
sing.
Add in strength and flexibility activities back into your exercise routine, in
addition to the cardiovascular exercise (walking, biking, swimming).
Drink the proper amount of water (taking small sips throughout your day) to
stay hydrated because of sweating while exercising.
If you have a bone or joint problem, try activities like exercising in the pool.
To manage loose skin, wear supportive clothing and undergarments.
You should feel good after exercise. Exhaustion and pain are indicators that
you are doing too much. Listen to your body.
58
Sample Exercise Plan
See Resource section of this book
Long Term Exercise Goals
To help prevent weight regain the recommended amount of exercise is 250 minutes or
greater of moderate intensity exercise, progressing to a combination of moderate to
vigorous intensity exercise. Try to spread out your exercise over the week. Aim for a
minimum of 30 minutes a day. Choose a variety of non-weight bearing (biking or
swimming) and weight bearing activities (walking). Include strength training 3 to 4
days a week to work all of the major muscles in the body.
To be most successful with incorporating exercise into your life, it is important to find
an activity that you enjoy doing. Tracking is another way to keep yourself motivated
and aware of how much activity you are doing each week.
59
Psychological Considerations After Surgery Many patients report an increase in health-related and weight-related quality of life
after weight loss with bariatric surgery. Most commonly, patients report
improvements in sleep quality, work performance, mobility and body imagine. This
is especially seen during the first or second year after surgery. However, there is great
variability in bariatric surgery outcomes between patients in terms of quality of life.
There are a number of factors that contribute to this.
Body Image
The first two years after surgery is a period of rapid body changes. While most
people experience an improvement in body image, rapid weight loss is often
associated with excess skin which can contribute to dissatisfaction with certain body
areas. Many people struggle with acceptance of their changed body and may have
difficulty with other’s responses to their body changes. For some people, it can take a
great deal of time to emotionally accept differences in their body changes. Seeking
support or counseling can help facilitate acceptance of your new body and help
improve body image.
Ongoing Difficulties with Unhealthy Eating Habits
Over time, patients are able to consume a larger quantity of food as well as variety of
food. It is possible to slip back into unhealthy eating habits like grazing, emotional
eating, mindless eating, binging or night eating. This is one of the reasons why
self-monitoring your food and emotions in a food journal is critical. It can help you
identify patterns in your eating and if in fact, you are using food to deal with
emotions.
Social Supports
It is important to rely on social supports during this time of rapid lifestyle and body
changes. Support can be in the form of family, friends or support groups. Support
can be found online or in person.
60
Weight Loss Expectations
Weight loss surgery itself is not a guarantee of losing all excess weight. Many
patients have high expectations of weight loss after surgery. Success depends on
lifestyle changes you make before surgery and the commitment to these lifestyle
changes after surgery. It is important to reflect on your weight loss expectations and
remind yourself of what is realistic. Remember to focus on other measures of success
from weight loss surgery, including different health-related and quality of life factors
such as reduction or elimination of medications, blood sugar control and increased
mobility.
Weight Loss Plateau After Surgery The most rapid period of weight loss is during the first 18 months after surgery.
Plateaus in weight change during this time are normal and expected. Many patients
will experience significant weight loss followed by no weight change at various times
during the first 18 months.
In general, weight will fluctuate from day to day and even during the course of the
day. Many factors contribute to this including activity levels. It is important to
remember that weighing oneself too frequently can be unhelpful and misleading,
given that weight can fluctuate daily. Think of weighing yourself as a tool to track
your weight loss or maintenance journey, rather than focusing on the specific number
on the scale. Periodically weighing yourself can help you understand whether your
current lifestyle behaviors are working or if change is needed. It is recommended to
self-monitor weight no more than once a week.
Weight Regain After Surgery It is common to regain some of the lost weight after bariatric surgery. Achieving and
maintaining a healthy weight is something that requires lifelong work. There are
metabolic changes that occur after surgery which contribute to this, but ultimately it is
adopting a healthy lifestyle through good nutrition and exercise that increases the
likelihood of success.
61
Seeking Help and Support The physical and psychological changes following bariatric surgery can be profound.
While many positive changes often follow bariatric surgery, adapting to your new
body and lifestyle can be difficult. If you experience emotional difficulties adjusting
to your new body and lifestyle or struggle with unhealthy eating habits, seeking
psychological support early after surgery is important. You can ask for a referral to
mental health services in your area from your family physician. There are many
online resources available as well. See the Additional Resources section of this book. Reminders The first year after surgery is a critical time that must be dedicated to changing old
behavior and forming new, lifelong habits that control your weight.
Eat 3 well balanced meals per day and 2 planned snacks. Nibbling, grazing, or
picking at food throughout the day results in a poor weight loss rate or may
even lead to weight regain.
Even though your staple line is probably healed, it is still possible to weaken it
or overstretch your new stomach by not being careful about what and how you
eat. Continue to eat or drink slowly and restrict portion sizes.
Keep food records. Even after surgery, this is one of the most useful tools to
help you keep on track with weight loss and lifelong weight management. It
helps ensure you are meeting your protein and fluid needs.
If food intolerances occur, eliminate the food for 1 to 2 weeks and then try it
again.
Take all nutrition supplements (calcium, multivitamins, iron, B12, and any other
supplements) as recommended.
Sleep an average of at least 7 hours each night.
Maintain a regular exercise program. This is essential to long term success.
Make a lifelong commitment to healthy eating, nutrition supplementation,
exercise, and regular follow up with health care providers.
Consider seeking out additional psychological support for managing difficult
emotions or stress associated with the required lifestyle changes as needed.
62
Additional Resources
Websites:
Guidelines: www.asmbs.org (American Society for Metabolic and Bariatric Surgery)
www.obesitynetwork.ca/ (Canadian Obesity Network)
Nutrition: www.dietitians.ca (Dietitians of Canada)
www.cookspiration.com (Meal planning help from the Dietitians of Canada)
www.healthcanada.gc.ca/cnf (Nutrient Value of Some Common Foods)
Exercise: www.sparkpeople.com (Online Exercise Videos)
www.csep.ca (Canadian Society for Exercise Physiology Guidelines)
www.participaction.com (Participaction)
Psychology: www.thecenterformindfuleating.org (The Center for Mindful Eating)
www.mindfulness-solution.com (The Mindfulness Solution)
http://psychsask.ca/?page=Find (Psychology Association of Saskatchewan – Finding a
Psychologist)
http://www.cci.health.wa.gov.au/resources/comsumers.cfm (Centre for Clinical
Interventions Workbooks)
Food and Exercise Journaling: www.myfitnesspal.com
www.loseit.com
www.eatracker.ca
www.fitday.com
www.sparkpeople.com
Books: The Weight Loss Surgery Workbook. Deciding on Bariatric Surgery, Preparing for
the Procedure and Changing Habits for Post-Surgery Success. Doreen A. Samelson.
New Harbinger Publications Inc. 2011.
63
Eating Mindfully. How to End Mindless Eating & Enjoy a Balanced Relationship
with Food. Susan Albers. New Harbinger Publications Inc. 2012.
50 Ways to Soothe Yourself Without Food. Susan Albers. New Harbinger
Publications Inc. 2009.
End Emotional Eating. Jennifer Taitz, New Harbinger Publications Inc. 2012.
The Complete Weight-Loss Surgery Guide and Diet Program: Includes 150
Delicious and Nutritious Recipes, Sue Ekersi. Robert Rose Inc. 2011.
64
Sample Weekly Exercise Plan
Increasing activity throughout the pre-surgical program
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Took the
dog for a
walk
during the
afternoon
30
minutes
Went to
aqua-size
class
during
lunch
45
minutes
Walked for
15 minutes
on each two
work break
30 minutes
Took the
dog for a
walk after
work
30
minutes
Did heavy
yard work
(pulling
weeds and
cutting
the grass)
45
minutes
Sample Weekly Exercise Plan After Surgery
Increasing activity gradually during the first year after surgery
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Took the
dog for a
walk
during the
afternoon
35
minutes
Went to
aqua-size
class
during
lunch
45
minutes
Walked
for 15
minutes
on each
two work
break
30
minutes
Walked for
15 minutes
on each two
work break
30 minutes
Took the
dog for a
walk after
work
20
minutes
Went to a
yoga
class
during
lunch
time
45
minutes
Did heavy
yard work
(pulling
weeds and
cutting
the grass)
45
minutes
65
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CEAC 1285 May 2017
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