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www.bidmc.org/wls
Main Phone: 617-667-2845
Fax: 617-667-2866
Diet Stages 1 through 3
for Weight Loss Surgery
Your Dietitians: Michelle Mamis, RD, LDN
Office Phone: 617-667-2824
Kate Otto, RD, LDN
Office Phone: 617-667-9081
For Confidential Email use https://www.patientsite.org You must login under one of our Surgeons (Dan Jones, Ben Schneider)
Updated: 05/2016
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Nutrition: Diet Stages 1 through 3
Your Dietitians:
Michelle Mamis, RD, LDN
Kate Otto, RD, LDN
This chapter has been designed to help you, your family, and your close friends start
learning about nutrition for weight loss surgery. In order to be successful losing weight
and keeping it off, you must learn how to modify your eating behavior permanently.
The surgery is only part of the treatment. These diet stages are different than any other
diet you may have followed in the past. It will progress through a series of 5 stages, the
first 4 lasting a total of 6-8 weeks. The Bariatric Surgery Team has designed each diet
stage to provide nutrition consistent with healing and tolerance. During your first post-
op appointment, 2 weeks after surgery, you will be evaluated if it is medically safe to
advance your diet and review the Stage 4 information. It is important to NOT self
advance your diet.
(Progression may slightly vary with each individual and type of surgery)
LOCATION AND
APPROXIMATE
SCHEDULE
STAGE GENERAL
DESCRIPTION
LENGTH
OF STAGE
(May vary)
Starts after surgery with IV
fluids continuing 1 water
(1 oz per hour) One day or less
Completed in the Hospital 2
low sugar, decaffeinated,
non-carbonated
clear liquids
(2-4 oz per hour)
One day or less
Getting ready for discharge you
will be introduced to Stage 3
and evaluated for tolerance. 3
low sugar, high protein
modified full liquids
(4-8 oz per hour)
Two to Three
weeks
Home - follow up in clinic
(2 weeks after surgery) 4 lean soft/ground Four to Five
weeks
Home - follow up in clinic
(Approx 6-8 weeks after
surgery) 5
lean meat, fish, & poultry,
protein bars,
fresh fruit & veggies,
whole grains & legumes,
healthy fat, and low fat dairy
Lifetime
3
Goal # 1 = Stay Hydrated (2 to 4 L = 64 to 128 oz fluid)
Fluid is an essential nutrient needed everyday for normal body functioning
Generally women aim for 2-3 liters (64-96oz) and men 3-4 liters (96-128oz) per day
o Extra fluid is needed during illness and exercise (perspiration)
Signs and symptoms of dehydration: unquenchable thirst, dry mouth,
lightheadedness, headache, muscle cramps, ears ringing, chronic fatigue
(although fatigued is normal following major surgery)
“Catch up” is almost impossible after surgery
Monitor your urine production to make sure you are properly hydrated
You may not be well hydrated if:
o Your urine is dark in color
o Your urine has a strong odor
o You are urinating less than 4 x per day and/or in a small amounts (< 1 cup)
Normal urine color is usually darker in the morning and lighter as the day goes on
Vitamins can darken the color of your urine
Caffeine must be avoided for at least 2 months following surgery. It is a diuretic
which only promotes dehydration and may be irritating to your new pouch.
Tips to increase you fluid intake:
1. Drink fluids throughout the day
2. Keep fluid by the bedside, on your desk, in your car, & in your purse/bag
3. Keep on sip, sip, sipping!
4. Drink water before, during, and after activity
5. Bring your own bottled water when traveling
Meeting your daily fluid needs helps to:
Prevent dehydration
Prevent constipation
Removes waste products
Prevent kidney stones
Keep you full between meals
Regulates body temperature
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Goal # 2 = Preserve Lean Mass (60 to 80g Protein daily)
Protein is essential for body growth, development, and healing
o Especially for wound healing
o As well as maintain muscle while you are losing weight
Generally aim for 60 to 80 grams per day
Your individual protein requirements will be assessed during your first follow up
appointment by your dietitian
The goal is to promote fat loss not muscle loss, lean muscle tissue burns more
calories
Goal # 3: Nourish and Energize (600 to 800 calories)
Weight loss occurs when calories IN minus calories OUT is negative
Your body uses calories to conduct its daily functions and provide energy
In the first 3 weeks we anticipate you will be able to consume approximately 600
to 800 calories daily
Over time your food tolerance will be enhanced and your calorie goals will
increase to 1200 (for women) and 1600 (for men)
Immediately Following Surgery
You will be “NPO” which, simply means that you will not receive fluid by mouth. You
will receive intravenous fluid to keep you well-hydrated and moist swabs to prevent
mouth dryness. You will begin Stage 1 when you become more alert and it is
determined that your stomach and intestines are showing signs of normal activity.
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Stage 1: Water Completed in Hospital
Lasts 1 day or less
1 oz (30 cc) of water per 15 minutes in a medicine cup
Sip slowly and stop sipping if you start to feel uncomfortable
Stage 2: Clear Liquids
Completed in Hospital
Lasts 1 day or less (Stage 2 helps to stimulate digestive function)
2-4 oz of clear liquids per hour
o non-carbonated: can put pressure on new sutures & possibly stretch the pouch
o decaffeinated: caffeine promotes dehydration
o low sugar: promotes dumping syndrome and add unnecessary calories
In Hospital Fluid Choices include water and broth (no juices…too much sugar)
Use a 1 oz medicine cup to prevent gulping and drinking too fast
Sip slowly and stop sipping if you start to feel uncomfortable
to
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Stage 3: Modified Full Liquids
Started in the hospital
Continued at home for 2-3 weeks (Do not self advance your diet)
Stage 3 is all liquids (no chunks) to avoid any irritation from food particles
o high quality protein, low saturated fat, low sugar
Start with 4oz low sugar protein supplement over 1 hour 3 times per day to help
meet protein goals
In Hospital Protein Choices include Gelatein 20, Optisource, Beneprotein, and
Low Sugar Carnation Instant Breakfast (CIB)
At Home: Additional options are on the next page
Continue to have sips (4-8 oz per hour) of low sugar clear liquids in-between
protein
Your tolerance to Stage 3 beverages should improve with time as you heal & the
swelling decreases
As a general rule, start your fluid intake with 4-8oz per hour but gradually
increase as tolerated
NO straws…this may add air to your digestive system and fill you up
Remember flavored water, gelatin, ice pops, and broth all count towards your
fluid goal
Taste test stage 3 foods and supplements PRIOR to surgery
to
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Stage 3 Beverages & Foods These choices start AT HOME!
BEVERAGES: 1. Low sugar, decaffeinated, non-carbonated fluid
(i.e. water, Crystal Light, Smartwater, Mio, Wyler’s light, Fruit 2 O, sugar free Kool Aid,
Minute Maid Light, Propel, Welch’s Low Cal, AquaCal, VitaZest, Diet Ocean spray, herbal
tea)
DAIRY PRODUCTS:
1. Skim or 1% milk (i.e. Hood, Over the Moon, Simply Smart)
2. Skim or 1% Lactaid, unsweetened soy or rice milk (good for lactose intolerance)
3. Smooth low fat, light yogurt (i.e. Dannon Light n’ Fit, Yoplait Light, Hood’s Carb
Countdown, Colombo Light, FAGE or Chobani Greek 0%, store brand) 4. Sugar free, fat free pudding (i.e. Jello, Hunt’s, Kozy Shack)
5. Blended/whipped low fat cottage cheese (i.e. Breakstone’s, Light n’ Lively, Friendship)
6. Part skim ricotta cheese (i.e. Dragone, store brand)
7. Home made Low fat, sugar free custard
SOUP:
1. Strained or blended low fat cream soups (i.e. Campbell’s, Pacific, Imagine, homemade)
2. Low fat broth/boullion (i.e. Swanson, College Inn, Healthy Valley, homemade)
OTHER NOURISHMENT: 1. Thin (able to pour) low sugar hot cereals (i.e. Quaker Oats, Uncle Sam, store brand)
• soupy cream of wheat, oatmeal, grits, and cream of rice
2. Sugar free ice pops (i.e. Popsicles, Edy’s)
3. Unsweetened applesauce (i.e. Musselman’s, Mott’s, store brand, homemade)
4. Sugar free gelatin (i.e. Jell-o, store brand)
5. Dried skim milk powder (i.e. Carnation, store brand: 8g PRO/1/3 cup)
ARTIFICIAL SWEETENERS:
1. Splenda (Sucralose)
2. Sweet n’ Low (Saccharine)
3. Equal (Aspartame)
4. Truvia (Stevia)
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Handy Utensils
o Shaker Cup
o Hand held blender
o Cooler for your car or office
o Strainer
o Whisk
o Measuring cups and spoons
o Small utensils (i.e. baby or cocktail spoons and forks)
o Sippy Cup or twist/squeeze top water bottles: allows only one sip at one time;
beneficial for those that like to drink fast or chug fluids
Protein and Calorie Cheat Sheet
The nutrition values below are estimates and may vary.
For accuracy, it is always best to read the nutrition fact label.
Food/Beverage Portion Calories Protein
(g)
water or flavored water - 0 0
skim and 1% milk (Lactaid too) 1 cup 80-110 8
low fat, Light yogurt 6-8 oz 60-120 5-8
low fat, Light yogurt smoothies 8 oz 80 6
fat free, Greek yogurt 6 oz 100 18
sugar & fat free pudding (mixed w/ milk) 4 oz 70 4
whipped low fat cottage cheese 4 oz 100 12-16
part-skim ricotta cheese ¼ cup 100 8
low fat cream soups ½ cup 35 1
low fat broths 1 cup 10 1
thinned hot cereals 1 cup 100 3-5
sugar free ice pops 1 pop 15 -
unsweetened applesauce 4 oz 50 -
sugar free gelatin 4 oz 10 1
dried skim milk powder 1/3 cup 80 8
protein powder 1 scoop 100 20
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Understanding Labels
Food packaging and claims can be very misleading. Therefore it is very important to do
some detective work and read the nutrition fact label as well as the ingredient list. The
ingredient list provides useful information for finding hidden Trans fats and sugars.
Remember the ingredients are listed from the most abundant to the least abundant.
Rules of Thumb Low sugar = 8 grams of sugar per 100 calories.
Except fruit and dairy have natural sugar so 15 grams of sugar per serving is
OK for these foods (i.e. milk, yogurt, and applesauce).
Low fat equals 3 grams of fat per 100 calories
What to look for in a protein supplement? 15-20 grams protein per serving
Check ingredient list for: Whey protein isolate (Best), Soy (Good), Collagen
based protein (NOT recommended)
~100 calories per serving
Low sugar (8 grams of sugar per 100 calories)
Minimal to no fat per serving
Serving Size: The list of
nutrients (i.e. fat and
protein) is the amount in
ONE serving only. It’s
important to look at how
many servings are listed
per container or bag.
Calories: This is a
measure of energy. The
number of calories listed
is for one serving.
Fat: Not all fat is alike.
Saturated fat (usually found in
animal products) and Trans fat
are linked to heart disease and
should be used sparingly. Poly
and Monounsaturated fat
(usually found in plants) are
better choices. Limit healthy
fat to 20-35% of total calories. Sugar: It is important to
limit foods high in added
sugars because this means
higher calories. Protein: remember your total protein
goal is 60-80 grams per day. So try
to pick foods with some protein
listed.
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Protein Supplements
1. Bariatric Advantage Meal Replacement (Lactose Free): www.bariatricadvantage.com
Sold online or by phone 1-800-898-888
15g PRO/ ready-to-drink bottle
2. Designer Whey Protein: www.designerwhey.com
Sold at GNC and Vitamin Shoppe
18g PRO/scoop of powder
3. EAS Myoplex and AdvantEdge: www.eas.com
Sold online at various websites and at GNC, Vitamin Shoppe, Target, and Shop & Stop
This company offers a variety of high protein products.
4. GNC Pro Performance: www.gnc.com
Sold online and at GNC stores
This company offers a variety of high protein products.
5. Isopure (Lactose Free): www.naturesbest.com
Sold online and at CVS, GNC, Vitamin Shoppe, and Rite Aid
40 g PRO/20 oz ready-to-drink bottle, 25 g PRO/scoop of powder
6. Nectar: www.syntrax.com
Sold at Vitamin Shoppe and online at various websites (i.e. www.bariatricadvantage.com)
23 g PRO/scoop of powder
7. Vitamin Shoppe 100% Soy Protein Powder: www.vitaminshoppe.com Sold online, and at Vitamin Shoppe
26 g PRO/ 2 scoops of powder
8. Unjury (Lactose Free): www.unjury.com
Sold online or by phone 1-800-517-5111
20 g PRO/packet or scoop of powder
9. Worldwide Pure Protein Shake: www.sportnutrition.com
Sold online, by phone (800) 854-5019, and at Trader Joe’s, Vitamin Shoppe, and GNC
21-35 g PRO/11 oz can
10. GNC Total Lean Shake: www.gnc.com
Sold online and at GNC stores
25 g PRO/ 2 scoops of powder or 14 oz bottle
11. Optimum Nutrition Gold Standard 100% Whey: www.optimumnutrition.com
Sold online and at GNC, Vitamin Shoppe
24 g PRO/scoop of powder
Places to Shop: www.bariatricadvantage.com
www.gnc.com
www.vitaminshoppe.com
GNC
Vitamin Shoppe
Vitamin World
Trader Joe’s
Whole Foods
Market
Victory Market
BJ’s
Sam’s Club
Stop & Shop
Shaw’s
Market Basket
A Typical Day on Stage 3
The number of protein supplements you will need each day depends upon your
selections and gram of protein it contains
As a general rule, start your fluid intake with 4-8oz per hour but gradually
increase as tolerated
Ability to consume fluids vary from person to person, some patients find it easy
while others struggle
You should be able to take in more fluids by weeks 3 & 4, than weeks 1 & 2
Generally sip/drink fluids every hour you are awake
Be creative to prevent flavor fatigue (see “Flavor Tips”) & choose a variety of
foods
Example # 1: Simplified Typical Day 8AM 4 oz blended cottage cheese
9AM 8 oz water
10AM 8 oz protein drink
11AM 8oz water
NOON 8oz protein drink
1PM 8 oz water
2PM 8 oz protein drink
3PM 8 oz water
4PM 8 oz sugar free gelatin
5PM 8 oz 1% milk
6PM 8 oz low fat broth
7PM 8 oz decaf tea
8PM 8 oz water
TOTAL Protein intake on this day will vary depending upon protein supplement choice
Example # 2: Detailed Typical Day 9AM 1 scoop “Designer Whey” (18g PRO/1 scoop)
mixed with 8 oz skim milk or reduced lactose milk (8g PRO/cup)
10AM 1 cup sugar free gelatin
11AM 24 oz bottle of “Propel”
2PM 8 oz low fat, light yogurt (8g PRO/cup)
3PM 1 cup broth
mixed with 1 scoop unflavored PRO powder (20 g PRO/scoop)
4PM 24 oz bottle of water
7PM low sugar “Carnation Instant Breakfast” (4g PRO/powder packet)
mixed with 8 oz 1% milk (8g PRO/cup)
8PM 8 oz glass of water
TOTAL 72 oz non-nutritive fluids, 66 grams of PRO, 605 calories
Hunger expectations after surgery:
The primary goal is to heal after surgery and
following the diet stages is important to avoid
complications.
Band: Since there are no hormonal changes it is
normal to still feel hungry.
Band: You may be able to drink/sip more
quickly than described.
Bypass/Sleeve: Patients may not feel hunger.
Bypass/Sleeve: You will probably feel full very
fast and need to drink/sip more slowly.
Call a dietitian if your hunger is unmanageable.
Flavor Tips
Add sugar free extracts to your protein supplement or other stage 3 foods:
“DaVinci”- sold online at www.bariatriceating.com or in TJ Max and Marshall’s
“McCormick” - sold at local grocery store in the spice isle
“Torani”- sold online at www.torani.com or at Shaw’s supermarket
Warm chocolate protein supplement in microwave to have a hot cocoa like drink
Blend protein supplement with crushed ice to make a frosty
Make your own soup and blend to a liquid, strain if still chunky (i.e. chicken
vegetable, lentil soup)
Invest in a few WLS cookbooks: o Recipes for Life After Weight-loss Surgery by Magaret Furtado, MS, RD
o Eating Well After Weight Loss Surgery by Patt Levine and Michele Bontempo-Saray
Search for recipes and flavor ideas online (see below)
Recipes from www.UNJURY.com makers of Unjury protein powder
Hi-Pro Jell-O Use Sugar Free Jell-O
Follow directions for preparation of a 4 oz/4 servings box of Sugar Free
Jell-O, any flavor
Follow package directions for dissolving Jell-O in boiling water.
Measure 1/2 cup of cold water.
Add two scoops of Unflavored UNJURY to cold water, one scoop at a time, stirring slowing to dissolve.
Add ice to water with UNJURY to equal one cup.
Stir UNJURY with ice into dissolved Jell-O until ice has melted
Place in freezer for at least 30 minutes to chill quickly.
Important Comments:
-- The protein will settle somewhat toward the bottom, but the taste is unchanged.
-- If you like this recipe with UNJURY Unflavored, you might also like it substituting the Vanilla UNJURY for
UU.
-- 1 cup Jell-O as prepared has 20 grams of protein
Hi-Pro Yogurt For Plain Yogurt use Vanilla UNJURY.
For Fruit-Flavored Yogurt you can use Unflavored UNJURY or Vanilla UNJURY.
Put about half of a 6 ounce container, or all of a 4 ounce container, in a small bowl.
The first time you try this recipe, mix in 1/4 or 1/3 scoop UNJURY. Stir until well blended.
If this works well, the second time you might experiment with 1/2 scoop.
Proteina Colada Mix one scoop Vanilla UNJURY with 8 oz Skim Milk
Add 2 drops McCormick Imitation Pineapple Extract, and
And 2 drops McCormick Imitation Coconut Extract
Adjust to taste.
Protein: 20 grams per serving
Adjustments for Diabetes
You will be discharged from the hospital on Stage 3, but you must carefully monitor
and record your blood sugar levels. This will provide pertinent information to your
diabetic doctor or PCP so that your medications can be adjusted accordingly. You may
need to incorporate a steady amount of healthy carbohydrates to maintain normal blood
sugar levels. The goal is to prevent your blood sugar from getting too low or too high.
Aim for safe levels as directed by your doctor (generally >80 mg/dL & <120 mg/dL). If
you are on insulin, it is important that you consume similar foods synchronized with the
time actions of insulin.
SIGNS OF LOW BLOOD SUGAR SIGNS OF HIGH BLOOD SUGAR Excessive sweating, faintness
Low blood sugar <80
Headache/irritability
Pounding of heart
Excessive hunger
Slurred speech
Increased thirst and urination
Elevated blood sugar >120
Weakness
Fatigue
Loss of appetite
High Protein Hot Cereal Recipe*
Yield = two servings
~15 grams of protein per serving
Ingredients
1 cup hot cereal (instant, unsweetened cream of wheat, oatmeal)
1/3 cup unflavored protein powder (“UNJURY”, “GNC unflavored whey”)
1/3 cup of milk
Flavorings: spice (i.e. cinnamon or nutmeg), sugar substitute (ex. Splenda), sugar free
syrup to taste
Directions
Prepare hot cereal according to package directions. Mix protein powder into 1 cup of
cooked cereal, add milk to THIN DOWN to yogurt consistency. Add spice, sugar
substitute, and/or sugar free syrup to taste.
* This recipe is not just for people with diabetes. Anyone can use this recipe.
Vitamins & Minerals
Vitamin and mineral supplementation will be a life-long commitment to maintain
your health after surgery
Depending upon which surgery you choose, your past medical history, and blood
work you may need a specific amount and kind of supplement
Supplementation may include:
o Calcium with Vitamin D to prevent bone disease
o Vitamin B12 for the nervous system
o Iron to help produce blood cells
Your dietitian will review your needs and make personalized recommendations
Once you are home from the hospital start with one chewable multivitamin per
day (ex. Flintstones Complete, Centrum Chewable, or a comparable brand)
o NO gummy multivitamins- they typically do not contain iron
Remember that vitamins and minerals are not replacements for meals or healthy-
eating, they “supplement” your food intake before and after surgery.