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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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66

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CEAC 1285 May 2017