Nutrition Following Bariatric Surgery

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1 Nutrition Following Bariatric Surgery Gastric bypass (Roux-En-Y) and Lap-Band surgeries help people to lose weight after other attempts at weight loss have failed. Weight loss from these surgeries can help prevent medical complications caused by severe obesity. However, the surgery is not a miracle cure. It is important to learn nutritious eating habits to help you stay healthy, prevent disruption of the staple line and/or obstruction at the opening of the stomach, and to keep the weight off once it s lost. Gastric bypass (Roux-En-Y) surgery is very effective in helping you lose weight because it reduces your stomach to the size of a small egg. The outlet leading from this new stomach pouch to the jejunum (second segment of the small intestine) is about the size of a dime. So, the contents of the new stomach are kept from emptying into the intestine too fast, leading to a feeling of fullness. Because part of your small intestine (the duodenum) is bypassed, you also absorb less of the food you do eat. The LAP-BAND System is similar to gastric bypass but is less invasive and does not bypass the remaining stomach or small intestine. The surgery uses laparascopy to wrap a gastric band around a small part of the upper stomach. This reduces the size of the stomach and controls the size of the outlet between the new stomach pouch and the remaining stomach. The amount of food that can be eaten at one time is restricted making you feel fuller and eat less. You will need to make healthy food choices to make sure you get the most nutrition possible in small amounts of food. Protein will be of very important with the smaller amounts of food. The bariatric surgery diet has been designed to provide your body with plenty of protein to keep good energy levels and enough vitamins and minerals to keep normal body functions. Some behaviors must be changed to reach and stay at the desired weight loss. The surgery helps impose discipline by forcing you to change your eating habits. With further education by a Registered Dietitian about nutrition following bariatric surgery, you will be on your way to a new healthier weight. The following nutrition information will guide you through the progression of your diet after surgery. Your surgeon or health care team will advise you through the diet stages of your recovery/adjustment period. With time you will be able to enjoy a wide variety of foods again but will always need to limit portion sizes, avoid high calorie, high fat foods, and maintain proper nutrition. Physical activity and exercise must also be included in your new lifestyle to reach and stay at a healthy weight. If you have questions after your education, please call your dietitian at (605)

2 Nutrition Following Bariatric Surgery Page 2 Bariatric Diet Key Points 1. Focus on fluids to prevent dehydration 2. Small portions (your stomach is the size of an egg) 3. Avoid fluids with meals (no fluid 30 minutes before and minutes after meals) 4. No straws for the first two months to prevent excess air intake 5. Avoid caffeine and alcohol 6. No carbonated beverages 7. Do not lie down for one hour after meals 8. Avoid sugar and sweets (sugar substitutes are allowed) 9. Good protein sources are important 10. Low fat 11. Chew food well 12. Stop eating or drinking when you feel full 13. Avoid chewing gum the first two months to prevent excess air intake (accidentally swallowing large pieces of gum may also cause an obstruction) 14. Slowly add new foods to assess tolerance 15. Diet restriction is for life Bariatric Diet Stage Progression General Guidelines Advancement of diet may vary per each person s tolerance. Do not advance to the next stage before the recommended time. You may stay at a stage longer than the guidelines specify. LAP-BAND Procedure Stage 1: 1 day post-op Stage 2: Next 1 week Stage 3: Next try foods from Stage 3 for at least 1 day before moving on Stage 4 & 5: Advance through Stage 4 to 5 as tolerated. Remember to follow guidelines to eat slowly, chew food well, and keep portion sizes small. Note: After your band is tightened at 6 weeks post surgery, return to the liquid stages of the diet and gradually progress through the diet stages again. Progress to each stage as tolerated. Roux-EN-Y Gastric Bypass Procedure Stage 1: for 2 days post-op Stage 2: start around 3 days post-op or at time of discharge Stage 3: start 10 days to 2 weeks post discharge Stage 4: one month post-op Stage 5: two months post-op

3 Nutrition Following Bariatric Surgery Page 3 Guidelines for Diet Progression You will be allowed small sips of water and ice chips once your bowel begins to function following surgery. The goal is to sip one ounce per hour (a medicine cup equals one ounce). Within 24 hours you are usually allowed to begin the diet progression outlined below. One ounce = 30cc = 1/8 cup = 2 Tb. = 1 medicine cup Stage One: Bariatric Clear Liquids Clear sugar free liquids only. If you are in the hospital you will receive 3 meals and 3 snacks consisting of 4-6 ounces of liquid each. Sip liquids slowly aiming for 2-4 ounces (1/4 1/2 cup) per hour or ounces per day. Take small sips at a time. Items Allowed: Clear broth or bouillon Herbal tea or decaffeinated coffee or tea Sugar free gelatin Sugar free Kool-Aid or Crystal Light (No tea flavors) Sport drinks containing no more than 50 calories per 8 oz. serving, such as Gatorade or Sport Drink (Limit to 1 cup total per day to avoid excess calories) Sugar free popsicles Water Diet Splash Stage Two: Bariatric Full Liquids Clear sugar free liquids with the addition of low calorie milk products, refined cooked cereal, and protein supplements. Continue to sip liquids slowly with a goal of 4 ounces per hour (1/2 cup) or 64 ounces per day. A low carbohydrate, low fat Protein Supplement is added at this time under the direction of your doctor or dietitian. This will be a very important part of your intake over the next few months. (refer to Bariatric Surgery Protein Supplement handout) Items Allowed: All items listed under Stage One Skim milk (if lactose intolerant, try Lactaid or Dairy Ease milk) Sugar free, low fat pudding, or custard Refined cooked cereal such as Cream of Wheat, Cream of Rice, Malt-O-Meal Sugar free, low fat yogurt (no fruit pieces) Strained soups Protein Supplement to provide 50 g protein a day Lap-Band: Oatmeal and blended soup allowed.

4 Nutrition Following Bariatric Surgery Page 4 Stage Three: Bariatric Pureed Foods During this stage add one new pureed food (the texture of baby food or applesauce) at a time. Eat 2-3 meals of no more than 1/2 cup each. Space your meals at least 5 hours apart. Try to eat your meal over about 20 minutes in order to stretch your new stomach to a point of fullness and satiety without over-stretching. Remember, it is always important to continue to take in adequate liquids. You ll need to sip on the liquids from the first two stages between meals. Avoid liquids at meal time (avoid fluids for 30 minutes before and minutes after meals). You will always need to take in ounces of fluid per day. You can increase your fluid as tolerated to more than 4 ounces per hour at this time. Continue to take your Protein Supplement as directed. (Drink between meals as part of your fluid intake or powder can be added to yogurt, etc.) You may find it hard to get in enough liquid at this stage so it is acceptable to only eat 2 meals as long as you are meeting your protein needs with supplements plus a good protein source at meals. Stage Three Pureed Type Foods Allowed: Low fat or non-fat cottage cheese Soft scrambled egg (may add milk to scramble moister egg) Mashed, boiled, or baked (no skin) potatoes Low fat cheese (less than 5 grams per ounce) Tofu Oatmeal Blended soft vegetables and fruits including applesauce (no sugar added), mashed banana V-8 or tomato juice Light or Diet fruit juice with less than or equal to 50 calories per 8 oz. (Limit to 1 serving per day) Blended soups Protein supplement to provide 50 g protein a day Once you are tolerating the above foods, low fat crackers (containing less than 3 grams fat per serving, such as Melba toast, soda crackers, and plain graham crackers) may be added to the diet.

5 Nutrition Following Bariatric Surgery Page 5 Stage Four: Gastric Bypass Soft Foods You may gradually begin adding soft foods to your meals at this time The goal is to never eat more than 1 cup (300 ml maximum) total volume of food at once in 3 meals daily. If only able to eat small meals (< 1/2 c.), 4 to 5 meals is acceptable. Try to space meals 3-5 hours apart. Sip on liquids continuously between meals. (Stop drinking liquids 30 minutes before and wait 30 minutes after meals of solid food.) Begin to focus on protein rich foods with each meal. Chew food well and eat the meal over approximately 20 minutes stopping at the first sign of fullness. Soft Foods to Add: (No Fried Foods!!!) Egg or egg substitute soft boiled or scrambled with non-stick cooking spray, or egg salad with low or non-fat salad dressing Seafood moist, white fish or shellfish and tuna (Do not start with clams or oysters as they are too chewy). Cold cereals with no more than 3 grams of sugar Toasted bread Rice Pasta with sugar free, low fat sauces (Cook rice and pasta well so it is fully hydrated or it will swell in your stomach.) Vegetables soft cooked such as carrots, green beans, broccoli (may cause stomach discomfort/gas) Fruits - ripe banana, melon, canned fruit with no sugar added or extra light syrup Meats lean poultry (red meat is usually not well tolerated in the first 3 months after surgery). Begin by grinding meat. Protein supplement to provide 50 g protein a day Stage Five: Regular Foods At this stage you can advance your diet to include many of the same foods your family or friends eat, only in much smaller amounts. Since the quantity of your intake is limited, it is very important that you eat highly nutritious foods avoiding empty calorie, junk foods. You will always need to avoid high fat foods and sweets. Chew your foods thoroughly, especially meat. Patients vary on the timing of this transition. Try small amounts of a new food in case it doesn t sit well. If you experience a problem with a particular food item wait awhile and then try it again. Limit for a lifetime the volume of food at each meal to 1 cup. (In most cases, you will not be able to tolerate 1 cup until at least 4-6 months after surgery or may never tolerate this volume at one time.) After 3 months post-op you can decrease your protein supplement to one serving per day (to provide grams protein per serving, as long as you are eating at least g of protein from food.

6 Nutrition Following Bariatric Surgery Page 6 Foods That May Not Be Well Tolerated Some patients have found the following foods difficult to tolerate. 1. Tough meats, especially beef buy lean hamburger, try marinating solid meats or use tenderizer. 2. Dried fruits such as raisins (unless re-hydrated) may be difficult to digest. 3. Membranes of oranges and grapefruit use only the canned orange or grapefruit sections or strained juices. Tough fibers of fresh pineapple may not be well tolerated 4. Skins of fruits and vegetables such as grapes, apples, potatoes - peel skins off apples, potatoes, etc. 5. Fibrous vegetables such as corn, celery use a blender and strainer as needed to avoid undigestible fiber such as stringy squash 6. Fresh bread can form into dough balls in the stomach try plain toasted breads 7. Fried or spicy foods bake, broil, or grill foods. Season foods lightly 8. Milk products try Lactaid or Dairy Ease and cooked milk products Dumping Syndrome Dumping results when simple carbohydrates (sugars and sweets) are dumped too quickly from the stomach into the intestine. The body dilutes the sugar by bringing fluid from body tissues into the intestine. This leads to abdominal fullness, nausea and crampy abdominal pain followed by diarrhea. Other symptoms of dumping may include dizziness, faintness, cold sweats, clammy skin, and a feeling of warmth. Dumping can also lead to low blood sugar. Because the small bowel is very effective in absorbing sugar, the rapid absorption of a relatively small amount of sugar can cause the blood sugar level to spike upward. The body responds by increasing insulin production causing blood sugar levels to fall. Low blood sugar symptoms tend to make an individual feel weak, sleepy, fatigued, and hungry. To prevent dumping, follow the diet guidelines for avoiding sugars and no fluids with meals. *Dumping syndrome is not a side effect with Lap-Band surgery since the stomach is not bypassed.

7 Nutrition Following Bariatric Surgery Page 7 Food to Always Avoid Coconut difficult to digest and can form into a ball which blocks the stomach opening causing prolonged nausea and vomiting. Carbonated beverages Caffeine Alcohol Fruit Juices except those that are light or diet with equal to or less than 50 calories per 8 oz. (Limit to 1 serving per day to avoid excess calories) Sugar and Sweets (simple carbohydrates): -Beverages sweetened with sugar including pop, punch, Kool-aid, lemonade, chocolate milk, sweetened juice -Cereals sweetened with sugar -Custard, pudding, regular gelatin -Ice cream, ice milk, frozen yogurt, sherbet -Cake, cookies, pies, donuts, frosting, candy, muffins, caramel corn, marshmallows -Jam, jelly, syrups, unless no sugar added or diet -Sweet pickles, pickle relish -Sweetened condensed milk Hidden sugars: (Read Food Labels) -Brown sugar -Sucrose -Corn syrup or corn syrup solids -Dextrose -Honey -Maple syrup -Molasses -High fructose corn syrup (fructose is allowed) -Sorghum and turbinado sugar -Mannitol, sorbitol, and xylitol High fat foods: -Mayonnaise, regular salad dressing -Margarine, butter -Sour cream, cream cheese -Olives or nuts -High fat snack crackers or breads, such as croissants -High fat, breaded, or fried meats -Fried foods Small amounts of added fats are allowed: light margarines and salad dressings are recommended.

8 Nutrition Following Bariatric Surgery Page 8 Nausea and Vomiting Nausea and vomiting can result from not following the nutrition guidelines. Notice the messages your body is giving you. If you feel pressure or fullness in the center of your abdomen or feel nauseated, STOP EATING! One more bite may cause pain and discomfort. It may help to briefly stand up during a meal to better assess your feeling of fullness. Any problems with nausea, vomiting, or discomfort should prompt you to ask the following questions: 1. Did I eat too fast or not chew food to a pureed consistency? 2. Did I drink fluids with my meal or too soon before/after the meal? 3. Am I eating more than I should? 4. Did I lie down too soon after my meal? 5. Did I eat hard to digest foods such as tough meat or fresh bread? 6. Did I eat foods from the next stage of the plan before being cleared by the surgeon to do so? Repeated vomiting may cause stress on the new stomach and result in irritation - or even worse - rupture of the staple line. If vomiting persists throughout the day, do not eat solid foods. Sip on clear liquids from Stage One. If vomiting continues for more than 24 hours, contact your doctor. Constipation After surgery, constipation may occur. Your food intake is very small compared to before surgery so bowel movements will be decreased. A bowel movement every two or three days may be normal for you. If you are having problems with hard stools, it may reflect inadequate fluid and fiber intake. You can include more fiber containing foods into the meal plan once you re past the first two stages of the diet. Examples of good fiber sources include oat bran or oatmeal, high fiber cold cereal, whole wheat toast, cooked prunes, beans and lentils, fruits and vegetables. If a high-fiber diet with adequate fluid does not correct the condition, it is safe to take a stool softener.

9 Nutrition Following Bariatric Surgery Page 9 Protein Sources Protein is a necessary component of the human body. It helps to preserve muscle tissue and aid in wound healing. Protein is also important in hair and nail growth. Because your body does not store protein, it must be consumed daily. The very small capacity of your stomach makes it difficult to meet your daily requirements unless you plan carefully. The amount of protein a person needs varies according to their ideal body weight. Stresses to the body such as surgery and infection increase your requirement for protein. As a general guideline, you will need to eat at least 60 grams of protein every day. For women over 5 6 and most men, aim for grams of protein per day. It is strongly recommended that you eat all the protein items first at your meals. Then go on to eat your fruits, vegetables, and grains. The type of protein you choose is also important. High biological value proteins (also called complete proteins) have all the essential amino acids needed for good health. Complete proteins come from animal origin (e.g. egg, milk/milk products, meat, fish, and poultry). Soy proteins are also considered complete or high biological value. You should aim to include 1-2 ounces of protein at each of your meals. Red meats and pork are usually not well tolerated the first 3-6 months after surgery due to in-adequate acid in the small stomach. As you begin tolerating more foods, use the following chart to determine if you re meeting the 60 grams recommended (70-80 g for men and women over 5 6 ). Protein Content of Selected Foods: Amount Food Grams of Protein 8 oz. Skim milk or light yogurt 9 1 (1/4 c.) Egg (egg substitute) 7 1 oz. Lean turkey, chicken, fish, beef, pork (cooked) 7 1/4 c. Tuna or ground meat/poultry 7 1/4 c. Nonfat/low-fat cottage cheese 7 1 oz. Nonfat/low-fat cheese 7 1/4 c. Mashed kidney beans, pinto beans, lentils 3 1/4 c. Low-fat Tofu or prepared textured soy protein 5 8 oz. Soy milk 7 1 oz. Soy cheese 5 1 pkt. Sugar free hot chocolate with 6 oz. skim milk 10 Ways to Add More Protein to Your Diet: Add nonfat milk, nonfat evaporated skim milk, or nonfat dry milk powder to soups, hot cereal, casseroles, breads, muffins, sauces, mashed potatoes, sugar-free puddings and custards. Add chopped, minced or pureed meat or fish to casseroles, soups, omelets, potatoes, and sauces. Mash cooked beans/legumes with low-fat cheese and milk. Add wheat germ to casseroles, breads, muffins. Sprinkle on fruit, cereal, or yogurt.

10 Nutrition Following Bariatric Surgery Page 10 Helpful Hints to Good Nutrition Good Eating Habits: Changing your eating habits is essential to your weight loss maintenance and lifelong success. Try some of the following behavior changes that may help improve your eating habits. Eat at the dining room or kitchen table. Prepare a place setting with a placemat, napkin, etc to make the meal more enjoyable. DO NOT eat in front of the television, as it distracting and you may not realize how much you are eating. Serve food on a small plate. Try small eating utensils, such as a baby spoon and small cup. Leave the rest of the food on the counter or stove where you prepared it, so you re less likely to take seconds. Or better yet, put the extras away before your meal. Chewing: You may block the outlet of your new stomach if you do not chew food well. This will result in PAIN, DISCOMFORT, NAUSEA and/or VOMITING. Remember the following: Do not skip meals. This may cause you to be too hungry and eat too quickly at the next meal. Chew each bite until it feels like mush in your mouth. Use a small fork/spoon and lay it down while you chew. This way, you ll eat smaller bites and control the speed of your eating. Learn to savor the flavor and texture of each bite of food. DON T BE RUSHED by others at the table. Enjoy your meal. Quick Meal Ideas: Sometimes you don t have time to plan ahead for a meal. If you are rushed, try some of the following ideas for easy meals instead of skipping a meal. Low-fat string cheese with whole-wheat crackers and carrot sticks Toasted pita bread or English muffin with tomato sauce and a little mozzarella or Parmesan cheese Minestrone soup with whole-wheat crackers Potato topped with low-fat chili Light yogurt with fruit and graham crackers Leftovers from low-fat meals, such as a piece of baked chicken, fish, or a slice of lean beef with cooked vegetables and fruit Baked tortilla chips with salsa and fat-free beans Low fat cheese on rice cakes or half a bagel with 1/2 banana

11 Nutrition Following Bariatric Surgery Page 11 Basic Food Group Plan Servings/Day Food Group Comments 2 Milk Group: These foods are high in protein and 1 c. Skim Milk (or 1%) calcium. Calcium is important for 2 c. Low-fat Buttermilk strong bones. 1 c. Light Yogurt 1 ½ Slices Fat-Free or Low-fat Cheese ½ c. Sugar Free Custard 3 Meat Group: These foods are high in protein and iron 1 oz. Cooked Lean Meat which is needed to prevent anemia and 1 Egg increase resistance to infection. ¼ c. Cottage Cheese 3 Fruit and Vegetable Group: This group provides vitamins and minerals ½ c. Cooked Fruit or Vegetable needed to regulate body processes, prevent ½ c. Vegetable Juice nutritional deficiencies and increase Resistance to infection. 2 Grain Group: These foods are needed in order to ½ c. Cooked Cereal supply proper amounts of iron, 2 Melba Toast B-Vitamins and Carbohydrates. 4 Saltines ½ c. Rice, Noodles or Macraroni NOTE: You may not be able to consume the recommended servings at first. You will gradually work up to this as you progress through the stages of the diet. Additional Resources American Society of Bariatric Surgeons Statistics related to Obesity Obesity Law and Advocacy Center Obesity Help Weight loss surgery information This information is designed as supplemental information. If you have questions, please ask your health care provider. Produced by Regional Health-Education & Development Department. Reprints may be made only with permission.