Gastric Bypass Surgery Patient Manual

Gastric Bypass Surgery Patient Manual 1

Table f Cntents Page Intrductin 4 Supplement Disclaimer 5 Surgery and Yur Hspital Stay 6 The Day f Surgery 7 In the Hspital 8 Pst-Operative Instructins: When Yu G Hme 9 Pst-Op Care 10 Care f Wunds and Danger Signs 10-11 Pain After Surgery 11 Prescriptin Medicatins and PRN Medicatins 11 Diet Prgressin Fllwing Gastric Bypass Surgery 12-13 Stage 1: Clear Liquids 14 Clear Liquids 15 Examples f Clear Liquid Supplements 16 Sample Clear Liquid Diet 17 Stage 2: Full Liquids 18 Full Liquids 19-20 Sample Full Liquid Diet 21 Stage 3: Sft Fds 22 Sft Fds 23-24 Sample Sft Fd Diet 25 2

Stage 4: Regular Diet 26 Regular Diet 27-29 Gastric Bypass: The Rules f the Tl 30-35 Pssible Prblems After Gastric Bypass Surgery 36-44 Nutritinal Supplement Recmmendatins 45 Mandatry Supplements 46 Optinal Supplements 47 First Mnth Plan 48 Prtein Pwer 49-50 Hw Much Prtein D Yu Need? 50 Prtein Surces 51 Helpful Hints t Bst Prtein Intake 52-53 Cmmercial Prtein Supplements 54 Exercising After Gastric Bypass Surgery 55-56 Recipes and Shpping List 57 Prtein Drink Recipes 58-59 Sample Shpping List fr Liquid Diets 60 Additinal Handuts 61 Key Pints t Remember 62 3

Intrductin We realize that yu have made a very imprtant and significant decisin when yu chse t have gastric bypass surgery. Gastric bypass can aid yu in lsing a significant amunt f weight in rder t imprve yur health. Yu understand that it will nt cure besity, but is a pwerful tl t be used t cntrl weight. Like any ther tl, it needs t be used prperly t achieve the best results. Gastric bypass surgery is still a weight lss plan, which requires prper fd chices, healthy eating habits and exercise t be successful. This manual will guide yu thrugh the pst-perative perid and help yu get the mst ut f this tl. It has been develped fr patients f PinnacleHealth Weight Lss Center. It may differ slightly frm ther Bariatric surgens prgrams. Each prgram is unique and is designed fr its specific ppulatin. Instructins and guidelines fr yur arrival hme and befre yur first pst-surgical visit are discussed first. Wund care, danger signs and prescriptins are cvered. The next part f the manual will explain the dietary transitins that are used immediately after surgery until the puch has healed and is ready t be used mst effectively. We recmmend that yu fllw the sample diets listed fr the liquid stages after surgery. They are designed t help prevent excess water weight lss immediately after surgery, which culd cntribute t dehydratin. They als prvide ample prtein t prmte healing. Yu may ntice that sme fds are recmmended during earlier stages, but nt later. These fds, althugh helpful during the transitin, may impede r slw weight lss. The fllwing sectin deals with lng-term dietary recmmendatins and advice n hw t get the best results frm yur surgery. Prtein needs and surces are discussed, as well as dumping syndrme. Vitamin and mineral needs are cvered in the nutritinal supplement sectin. There is als a sectin n pssible prblems that can ccur after gastric bypass surgery and hw t either avid r manage them. Sme prblems deal with symptms yu may experience after surgery, while thers discuss cnditins that may develp. The last sectin includes prtein supplement recipes, sample grcery list fr pst gastric bypass diet restrictins, and exercising befre and after gastric bypass surgery. We hpe yu find the infrmatin cntained in this manual helpful. The manual cvers mst f the issues yu may face after gastric bypass surgery, but is by n means all-inclusive. Please d nt hesitate t cntact ur ffice with any questins r cncerns yu may have. 4

Supplement Disclaimer Thrughut the manual there may be recmmendatins that include supplements ffered by ur facility. Often, patients have been unsure r cnfused abut which supplements they shuld use after surgery. When we surveyed ur patients, we fund they preferred specific recmmendatins fr the dietary stages pst-surgery, as well as nutritinal supplements. We lk at the fllwing areas when evaluating supplements. Quality The prducts must be frm cmpanies that use high quality ingredients and have strict quality cntrl plicies. Apprpriate After Gastric Bypass The prducts must be in frms that are apprpriate and effective in the changed bdy envirnment that is present after gastric bypass surgery. Cst. We cnsidered the csts f supplements. Supplements shuld be nt nly effective, but als affrdable. Taste. Many patients expressed dissatisfactin with the taste, cnsistency r vlume f many f the ppular supplements available t the public. We tried every supplement befre recmmending it. We have fund sme supplements that we feel meet all f these requirements and recmmend them. Due t the high quality and standards, many are available nly t the medical cmmunity. We attempt t give alternative ptins thrughut the manual. The supplements are ffered thrugh ur facility t assist patients in using high quality, affrdable prducts. We feel that they will help yu t get the best results frm yur surgery, but the use f specific brands f supplements is ptinal. We are in the medical business, nt the supplement business. Please d nt feel that yu are bligated t purchase the supplements available fr purchase in ur ffice. 5

Surgery and Yur Hspital Stay 6

Surgery and Yur Hspital Stay The Day f Surgery D nt wear makeup. D nt wear jewelry. Remve all piercings. Remve nail plish. Wear lse, cmfrtable clthing. Yu will reprt t the Admissins department at the hspital. Once yur registratin infrmatin is verified, yu will be taken t the pre-surgical area. A nurse will g ver the cnsent fr surgery and ask yu sme questins abut yur medicatins and medical histry. Yu will be asked t remve all jewelry (if yu haven t dne s already) and clthing then change int a hspital gwn. The nurse will place special stckings (TEDS) n yur legs t aid in circulatin during yur hspital stay. An I.V. will be placed in yur arm fr easy access fr medicatins. Yu will meet with the anesthesilgist and discuss yur cncerns fr the surgery. At sme pint yu will be taken t the perating rm and put t sleep fr the peratin. A catheter will be placed in yur bladder t vid yur urine. Fllwing the peratin, yu will awake in the recvery rm. After yur vital signs have been taken, and yu are stable, yu will be taken t yu rm. Please remember that mrnings are a very busy time fr the perating rm and staff. There are times that there may be delays in yur surgery r yur pre-perative care. We ask that yu be patient and realize that a delay wuld nly ccur fr an emergent reasn n anther patient/surgen s behalf. Yur family will be with yu until yu g t the perating rm. At that time, they will be shwn t the surgical waiting area. The surgery takes apprximately 1 hur. Yur family, in mst cases, will nt see yu until yu g t a regular hspital rm. The surgen will cme t talk t them fllwing yur surgery, while yu are in the recvery rm. 7

In The Hspital Yu shuld expect t be in the hspital a ttal f 3-4 days fllwing yur surgery. When yu awake, yu may have a drain attached t yur gwn. This drain is t help remve excess fluid frm the surgery. The drain is usually remved befre yu leave the hspital. Yu may als have a urinary catheter in place. In mst circumstances, the catheter in yur bladder will be remved within 24-hurs fllwing yur surgery. Yur diet will be NPO (nthing by muth). Ice chips will be restricted t 1 cup every 8 hurs. Additinal nutritin and fluids may be given by use f yur I.V. until prper testing can access yur surgical prgressin. Yur pain management will depend n yur discussin with the surgen and/r anesthesilgist preperatively. Sme patients will have patient cntrlled analgesic pumps (PCA); thers will receive pain medicatins thrugh their I.V. s r by injectin. If at any time yu feel that yur pain is nt under cntrl, please discuss this with yur nurse, r with the dctr that will visit with yu each day. Als remember, pain management des nt mean pain free. It will be impssible t relieve all the aches and pains that yu shuld expect. This sreness will decrease ver the next few days. Nurses and Persnal Care Assistants will check yur incisin areas and vital signs (bld pressure, temperature, and pulse) at regular intervals. This will include late night and early mrning visits. Please remember that everybdy invlved has yur best care in mind. These late night/early mrning visits are t help ensure yur health and safety. Yu may be asked t d breathing exercises with an incentive spirmeter, t help prevent pneumnia and ther respiratry prblems. Yu will als be assisted ut f bed and encuraged t walk as much as pssible. Being mbile will help prevent pneumnia, bld clts, cnstipatin and ther pst-perative prblems. Yu will be asked t walk the halls at least twice a day and t sit in a chair, ut f bed, as much as pssible. The hspital asks that patients nt leave the flr except fr testing r prcedures withut permissin frm the physician. Visiting hurs are frm 12 nn until 8:00 p.m. Exceptins are smetimes made fr patients wh are ging t early r late prcedures, s that family members may be present. Please speak t the charge nurse if this situatin applies t yu. Please remember t be cnsiderate f yur rmmate. Tw days after yur surgery, yu will underg a blue dye test t check fr leaks at the stmach surgical site. Pending the results f that test, yu may have permissin t begin yur clear liquid diet. This diet will be fllwed accrding t yur discharge instructins. Please infrm the hspital staff if yu are having difficulty tlerating liquids. 8

Pst-Operative Instructins: When Yu G Hme 9

Pst-Operative Instructins: When Yu G Hme Pst-p Care Upn arriving at hme, call the Weight Lss Center t schedule a ne t tw week fllw-up appintment with yur surgen. At hme, patients are encuraged t engage in light activity until they are evaluated at the first fllw-up appintment with the surgen, apprximately ne t tw weeks after discharge. Patients may g up and dwn stairs, walk in and arund the huse and drive in a car. T decrease yur pst-surgical risk, avid the fllwing: N heavy husewrk (this includes vacuuming) N lifting r hlding children r animals N lifting mre than 10 punds N sexual intercurse These restrictins will be mdified nce yu have yur first fllw-up appintment with the surgen. Any ther activity can be dne in mderatin as tlerated. Tw weeks after surgery, mst patients can begin an exercise prgram, such as walking. Care f Wunds and Danger Signs Care f yur surgical wunds is imprtant. In mst cases, patients will have abut 5 small incisins n their abdmen. These incisins are clsed with stitches n the inside and disslve in 4-6 weeks. The clear cver dressing ver these incisins can be remved in 3 days. Yu may shwer 3 days after surgery with hspital assistance. Yu shuld nt take a bath (stand up shwer nly) until yu have had yur first fllw-up appintment t ensure that yur incisins are healing well. N intments r special creams are recmmended t be used n these incisins. A bariatric surgen is available fr emergency assistance 24 hurs a day by calling The PinnacleHealth Weight Lss Center. Yu shuld call ur ffice if yu develp any f the fllwing: Temperature f greater than 101 F Increased abdminal pain r swelling Increased incisin pain, redness, heat r swelling Pus-like drainage frm yur incisin Persistent nausea r vmiting Persistent cugh and shrtness f breath Difficulty swallwing that des nt g away within 2 weeks Bleeding 10

Any f these symptms may indicate a wund infectin r ther cmplicatin. One f the mst cmmn signs f infectin is incisin drainage. Nrmal drainage may lk like bld r a yellw-red clr. If it is thick and brwn r yellwish yu shuld call ur ffice. Als, if there is any dr r pus-like discharge, place clean dry gauze dressing ver the site and call ur ffice A.S.A.P. Pain after Surgery Althugh laparscpic surgery causes less pain than pen surgeries, it des nt prevent all pain. Everyne experiences pain after surgery. Hw much pain varies per persn and is affected by that persn s pain tlerance. Yu will be given prescriptins fr pain medicatins when yu are discharged frm the hspital. Expect t be sre the first week after surgery. The pain shuld be tlerable. Yu shuld nt have s much pain that yu are unable t functin at hme. Cntact the ffice if yu are experiencing significant pain. Mst patients experience pain under the leftmst surgical incisin fr abut a mnth after surgery. Prescriptin Medicatins and PRN Medicatins Upn discharge frm the hspital yu may be given prescriptin pain medicatin and ther medicatins. Please remember t take yur prescriptins as directed. Shuld yu find that a certain medicatin is nt wrking well fr yu, please call ur ffice. Prescriptins can be requested Mnday thru Friday, 8:15am t 5:00pm. N weekends r hlidays. Please have yur pharmacy phne number available. Unfrtunately, we are unable t prescribe medicatins that were nt initiated by ur ffice. This means that if yur family dctr has prescribed medicatins fr yu, we are unable t call-in refills. If yu are prescribed Celebrex, please be aware that the cst may nt be cvered by yur insurance. If this is the case, yu may ask yur pharmacist t fill half the prescriptin, and return t the pharmacy in the event yu shuld need the remainder f the prescriptin. Yu shuld discuss all f yur medicatins with the dctr prir t discharge frm the hspital. Bld pressure medicatin, insulin, bld thinners and ther nn-gastric bypass related medicatins shuld be addressed. Fllw the medicatin instructins given t yu at the time f yur discharge frm the hspital. If yu have any questins r cncerns, feel free t call the ffice. We will ask yu t update ur ffice, with yur medicatin list, at every visit. Yu will als be asked t take a multi-vitamin every day. Bld wrk will be dne at specific intervals (i.e. 3 mnths, 6 mnths, and yearly) t check yur varius levels. 11

Diet Prgressin Fllwing Gastric Bypass Surgery 12

Diet Prgressin Fllwing Gastric Bypass Surgery The fllwing stages describe the prgressin f yur diet fllwing gastric bypass surgery. Yur newly frmed puch and cnnectins require time t heal and adjust t the changes created by the surgery. The fllwing stages allw this prcess t ccur withut putting und stress n these areas. Fllwing these guidelines will help imprve yu tlerance t fd, prmte healthy eating habits and supprt weight lss. Immediately fllwing yur surgery, yu will nt be allwed t eat r drink anything except ice chips. Yu will receive fluids and nutritin intravenusly. Prgressin Starting after Discharge frm Hspital Stage 1 (Clear Liquids) Duratin: Clear liquids fr 1 ½ days at hme. After surgery, yu will be started n a clear liquid diet. Yu will cntinue t cnsume clear liquids at hme. The main purpse f the clear liquid diet is t prvide adequate fluids t prevent dehydratin while the digestive system recvers frm surgery. Stage 2 (Full Liquids) Duratin: Full liquids fr 7 days. At the secnd stage, the digestive system is recvered frm the effects f surgery and can tlerate mre fds. This stage still prevents dehydratin but als prvides nutritin t prmte recvery and healing. Stage 3 (Sft Diet) Duratin: Sft diet fr 14 t 21 days. It takes apprximately 4-5 weeks fr the suture lines t heal after surgery. The Sft diet stage cnsists f mechanically sft fds that will nt place stress n the new stmach. It is als a time t learn what full is. The amunt f high-calrie liquids that may be cnsumed changes slightly at this stage. Stage 4 (Regular Diet) Duratin: Frm 1 mnth, nging. Yur stmach has nw healed t the pint where it can be used in the capacity f a weight lss tl. Yu will prgress t a regular diet as tlerated. We recmmend that yu eat three small meals a day and cnsume a high-prtein drink r snack. Nearly all f the beverages yu drink shuld be nn-calric beverages. Fllw the guidelines in the Sleeve Gastrectmy: The Rules f the Tl handut. Talk t yur dctr if yu have any truble advancing yur diet frm ne stage t anther, especially if the truble ccurs frm liquids t slid fd. 13

Stage 1: Clear Liquids 14

Stage 1: Clear Liquids Apprximately ne and a half days after surgery, yu will be started n a clear liquid diet. The clear liquid diet is used initially fllwing gastric bypass surgery, as it requires minimal digestin and des nt stress the newly frmed puch. Clear liquids are defined as liquids yu can see thrugh. Yu will stay n clear liquids fr ne and a half days befre advancing t a full liquid diet. Cnsume at least 60 grams f prtein per day. Sme patients may require mre, as advised. A minimum f 32 unces (4 cups) per day is required t prevent dehydratin. It is best t drink liquids at rm temperature. Liquids shuld be sipped, nt gulped. Drink 1 z. every 30 minutes frm a 30-cc medicine cup r 1-unce sht glass, always measure. D nt use a straw. Avid chewing gum. Yu may eat the fllwing fds while yu re n the clear liquid diet: Clear Liquid Prtein supplements (see next page) Clear unsweetened fruit juice: apple r cranberry (must be 100% juice) Water Unsweetened cffee r tea (decaf) Sugar-free drinks: Crystal Light, Fruit-2-O, and sugar-free Snapple Sugar-free drink mixes Clear brth r builln Sugar-free gelatin Sugar-free ppsicles (flavred water type) Sugar substitutes: Splenda, Equal, and Sweet-n-Lw. AVOID Fruit nectars, juices with pulp, sweetened fruit juices, sweetened drink mixes, milk, milkshakes, cca, sprts drinks, alchl, and carbnated beverages: sda, club sda, sweetened flavred water, regular gelatin, ice cream/ppsicles r ppsicles with fruit pieces. If it is nt n the list, d nt drink it. Stay n the clear liquid diet fr ne and a half days. 15

Clear Liquid Prtein Supplement Optins New Directin Clear Liquid Fruit Drinks (WLC) (1 pack: 70 calries, 15 gm prtein) UNJURY unflavred prtein pwder (mixed with clear liquid beverages)*+ (1 scp: 80 calries, 20 gm prtein, 1 gm carb) UNJURY chicken sup flavr (mixed with warm water)*+ (1 scp: 90 calries, 21 gm prtein, 1 gm carb) UNJURY strawberry srbet flavr (mixed with water)*+ (1 scp: 100 calries, 20 gm prtein, 3 gm carb) Pure Prtein Whey Sht (1 vial: 210 calries, 50 gm prtein, 3 gm carb) Nature s Best Ispure Zer Carb* (20 z. bttle: 160 calries, 40 gm prtein, 0 gm carb) New Whey Liquid Prtein Sht (3.8 Fluid unces r 1 tube: 180, 42 gm prtein, 2 gm carb) *= Gluten Free prduct + = Unjury prducts are available at www.unjury.cm nly. 16

Stage 1: Sample Clear Liquid Diet During the clear liquid phase f yur diet prgressin after surgery, yu will need t cnsume a minimum f 32 unces (4 cups) f liquid daily t prevent dehydratin. Drinking mre than this amunt is helpful and recmmended. The sample menu belw is recmmended t prvide the amunt f fluids, calries and prtein needed t ptimize yur recvery and weight lss fllwing surgery. It will als minimize excess fluid lss. We have researched the fd supplements listed. They prvide a high quality surce f prtein in a vlume cmpatible with bariatric surgery. We als feel they are sme f the best tasting supplements available. Fllw this diet fr three and a half days. Of curse, yu may chse t select ther fd items that are listed in the clear liquid diet sheet. Sample Menu (using Weight Lss Center Prtein Supplements) New Directin Prtein Supplements: Cnsume fur packs daily. Unsweetened fruit juice: Limit t 8 unces daily. Any additinal liquids must be chsen frm the clear liquid list and shuld be lw r nn-calric drinks. Sample Liquids fr 60 grams Prtein in One Day Prtein (grams) 8 z. High-prtein, lw-sugar liquid prtein drink 20 g 8 z. High-prtein, lw-sugar liquid prtein drink 20 g 4 z. f fruit juice 0 gm 8 z. High-prtein, lw-sugar liquid prtein drink 20 g 4 z. water 0 gm 44 Ttal unces Liquid 60 grams Ttal Prtein If yu experience dumping syndrme symptms after drinking fruit juice, dilute it 1:1 with water. 17

Stage 2: Full Liquids 18

Stage 2: Full Liquids The full liquid diet is used fllwing surgery as a transitin between clear liquids and slid fds. The full liquid diet prvides mre nutritin and variety than the clear liquid diet. Liquids shuld be sipped slwly. Yu will stay n full liquids fr 7 days befre advancing t a sft diet. Cnsume at least 60 grams f prtein per day. Drink 1-2 unces every 30 minutes. Drink fluid slwly. A minimum f 32 unces per day is required t prevent dehydratin. Stp eating/drinking befre becming full. Avid chewing gum. D nt drink frm a straw. Yu may eat the fllwing fds as well as fds n the clear liquid diet sheet while yu are n the full liquid diet. Prtein-Cntaining Prducts Dairy Prducts Milk - skim, 1%, Lactaid, sy Light Artificially sweetened ygurt (n seeds r fruit) Ygurt shake* High prtein eggng* Sugar-free pudding New Directin (WLC) Prtein Supplements Drinks, puddings/shakes, and sups. Cmmercial Prtein Prtein shakes, pwders (flavred r unflavred) Supplements Pre-mixed liquids (fr examples see page 54) (Less than 8 g carbhydrate, less than 120 calries per serving) *Recipes n page 58. 19

Stage 2: Full Liquids (cntinued) Yur guide t chsing the best ygurt One serving f ygurt (4-6 unces) shuld have Less than 20 grams f sugar 140 calries r less 7 grams r mre f prtein Recmmended ygurt Chbani Greek ygurt -plain, vanilla, lemn, r peach (withut the chunks f peaches during full liquid) Oiks Greek vanilla ygurt Yplait Greek vanilla ygurt Stnyfield 0% fat, 100 calries ygurt -vanilla Nn-Prtein Prducts Sups Vegetables Fruits Brth, builln, strained lw-fat cream sup All vegetable juices All 100% fruit juice (Attempt t limit t ne 8-z serving daily) Desserts Beverages Sugar-free gelatin, sugar-free ppsicles All beverages listed n clear liquid sheet, Sugar-free cca Miscellaneus Salt, mild spices, sugar substitutes 20

Stage 2: Sample Full Liquid Diet During the full liquid phase f yur diet prgressin after surgery, yu will need t cnsume a minimum f 32 unces (4 cups) f liquid daily t prevent dehydratin. Drinking mre than this amunt is helpful and recmmended. Remember t cntinue t drink 1-2 z. every 30 minutes, always measure. The sample menu belw is recmmended t prvide the amunt f fluids, calries and prtein needed t ptimize yur recvery and weight lss fllwing surgery. We have researched the fd supplements listed. They prvide a high quality surce f prtein in a vlume cmpatible with bariatric surgery. Fllw this diet fr seven full days. Of curse, yu may chse t select ther fd items that are listed n the full liquid diet sheet. Sample Menu (using Weight Lss Center Prtein Supplements) New Directin Prtein Supplements: Cnsume fur packs daily. Milk (skim r 1%): May be used t prepare all full liquid prtein supplements Any additinal liquids must be selected frm the full liquid list and shuld be lw r nn-calric drinks. Sample Diet fr 70 grams Prtein per day 8 z. High-prtein, lw-sugar liquid prtein drink 20 g 8 z. skim r 1% milk 8 g 8 z. High-prtein, lw-sugar liquid prtein drink 20 g 8 z water 0 8 z. High-prtein, lw-sugar liquid prtein drink 20 g 12 z. Water 0 8 z. High-prtein, lw-sugar liquid prtein drink 20 g Prtein (grams) 60 Ttal unces Liquid 88 Ttal grams Prtein If yu experience dumping syndrme symptms after drinking fruit juice, dilute it 1:1 with water. This sample menu prvides at least 60 z. f liquid, 88 gm f prtein, and 500 calries. 21

Stage 3: Sft Fds 22

Stage 3: Sft Fds The sft diet is used fllwing surgery as a transitin between full liquids and regular slid fds. Yu will stay n a sft diet fr furteen t twenty-ne days befre advancing t a regular diet as tlerated. Limit yur prtin size t ¼ cup per meal. Stp eating when yu becme full. Eat three meals a day. Cnsume at least 60 grams f prtein per day. Supplement yur prtein needs with lwcalrie, lw-carbhydrate prtein supplements as needed t meet the recmmended daily amunt f prtein. Cntinue t drink at least 32-64 unces f liquid per day. Yu may be able t drink several unces f liquid every thirty minutes. Drink slwly and d nt swallw mre than ne unce at a time. Avid drinking fluid with meals and drink all fluids between meals. Stp drinking 30 minutes befre eating d nt resume drinking fr 45-60 minutes after eating. D nt use a straw. Avid chewing gum. Begin with sfter, mushier fds. It is very imprtant that fds are chpped r pureed t a fine and mist cnsistency; add light may, fat-free gravy, mustard, water, r milk t misten. Yu may eat the fllwing fds n a sft diet. Sft Fds Cntaining Prtein New Directin (WLC) prtein Supplements Eggs Drinks Puddings/shakes Oatmeal Sups Sft r hard-biled egg Scrambled egg with/withut cheese Omelet with/withut cheese Egg salad Dairy prducts Milk- skim, 1%, Lactaid, sy Ygurt, Greek ygurt with r withut fruit (less than 20 grams sugar in 4-6 unce serving) Pudding (sugar-free) Peanut Butter (creamy) Cheese Cttage cheese 1% Rictta cheese, part skim Pultry and Fish (avid 1 st week f sft stage) Chicken, white r dark Turkey, white r dark Tuna Fish: haddck, flunder (mild, flaky fish) ***Chicken, tuna and turkey shuld be chpped very finely in a blender r fd prcessr. Add light may, light gravy, r brth t misten. D nt add celery r nin. 23

Stage 3: Sft Fds (cntinued) Nn-Prtein Sft Fds Brth r builln Sups (lw-fat, pureed, n legumes) Cereals Cream f wheat Cream f Rice Farina Oatmeal Vegetables Ptates- baked, mashed r biled (Remve skin) Sweet ptates (remve skin) Sft, tender cked vegetables (withut peels r seeds)- such as carrts and green beans Fruits Applesauce Ripe banana Canned unsweetened fruit (n pineapple r mandarin ranges) Mushy peeled fruits N citrus fruit sectins 24

Stage 3: Sample Sft Fd Diet Cnsume at least 60 grams f prtein per day. Sme patients may require mre as advised. Yu will stay n a sft diet fr apprximately furteen t twenty-ne days befre advancing t a regular diet as tlerated. Limit yur prtin size t ¼ cup. Because these fds are sft, they may mve thrugh the puch quicker, allwing yu t eat mre than yu culd with mre dense fds. Stp eating when yu becme full. Use this stage t learn what full feels like. Drink liquid cntinuusly between meals Eat three meals a day. If yu becme hungry between meals, select a lw-calrie, lwcarbhydrate prtein supplement. Supplement yur prtein intake as needed t meet estimated prtein needs. Mre supplements may be necessary if adequate prtein is nt btained thrugh fd alne. Cntinue t drink 32-64 unces f liquid per day. Stp drinking 30 minutes befre eating d nt resume drinking fr 45-60 minutes after eating. This will prevent filling up with liquids r flushing fd thrugh the puch. Sample A Sample B Breakfast 1 scrambled egg ¼ cup f cream f wheat Lunch ¼ cup Greek ygurt ¼ cup cttage cheese Prtein Supp Prtein shake (15-20 g) Prtein shake (15-20 g) Dinner ¼ cup tuna salad ¼ cup chicken salad Prtein Supp Prtein Drink (15-20 g) Prtein Drink (15-20 g) 25

Stage 4: Regular Diet 26

Stage 4: Regular Diet At this time, yur puch has had time t heal and yu are ready t begin using yur new tl in earnest. Remember that this surgery wrks by primarily reducing the amunt f fd yu can eat at a time. Yu may experience dumping syndrme (see page 44). It is imprtant t avid fds that are high in sugar and fat cntent. Yu may have difficulty eating spicier fds and fds with crunchy textures. It is pssible that fds that irritate yur stmach at first may becme mre tlerable with time. Infrm yur dctr if yu are having difficulty prgressing frm sft t regular fds. It is very imprtant t use this tl apprpriately in rder t have the mst success. Use the fllwing guidelines when yu begin the regular diet. Eat three meals a day. Use a lw-calrie, lw-carbhydrate prtein supplement t meet yur prtein requirements. Cntinue t drink 64 unces f lw r nn-calric liquids daily. Yur estimated daily prtein needs: Meals. Begin with meals apprximately ¼ cup (= 2 z. r 4 TBSP) in vlume. Since the fds yu will be eating are mre slid than the sft diet fds, yu will mst likely be able t eat less at the beginning f this stage. Eat 1/8 cup r 1 z. f fd ver 15 minutes. If yu feel full, stp eating. If nt, cntinue t eat ver the next 15 minutes until yu feel full, r eat a ¼ cup f fd, and then stp. Yu may nt be able t eat yur full meal. At least ½ f each meal shuld cnsist f prtein. In the beginning, nearly all f yur meal may be prtein. Several mnths after surgery, when yu are able t eat 2-3 z. f prtein at a meal, yu may add ther fds. Eat the prtein first t make sure yu d nt get full first. Chse lean surces f prtein. The remainder f the meal shuld cnsist mainly f nn-starchy vegetables r fruit. Starches shuld be the smallest prtins. Drinking liquids. Stp drinking 30 minutes befre meals. D nt resume drinking fr 45-60 minutes after a meal. Limit r avid high calrie beverages. Limit fruit juice t n mre than 6 z. f 100% fruit juice per day. 27

Meal Prtin Recmmendatins Cntrlling the size f meals prevents ver-stretching f the puch. Fllw this guide fr the first year after gastric bypass surgery. Meal Size Limit in Mnths after Surgery ¼ cup ½ cup ¾ cup 1 cup 3 mnths 6 mnths 9 mnths 12 mnths The prtin indicated refers t an entire meal. Practice measuring yur meals in a measuring cup. The meal size at ne year after surgery shuld be 1 cup f fd three times per day. This is where prgressin stps and yu cntinue having 1 cup f fd per meal. Until prtin size reaches ½ a cup per meal, patients require additinal prtein supplements in between meals in rder t meet individual prtein needs. Reintrducing Fds n a Regular Diet Yu will find that yur new puch is similar t a baby s stmach. There will be sme fds that yu may nt tlerate immediately after surgery, but d fine with later. There may be sme fds that yu never tlerate after surgery. Intrduce new fds as yu wuld with a baby; ne new fd at a time and take a small amunt. If the fd des nt agree with yu, try again in a few weeks. Each patient tlerates certain fds differently. We have fund the fllwing recmmendatins will serve mst patients. Red meat: Avid red meat fr the first 4-6 weeks after surgery. Red meat may be the fd that takes the lngest t tlerate. It is because beef (and prk) is denser and cntains a large amunt f cnnective tissue, which makes it harder t digest. Start with grund beef cked in a crumbled frm. Hamburgers must be chewed very carefully. D nt attempt steak until 3 mnths after surgery. Chse a cut such as a filet and marinate and tenderize it. The first time yu try beef, eat a bite r tw t see if yu can tlerate it. Fish and pultry: Fish is usually the best tlerated with pultry next. Yu n lnger need t finely chp all f yur fish and chicken. Yu may find dark-meat pultry is easier t tlerate than white meat. 28

Breads and Starches: Avid bread, rice, pancakes, waffles, and pasta until 3 mnths after surgery. Mst breads are made f refined carbhydrates and shuld be eaten in limited amunts. Whle grain breads are the best chice. When trying bread, first try it tasted t prevent it frm gumming up. Crispy crackers r baked trtilla chips may be used in limited quantities. Many peple d nt tlerate pasta, ndles r rice initially after surgery. Like bread, they are usually refined starches and shuld be eaten in limited quantities. Overck them t prevent expansin in yur puch. Ptates: Ptates are a frm f starch and shuld be limited similar t breads and ndles. D nt eat the skin f the ptat; it may cause a blckage. Avid adding high-fat fds like butter r sur cream t ptates. Vegetables: Avid raw crunchy vegetables fr the first 4-6 mnths after surgery. Lettuce may be tried at three mnths, but shuld be shredded r chpped. Nn-starchy vegetables are encuraged after gastric bypass surgery. Take precautins t avid pssible blckages. Vegetables shuld be cked until very sft and chewed thrughly. Vegetables with tugh skin may need t be peeled. Sups: D nt use sup as a regular fd. Sup is ften a cmbinatin f liquid and slid fd. Yu must separate liquid frm slid. Eat slids first, wait 45 minutes and then drink the liquid. Avid cream based sups due t their high fat cntent, unless skim milk is used. Be careful with large pieces f meat. Fruits: Fr the first 3 mnths after surgery, peel fruits t avid the skin clgging the puch; avid citrus fruit sectins and whle grapes. Althugh fruits naturally cntain sugar, they are usually tlerated after surgery and shuld be a part f yur diet. As with vegetables, take precautins t avid blckages. After 3 mnths, yu shuld be able t eat the fruit with skin if yu take small bites and chew thrughly. Avid dried fruits after surgery. Fats: High fat fds shuld be avided because they are very high in calries and may nt be tlerated. Avid fried fds and fast fds. Avid full fat dairy prducts and high fat meats. Limit added fats such as butter, margarine, regular maynnaise r spreads, and regular salad dressing. Try the lw fat alternatives. Yu need t eat sme healthy fats, such as extra-virgin live il, canla il, nuts, nut butters, r avcad. Alchl: If yu drink alchl, d nt drive. T prevent weight gain and ther pst-surgical cmplicatins, it is best t avid alchl after surgery. Alchl is absrbed much mre quickly after surgery and will reach much higher levels in the bld. Yu may becme intxicated frm a small amunt f alchl. Alchl als dehydrates yu and adds unwanted calries. D nt drink mre than 2 drinks within a 24 hur perid. Save drinks fr special ccasins. 29

Gastric Bypass: The Rules f the Tl 30

Gastric Bypass: The Rules f the Tl The fllwing guide will help yu t use yur new tl mre effectively. It will help yu t avid prblems that may ccur as well as maximizing yur weight lss. Remember, lng-term success is dependent upn hw yu use yur tl. The Rules 1. Eat three meals a day 2. Use lw-calrie, lw-carbhydrate prtein supplements t meet prtein needs 3. Eat small prtins 4. Try new fds ne at a time 5. Eat slids 6. Eat slwly 7. Chew fds well 8. Stp eating when yu are full 9. D nt drink with yur meals 10. Drink at least 64 unces (8 glasses) f lw r nn-calric liquids daily 11. D nt eat between meals 12. Avid sda and caffeine 13. Eat a balanced diet 14. Avid sugar 15. Avid high calrie fds 16. Take the recmmended nutritinal supplements 17. Exercise 18. Make a cmmitment fr a lifestyle change 31

The Rules f the Tl 1. Eat three meals a day One f the majr ways that gastric bypass surgery wrks is by decreasing the amunt f fd yu are able t eat at ne time. This restricts the amunt f calries yu can cnsume. Eating less than three meals a day makes it very difficult t meet yur nutritinal needs and can actually slw weight lss. At least half f each meal shuld cnsist f prtein. 2. Use lw-calrie, lw-carbhydrate prtein supplements t meet prtein needs It is very imprtant t eat an adequate amunt f prtein fllwing weight lss surgery. The handut, Prtein Pwer, explains the rle f prtein, hw much yu shuld eat, and a list f surces. We recmmend that yu attempt t meet yur prtein needs primarily thrugh meals. Hwever, it can be difficult, especially when meal sizes are small, t meet the recmmended amunts slely thrugh meals. Many peple find they need t cnsume extra prtein. We recmmend accmplishing this thrugh liquid prtein rather than eating extra meals. In rder t prevent cnsuming unwanted calries r sugar, use supplements that are lw-calrie and lw-carbhydrate. We d nt recmmend slim-fast, Ensure, Bst, regular Carnatin Instant Breakfast r ther meal replacements. They cntain t many carbhydrates and verall calries. 3. Eat small prtins Yur newly frmed puch is abut 1/8 cup (1 z. r 2 TBSP.). Initially, it can hld apprximately ¼ cup (4 TBSP.), depending n the cnsistency f the fd. Limit prtin size t ¼ cup t help prevent verstretching f the puch r vmiting. Limit meal size t ¼ cup r less fr the first three mnths after surgery. Yu may be able t increase the amunt f fd eaten at a meal as the puch naturally stretches. Measure prtins as ften as pssible t ensure prper prtin size. Try eating meals n a saucer fr the less is mre appearance. 4. Try new fds ne at a time After surgery, certain fds may cause nausea, pain, vmiting r may blck the pening f the stmach. The ability t tlerate fds varies frm persn t persn. Try ne new fd at a time and chew thrughly befre swallwing. If a fd causes discmfrt, dn t eat it. As time passes, yu may be able t eat this fd. Fds and liquids that cmmnly cause discmfrt include meat, bread, pasta, rice, raw vegetables, and milk. Fd textures nt tlerated well include dry, tugh, sticky, r stringy fds. 32

5. Eat slids Nw that yur puch has healed, eat fds that will fill the puch and nt empty quickly. Avid very sft r liquid fds as regular fds such as sup, applesauce, mashed ptates and ygurt. Avid high calrie drinks. 6. Eat slwly Eating slwly will help prevent vereating and vmiting. Take 20-30 minutes t eat each meal, even when the meal is nly ¼ cup. The nerve fibers in the stmach that signal the brain that yu are full are slw-acting fibers. It takes abut 15-20 minutes fr the full signal t reach yur brain. Eating quickly can cause yu t eat t much. D nt spread a meal ut any lnger than 30 minutes. If yu becme full, stp eating fr that meal. Putting fd in ne end f the puch as it leaves the ther defeats the purpse f the puch. Cut each piece f fd individually and put the utensils dwn while chewing. 7. Chew fds well Chew fds thrughly t prevent nausea, vmiting and blckage f puch. Begin by cutting fd int very small pieces t limit its size. Then chew the fd until it is a mushy cnsistency. Chewing fd well als mistens it and starts the digestive prcess. Chew every bite f fd 20 times. 8. Stp eating when yu are full This may be easier said than dne. Peple may have different perceptins abut what full is. Stp eating as sn as yu feel mild pressure r fullness in the area just beneath the rib cage. Overeating can cause verstretching f the puch and vmiting. 9. D nt drink with yur meals Fr sme peple, this may be ne f the harder adjustments t make after surgery. Hwever, it is an imprtant rule t fllw. Drinking t sn befre a meal will prevent yu frm being able t eat the nutritius fd that yu need. Drinking with a meal can turn the meal int a supy cnsistency that will allw the puch t empty t quickly and affect yur hunger. Yu may take a sip f water if needed fr dry fds. 10. Drink at least 64 unces (8 glasses) f lw r nn-calric liquids daily During the weight lss that ccurs after gastric bypass surgery yur bdy will tend t lse water while burning and prcessing fat. Therefre, it is extremely imprtant that yu drink enugh fluid t prevent dehydratin. This can be challenging with the small puch capacity. Carry a water bttle with yu thrughut the day and sip water cntinuusly. Als, drink water immediately upn awakening in the 33

mrning and right befre ging t bed at night. The majrity f the fluids yu drink shuld be lw r ncalrie t prevent unwanted calries. Signs f dehydratin include dizziness, weakness, dry muth, rapid heartbeat and cncentrated urine. Dehydratin is als the main cause f cnstipatin after surgery. Dehydratin als places yu at higher risk fr develping kidney stnes and gut. 11. D nt eat between meals Snacking, grazing r eating between meals shuld be avided. It can lead t unwanted calries, which may impede r prevent weight lss. If yu must snack, attempt t chse healthy fds such as a lw calrie prtein r fruit/vegetables. Try t avid high calrie snacks. 12. Avid sda and caffeine We recmmend that patients avid carbnated beverages after surgery. The carbnatin can stretch the puch when it warms and expands in the puch. Avid caffeine fr tw weeks after surgery. After tw weeks, caffeine cntaining beverages shuld be avided r used sparingly (limit t 1-2 cups per day). Caffeine is a diuretic and can cause dehydratin. Caffeine may als be an appetite stimulant and may cause yu t becme hungry. 13. Eat a balanced diet Gastric Bypass is a pwerful tl t aid in significant weight lss. Hwever, it des nt replace eating a nutritinally balanced and healthy diet. Due t the limitatins in the amunt f fd yu can eat after surgery, it is even mre vital t chse healthy fds. Initially, yu may find that yur diet cnsists mainly f prtein surces. Use lw-fat cking methds and avid high calrie sauces and cndiments. Remember t eat the prtein prtin f yur meal first t be sure yur prtein needs are being met. 14. Avid sugar Sugar cntaining fds cause a number f prblems. Firstly, they are typically high calrie fds with little nutritinal value. Refined sugars may als affect insulin and glucse levels in yur bdy, which can prevent weight lss and create hunger. Sugar cntaining fds can als cause dumping syndrme (see page n Dumping Syndrme). Artificial sweeteners are allwed. There is a small grup f peple in which these may increase hunger. If this ccurs t yu, avid artificial sweeteners as well. 34

15. Avid high calrie fds High calrie fds and beverages will slw dwn r prevent weight lss. Tw types f fd can add significant calries. They are crispy fds and fds that melt in yur muth. Bth types take up a much smaller vlume after they are eaten which allws yu t eat a much larger prtin. Crispy fds include ptat chips, cheese curls, pretzels and crackers. Fds that melt in yur muth include ice cream, chclate and puffy breads and pastries. 16. Take the recmmended nutritinal supplements It is imprtant t take the recmmended vitamins and nutritinal supplements after gastric bypass surgery. The nature f the surgery and calrie restrictin makes it difficult t btain the needed amunts thrugh fd alne. The surgery affects the absrptin f primarily the B-vitamins, B-12, and flic acid. It can affect the absrptin f the minerals, irn and calcium. These vitamins and minerals are vital t prper bdy functin. Deficiencies can cause majr medical prblems, which may nt surface until years after surgery. Mst prblems are caused by patients failing t take the recmmended supplements and sme f the effects can be permanent. 17. Exercise Research has shwn that exercise r increased activity is a necessary part f any successful weight lss and maintenance prgram. Besides helping weight lss, it prvides numerus ther medical benefits. Yu shuld find exercising much easier as yu lse weight and have increased energy. The bttm line Yu have t d it! 18. Make a cmmitment fr a lifestyle change While gastric bypass surgery will trigger significant weight lss, yu must d yur part t maintain the weight lss by making lifelng changes. This invlves making changes in yur eating habits and chsing healthy, lw-fat, nutritius fds. It invlves changing yur activity level and exercising. It invlves making behaviral changes t deal with bstacles that interfere with yur success. 35

Pssible Prblems After Gastric Bypass Surgery 36

Pssible Prblems After Gastric Bypass Surgery Nausea & Vmiting Nausea and vmiting that ccurs after gastric bypass surgery is usually caused by eating t fast, eating t much, r nt chewing fd prperly. It may als ccur if yu drink liquids t sn after a meal. Certain fds may be mre likely t blck the puch r be prly tlerated in the first few mnths after surgery. A stricture f the stma (the cnnectin between the puch and the small intestine) can als cause vmiting. Fllw the guidelines in the Rules f the Tl handut t prevent these prblems. Puch Blckage If yu d nt chew yur fd prperly r yu eat tugh fds (nes that cntain tugh skins r membranes) yu may blck the puch. Symptms include pain in the lwer chest r upper abdmen area in bdy midline. Yu may feel nauseus. D nt frce yurself t vmit. Mst fds will pass thrugh the pening after a few hurs. Taking a few sips f a ht liquid like tea and lying n yur left side may help the fd pass. D nt try t flush the fd thrugh by drinking larger amunts f fluid. This may cause t fluid t back up and induce vmiting. D nt eat r drink again until the pain has subsided. Then revert back t liquids fr the remainder f that day. Stma Stricture Less than 5% f patients develp a stricture f the stma after surgery due t excess scarring during the healing prcess. If yu develp vmiting n a cnsistent basis even n sft fds r liquids, yu may have develped a stma stricture. If this des ccur, fllw the same guidelines listed abve fr vmiting, but stay n liquids. The symptms may reslve after a few days. Cntinue t drink t prevent dehydratin. If vmiting cntinues even with liquids r if there is n imprvement within a few days, call the ffice. Yu may need t be evaluated r be scheduled fr an endscpy (EGD). The EGD is the same test yu had befre surgery t evaluate the stmach. When a stma stricture is present, a balln is used t dilate the stma. Usually, ne r tw dilatatins are all that is needed t crrect this prblem. Occasinally, mre treatments may be needed. There is a very small risk that the stma may crack during the prcedure. If this ccurs, yu may need t be hspitalized fr bservatin r underg surgery t repair the crack. If yu d have t have an endscpy after surgery, have smene drive yu t and frm the test. Plan n taking the rest f the day ff. Call the ffice immediately if yu experience severe pain after the prcedure. Revert back t a clear liquid diet fr ne day, then a sft diet fr ne week befre resuming a regular diet. 37

Nausea & Vmiting (cntinued) What t d if yu vmit If vmiting des ccur, there will be sme swelling f the puch and stma. Revert back t a liquid diet fr the remainder f the day. Try a sft fd the next mrning befre prgressing t regular fds. If yu vmit after attempting a new fd, wait a few weeks befre trying it again. Make sure the fd is nt n the fd tlerance list (Rules f the Tl handut.) Dehydratin After surgery, bth the amunt and the rate f fluid yu are able t drink are markedly reduced. This places yu at a higher risk f develping dehydratin and als makes it mre difficult t treat. Als, the increased metablism f fat tissue tends t cause the bdy t lse fluid. Dehydratin can als ccur due t nausea, vmiting r diarrhea. Becming dehydrated places stress n yur bdy and can increase yur risk f develping kidney stnes and gut. Yu may need IV fluid replacement if yu d becme significantly dehydrated. Therefre, it is extremely imprtant t prevent dehydratin by drinking plenty f fluids. Try t drink at least 64 unces per day. Drink water when yu wake up in the mrning and befre yu g t bed at night. Carry a water bttle with yu t drink thrughut the day. Cnstipatin The amunt f fd cnsumed is greatly decreased, as is the quantity f fiber, fllwing gastric bypass surgery. Pain medicatins, as well as supplements cntaining irn, may als affect bwel functin. The number f bwel mvements will decrease, causing less frequent bwel activity, which can result in cnstipatin. Hwever, the mst cmmn reasn fr cnstipatin is nt drinking enugh fluids. Cnstipatin can be treated by increasing fluid intake, increasing dietary fiber thrugh fd r supplements and increasing activity. When yu are allwed t resume regular fds, yu can start eating high fiber fds such as high fiber cereals (3 r mre grams f fiber per serving), fresh fruits, vegetables, and legumes. Add high-fiber fds gradually. A rapid increase in fiber may cause blating, cramping, and gas. Chew all fiber-cntaining fds very well. Drink plenty f fluids when increasing fiber in the diet. T increase fiber we recmmend adding fiber like wheat bran t fd r using fiber supplements. Benefiber is a sluble fiber, which can be mixed with fds r liquids. 38

Cnstipatin (cntinued) We d nt recmmend taking fiber in a pill frm unless it is crushed t prevent swelling and pssible puch blckage. If yu use the fiber supplements Metamucil r Citracel, start with ¼ f the recmmended dse. These supplements may gum up in the puch if used at nrmal dses. Be sure t drink fluid with any fiber supplement use. Medicatins can be used as prescribed by yur dctr if ther attempts fail. A stl sftener may be used fr the first few mnths after surgery if needed. Examples are Surfak and Clace. Mild laxatives such as Milk f Magnesia and Senekt may als be used n ccasin if needed. Duclax tablets r suppsitries may be used if the abve measures are unsuccessful. Diarrhea Diarrhea may ccur after gastric bypass surgery. Sme patients may experience mre watery stls the first few weeks after surgery as the small intestine adjusts t the new changes. Diarrhea may als be a sign f dumping syndrme frm eating fds with a high sugar r fat cntent. If yu ntice that yu are experiencing diarrhea with the fruit juices r dairy prducts while n the liquid stage diets, try diluting the liquids. If this des nt reslve the prblem, eliminate that fd frm yur diet fr a few weeks. Lactse Intlerance Our bdies need the enzyme, lactase, t digest the milk sugar, lactse. Lactase is nt fund in large quantities in the lwer small intestine. As a result, milk and milk prducts may nt fully be digested. They are then fermented by bacteria, which can cause gas, cramps, & diarrhea. Lactse intlerance can be treated with Lactaid, a pill t help yur bdy digest lactse. Red Meat Intlerance Red meats may nt be well tlerated immediately fllwing surgery. Yu may want t avid red meats until yur stmach is functining well, usually after 1 mnth. Begin with grund beef, cked lse (nt a burger). Wait until 3 mnths after surgery befre attempting t eat steak. Mst peple d nt tlerate it sner than this. Sme peple never d well with steak after gastric bypass surgery. Sugar Intlerance Refined sugars ( sweets ) pass rapidly thrugh the stmach int the small intestine. When this ccurs after gastric bypass surgery, a cnditin called dumping syndrme may ccur. Symptms f dumping include nausea, vmiting, diarrhea, abdminal cramps, palpitatins, rapid pulse, dizziness, lightheadedness, paleness, and sweating. Aviding all sugar cntaining fds and fluids can decrease dumping. 39

Hair Lss Many peple experience thinning f their hair r hair lss after gastric bypass surgery. In sme peple, hair fllicle lss may increase by 30-40%, rather than the usual 10% due t the stress f rapid weight lss. It usually ccurs between three and six mnths after surgery. This is a temprary effect and reslves when nutritin and weight stabilize. Maintaining an adequate intake f prtein and taking the recmmended nutritinal supplements may prevent r reduce hair lss. (See the Nutritinal Supplement Recmmendatins handut.) Pantene Age Defy shamp and cnditiner may help with hair lss. Bdy Odrs One f the unexpected side effects that patients may encunter after surgery is the presence f unpleasant drs emitted by their bdy. Unfrtunately, this can ccur at bth ends. Yu may ntice yu have bad breath after surgery caused by the ketsis r the burning f fat as energy. This will stp as the vlume f fd yu can eat increases and yur weight lss slws. Many peple als find that their stls and bwel gas have a strng, unpleasant dr after gastric bypass surgery. This is caused by fd being expsed t the bacteria in the intestines in a less digested state. Althugh ur facility has n experience with the prduct, sme patients reprted imprvement with a supplement, Devrm (Bismuth Subgallate) used by clstmy patients. It is available frm The Parthenn C., Inc. (www.parthenninc.cm). Sme patients just light a match! Ulcers In rder t help prevent stmach ulcers we recmmend aviding anti-inflammatry medicatins (NSAID s) that may irritate the stmach. Avid aspirin, ibuprfen, Mtrin, Advil, Naprsyn and Aleve and any ther NSAID s. Tylenl r acetaminphen may be used fr pain relief. We als advise against the use f ral crticsterids such as prednisne unless necessary. There are ther prescriptin pain and antiinflammatry medicatins available. Vitamin & Mineral Deficiency Gastric bypass surgery alters the way yur bdy prcessed the fd yu eat. The prtins f the digestive system that are n lnger expsed t fd are regins where the bdy absrbs certain nutrients, vitamins and minerals mst effectively. Als, the diet after gastric bypass surgery is initially inadequate t supply cmplete nutritin. The nutrients that are mst affected after surgery are Vitamin B12, Flic acid, Irn, and Calcium. In rder t meet yur vitamin and mineral needs, a high ptency multivitamin and mineral supplement must be taken daily fr the rest f yur life. Vitamin and mineral deficiencies are tested fr as part f yur lng-term fllw-up after surgery. 40

Prtein Deficiency Prtein is the essential nutrient f which ur muscles and rgans are all cnstructed. Our bdies require a cnstant supply f prtein building materials t repair and replace tissues, which becme wrn ut r damaged. Bariatric surgery reduces the capacity f the stmach t a very small vlume, s that prtein fds must be carefully eaten with every meal t be sure that the bdy gets enugh t maintain itself. If prtein is eaten at every meal during the first half f the meal, deficiency is less likely t ccur. Lss f Muscle Mass Exercise can prevent lss f muscle mass. It is very imprtant during active weight lss t exercise daily fr at least 20 t 30 minutes. Daily exercise nt nly preserves muscle mass, but als enhances fat burning and hastens weight lss. Adequate prtein intake als helps t maintain muscle tissue. (See the Exercising after Gastric Bypass handut.) 41

Psychlgical prblems Gastric bypass surgery causes a significant weight lss in a relatively shrt perid f time. Fr many peple, it is a surgery that changes their life. As with any majr change in yur life, yu may find it stressful at times. It frces immediate lifestyle changes t ccur, which may be difficult t cpe with. It is nt unusual t haves ups and dwns during the first few mnths after surgery. Cnsider this time as a transitin perid. The supprt grup can be a valuable resurce t help during this time f change. Tw t three weeks after surgery, sme patients may experience a significant drp in their energy level alng with irritability r mild depressin. This may be caused by the bdy s attempt t cnserve energy as much as pssible in the face f severe calrie restrictin. It usually nly lasts a few weeks. The best way t prevent this frm ccurring r t treat it is t exercise. This can help restre yur metablism t an active mde. Of curse, the best time t begin exercising is befre surgery. (See the Exercising after Gastric Bypass Surgery handut.) Depressin Sme peple develp mild depressin after gastric bypass surgery. Yur life has literally changed vernight. Sme peple have difficulty adjusting t these changes s rapidly. Their relatinship with fd has changed. It may n lnger be available as a surce f cmfrt. If yu use eating t treat emtinal difficulties, yu may benefit frm cunsel bth befre and after surgery. There are als a number f excellent bks available dealing with this issue. If yu take prescriptin antidepressant medicatin befre gastric bypass surgery, we recmmend yu cntinue it fr at least the first 4-6 mnths after surgery. The final decisin in regard t medicatin fr depressin is between yu and yur primary care physician r mental health care prvider. If yu feel yu are develping depressin after surgery, see yur primary care physician. Relatinship Distress Every interpersnal relatinship will change as the dramatic weight lss ccurs. The change affects all relatinships. Yu will change and the attitudes thers have abut yu may change. The marital relatinship may be affected. A high percentage f patients get divrced within the first tw years after weight lss surgery. Cnsider this befre surgery. If marital prblems ccur befre surgery, cnsider cunseling befre surgery. If yur relatinship begins t suffer after surgery, seek help. 42

Dumping Syndrme Dumping syndrme is a side effect that can be caused by the cnsumptin f sugary fds and fluids. Dumping ccurs as a result f the rapid mvement f liquids and sweets ut f the puch and int the small intestine. Symptms f dumping syndrme include lightheadedness, dizziness, paleness, rapid pulse, palpitatins, sweating, abdminal cramps, blating, nausea, vmiting, and/r diarrhea. Lying dwn immediately after eating reduces these symptms. Dumping syndrme symptms can als ccur with fds that have a very high fat cntent. Sme peple are very sensitive t dumping syndrme while thers d nt seem t be affected. In ur practice, we have fund that the patients wh are diligent abut aviding sugary fds in the first six mnths after surgery tend t remain sensitive t high sugar cntaining fds. Patients wh push the limits by keeping the amunt f sugar cnsumed just belw the pint where they experience dumping tend t lse the sensitivity and may n lnger dump. This may be frm the intestine s ability t adapt t the fds t which it is expsed. Mst patients desire t have sme level f sensitivity t dumping syndrme. It prvides anther tl t help avid certain fds that can slw r prevent weight lss. We therefre recmmend that yu avid the fds listed belw as much as pssible, especially fr the first 4-6 mnths after surgery. After that pint, a taste f these fds at the end f a meal n special ccasins shuld nt cause any difficulty. Reading fd labels can help determine if a fd has t high f a sugar cntent, which may cause dumping syndrme. Lk at bth the amunt f sugars listed and the ingredient list. The fllwing are different frms r names f sugar that may be seen in the list f ingredients: sugar high hney srbitl sucrse fructse maple mannitl dextrse crn syrup syrup glucse crn mlasses sweeteners srghum A gd rule f thumb t fllw is: Avid fds that have ne f the abve sugars listed as ne f the first three ingredients. The exceptins are fructse and lactse. Fructse is the natural sugar fund in fruit and fruit juice. Lactse is the natural sugar fund in dairy prducts. Bth f these sugars are well tlerated after gastric bypass surgery. Diabetics If yu are a diabetic, yu must be extra careful after gastric bypass. The symptms f dumping syndrme are similar t hypglycemia, r lw bld sugar. Test yur bld glucse levels if yu experience these symptms. What yu think is a lw bld sugar reactin may actually be dumping syndrme. Als, if yu d experience hypglycemia after gastric bypass surgery, yu must be careful hw yu treat it. Treat a lw bld sugar with milk r fruit juice, nt by having a sugary drink, which may cause dumping. Dumping can be avided by minimizing the cnsumptin f fds that have a significant sugar cntent such as desserts, sweets, candies and certain beverages. Avid the fds n the list prvided t prevent dumping syndrme. 43

Fds that May Cause Dumping Syndrme Beverages Alchl Milkshakes Cca Sprts drinks Sweetened drink mixes Desserts & Sweets Cakes Candy Ckies Marshmallw Pies Gelat Pastries Sugar Chclate Syrups Gelatin (regular) Breads & Cereals Pastries Dughnuts Muffins Meats and Mixed Meat Dishes Flavred milk Sweetened cffee Sweetened fruit juice Carbnated beverages Sweetened tea Mlasses Ice Cream Hney Ice Milk Jelly Frzen Ygurt Jam Italian Ice Ygurt (regular) Ppsicles Sweet rlls Breads with frstings r glazes Sugarcated cereal Fast Fd Baked Beans Chinese Fd Hney-baked Ham Fruits Sweetened fruit juice Fruits canned in heavy r light syrup Vegetables Any t which sugar has been added (i.e. candied sweet ptates r carrt) 44

Nutritinal Supplement Recmmendatins 45

Nutritinal Supplements Recmmendatins Mandatry Supplements Vitamin Start Date Frm and Dsage Frequency Instructins: Multi-vitamin Day 1 at hme -Adult chewable multi-vitamin fr the first mnth -1-2 daily, accrding t package instructins - During the first mnth after surgery, yu must use an adult frmula (nt a children s chewable). -Stp taking chewable multi-vitamin at 1 mnth. 1 mnth after surgery -Bariatric Multi-Vit custm frmula vitamin, twice a day r 1-adult highptency multi-vitamin twice daily. -Take first dse with breakfast and secnd dse with dinner - Take at meal time with small sip f water fr best tlerance - Over the cunter, nn-chewable frms shuld disslve in water within 20-30 minutes. Vitamin B-12 Day 1 at hme - Sublingual Vitamin B-12 5,000 mcg r - Injectable Vitamin B-12 (by prescriptin nly) Irn 2 weeks after surgery (when starting sft fd) - Vitrn-C, 65mg r - Ferrus fumarate, 65mg r - Ferrus glucnate, 65mg -1 weekly under the tngue -Quarterly -1 Daily -1 Daily -1 Daily - Symptms f Vitamin B-12 deficiency are irreversible and they include memry lss and neurlgical dysfunctin. - Vitamin B-12 cannt be a swallwed pill after surgery. - Only menstruating wmen r thse prne t anemia shuld take extra irn rutinely. (Other patients nly take under physician guidance) - D nt take irn and calcium supplements at the same time. Calcium 1 mnth after surgery - Citracal +D r -Calcium citrate malate (best-absrbed frm) 2-250mg tablet twice a day -2 tablets Daily -2 tablets Daily - D nt take mre than 500-600mg f calcium at ne time. - D nt take calcium and irn supplements at the same time. 46

Nutritinal Supplements Recmmendatins After gastric bypass surgery, yur bdy will absrb vitamins and minerals differently. Certain vitamins and minerals are mre difficult t absrb. This can lead t deficiencies f these nutrients, which in turn can cause serius health prblems. Fr this reasn, all patients wh underg gastric bypass surgery are required t take daily vitamin and mineral supplementatin fr the rest f their lives. Avid taking all supplements at ne time. Vitamins and minerals cme in many different frms. The bdy absrbs sme frms mre easily than thers after gastric bypass surgery. Als, certain supplements may interfere with each ther if taken at the same time. We have develped the fllwing recmmendatins fr nutritinal supplements based upn these facts. If there is a preferred frm f a supplement, it will be in bld letters. Unless nted, take supplements with fd. Our center ffers custm frmulated supplements designed fr gastric bypass patients. Optinal Supplements Name f Vitamin Frm and Dsage Instructins: Essential Fatty Acids (EFA) Magnesium -1 TBSP Flaxseed il daily -2-3 Flaxseed il capsules daily r -Fish il per label directins -1 Magnesium glucnate 500mg tablet at bedtime -Supplementatin may help r prevent hair lss after surgery. -American diets are frequently deficient in the essential fatty acids. -Diets after gastric bypass are typically lw fat and lw in EFA. - Magnesium is frequently lw after surgery; magnesium supplementatin may help prevent fatigue and muscle cramps. 47

First Mnth at Hme After Surgery Mnth: Arrive Hme Start Clear Liquid Diet Start Sublingual Vit B12 Start Chewable MVI daily Advance t Full Liquid diet Take Sublingual Vit B12 Advance t Sft fds Start taking irn supplement daily (by recmmendatin nly) Take Sublingual Vit B12 Take Sublingual Vit B12 Take Sublingual Vit B12 Advance t Regular Diet Stp Chewable MVI Start Bariatric MVI daily Start Calcium daily 48

Prtein Pwer 49

Prtein Pwer Prtein is an essential part f every cell and tissue in the bdy. Prtein is the primary nutrient that is used t build and repair the bdy (i.e. grwth, muscle building, wund healing). Adequate prtein imprves the bdy s resistance t ward ff illness. Fllwing surgery, adequate prtein intake will prmte healing f the incisin, prevent hair lss, and maintain immune functin. Prtein is cmpsed f building blcks called amin acids. There are tw types f amin acids: nnessential and essential. The bdy makes the nn-essential amin acids. Hwever, the bdy cannt prduce the essential amin acids, s these must cme frm fd. There are tw surces f prtein in the diet. Prtein can be fund in animal prducts and plant fds (grains and vegetables). Typically, animal prducts are higher in prtein than plant surces. Hwever, there are a few plant fds listed here that cmpare t animal prducts in their prtein cntent. When yu eat, make sure that every meal cntains ne serving f prtein. Always eat the prtein surce first t ensure yur prtein needs are met and remember t chew meat, fish, and pultry well. Since animal prteins cntain fat, yu want t primarily chse lean r lw-fat chices, saving the higher fat chices fr ccasinal use. Hw Much Prtein D Yu Need? During the weight lss perid fllwing gastric bypass surgery, yur bdy s prtein needs are higher than the weight maintenance phase. Men have higher prtein needs than wmen due t a greater amunt f muscle. Listed belw are recmmended ranges fr wmen and men based n height and ideal bdy weight. The lwer number is the prtein needs during weight maintenance and the higher number is the target prtein needs during rapid weight lss. Men shuld make sure they meet at least Height Wmen s Daily Prtein Needs Men s Daily Prtein Needs 5 0 5'1" 45 65 grams 50 75 grams 5'2" 5 3 50 80 grams 55 85 grams 5'4" 5'5" 55 85 grams 60 90 grams 5'6" 5'7" 60 90 grams 65 100 grams 5'8" 5'9" 65 100 grams 75 110 grams 5'10" 5'11 70 105 grams 80 115 grams 6'0" 6'1" 75 110 grams 85 125 grams 6 2 6'3" 80 120 grams 90 130 grams the upper range listed fr wmen if they are unable t meet their upper range amunt. If yu have kidney disease, the physician may recmmend a lwer amunt f prtein be cnsumed. 6'4" 6'5" 85 125 grams 95 140 grams 50

Prtein Surces Surce Serving Size Prtein Pultry: 1 unce 7 grams Fish: 1 unce 7 grams Shellfish: 1 unce 7 grams Beef: 1 unce 7 grams Prk: 1 unce 7 grams Lamb: 1 unce 7 grams Veal: 1 unce 7 grams Game: 1 unce 7 grams Dairy: skim & 1% milk 1 cup 8 grams high prtein eggng 1 cup 17 grams ygurt shake* 1 cup 15 grams nn-fat r lw-fat cttage cheese 1/4 cup 7 grams whle milk cheese 1 unce 7 grams Other: eggs 1 7 grams egg whites 2 7 grams egg substitutes 1/4 cup 7 grams lw-fat lunch meat 1 unce 7 grams Plant Surces: tfu 1/2 cup 7 grams tempeh 1/4 cup 7 grams sy milk 1 cup 7 grams dried beans, peas, lentils 1/2 cup 7 grams peanut butter 2 TBSP 7 grams nuts 1 unce 4 grams * See page 58 fr recipes 51

Helpful Hints t Bst Prtein Intake Yu can add prtein t yur diet withut increasing the amunt f fd yu eat. Here s hw. Cttage r Rictta Cheese (part-skim r 1%) Add t spaghetti r pasta dishes. Add t pancake r waffle batter. Add t casserles & egg dishes (quiche, scrambled eggs, & sufflés). Stuff fruits & vegetables. Eggs and Egg Substitutes Add an extra egg substitute t French tast, pancake, r waffle batter. Add finely chpped, hard-cked eggs t casserles, sandwiches, sauces, salads, & vegetables. Legumes (dried beans & peas; lentils) Mash cked r canned legumes with cheese and milk fr a sandwich r cracker spread. Add cked r canned legumes t salads. Mix cked r canned legumes int casserles, pasta, r rice. Meat, Fish, & Pultry Add chpped r pureed pieces t: baked ptates biscuits casserles melettes pasta ptates quiche rice salads suffles sups stews stuffing vegetables Milk (skim r 1%) Use in any recipe calling fr water: casserles ht cereal mashed ptates salad dressing sauces sup sugar-free pudding. Serve in sauces with vegetables, rice, ndles, r pasta. 52

High Prtein Pwder (nn-fat milk pwder & thers) Add 1 tablespn virtually anywhere: applesauce casserles cereal(ht/cld) cleslaw cttage cheese custard French tast gravy grund meat mashed ptates meat laf melettes pancakes pasta salad pudding rictta salad dressing sauces scrambled eggs skim milk sup spreads/salads waffles ygurt fruit juice vegetable juice gelatin pasta dishes quiche Sme guidelines fr use: Grund meat: Add ½ -¾ cup pwder t each pund f meat. Cked cereal: Mix an equal measure f pwder with dry cereal befre cking. Creamed r mashed vegetables: Add 1/3 cup pwder t 2 cups vegetable puree. Add skim milk t reach preferred cnsistency. Sauces, sups, puddings, & custards: Add 4 tablespns pwder t each cup f fluid milk in recipe r ½ cup pwder t each cup f water in recipe. Nuts Add chpped r grund t the fllwing: bread burger cereal meat laf pancakes puddings salads sandwiches vegetables waffles ygurt Ygurt Add t fruit & vegetable dishes. Tp pancakes, waffles, French tast, ht r cld cereal. Use as a filling fr stuffed baked ptates. Add t fruit salad dressing. 53

Cmmercial Prtein Supplements PinnacleHealth Weight Lss Center ffers high quality prtein supplements t ur patients t assist them in meeting their prtein needs. Hwever, sme patients prefer t use ther supplements that are available thrugh retail stres. There are a vast number f prducts available. If yu chse t use these prducts, we recmmend yu buy nly prducts frm reputable, well knwn cmpanies t ensure quality. Als, read the nutritinal labels carefully t avid prducts that may cntain sufficient quantities f sugars t cause dumping syndrme, r prducts high in calries. Als avid prducts that add ther supplements fr muscle building. Creatine is ne example. Sme f these supplements can present prblems t patients after surgery. Belw is a list f prtein supplements that ur clinic feels are apprpriate and have been well tlerated by ur patients. There are many ther prtein supplements sld cmmercially. Cnsult a dietitian r physician f the Weight Lss Center if yu are uncertain abut a prtein surce. New Directin (WLC) Prtein Shakes (1 shake = 15 g prtein; 80-100 calries) Ispure Zer-Carb Prtein Pwder* (1 scp= 25 g prtein; 105 calries) (available at GNC) NewWhey (3.5 z. pre-mixed liquid =42 g prtein) Just Whites (2 tsp = 3 g f prtein and 12 calries) (available at mst supermarkets) This supplement is best used as an additin t fds increase prtein cntent. UNJURY Prtein pwder* (1 scp= 20 g prtein; 80-100 calries) (www.unjury.cm) Prtein Pwders 1 scp = 17-20 grams f prtein 90-120 calries 1 TBSP = 4-5 grams f prtein Available at GNC, Vitamin Shppe, and health fd stres. Limited availability in grcery stres. Cmmn Prtein-pwder Brands Designer Whey Prtein (available at Rite-Aid) PrPerfrmance Prtein Pwder 100% Whey Pwder (available at GNC, drug stres, supermarkets) GNC Sy Pwder Pure Prtein whey pwder r shake Muscle Milk Rckin Refuel, Muscle Builder * = Gluten-Free 54

Exercising After Gastric Bypass Surgery 55

Exercising after Gastric Bypass Surgery Increasing yur activity level r exercising is very imprtant after gastric bypass surgery and will greatly influence hw successful yu are. Patients wh d nt exercise may gain back sme f the weight they initially lst after tw t three years. The Benefits f Exercise Burns calries. Althugh this is imprtant, the number f calries yu burn while exercising has less impact than the number f calries yu eat. Helps cntrl appetite. Studies have shwn that exercise can help cntrl appetite. This is especially imprtant when yur appetite returns after surgery. Preserves lean bdy mass. Yu lse bth fat and muscle when yu lse weight. Exercising maximizes fat lss and minimizes muscle lss. Increases metablic rate. Eating less and lsing weight slw dwn yur metablism. This means yu burn fewer calries. Exercising helps t ffset this drp. Imprves sense f well-being. Exercise makes yu feel gd. It als helps relieve stress. It is the best predictr fr lng-term success. Peple wh exercise are mre likely t keep ff weight they have lst. Hw t exercise after gastric bypass surgery If yu have a histry f heart disease, hypertensin, diabetes, high chlesterl r ther risk factrs fr heart disease, check with yur dctr befre starting an exercise prgram. Stp exercising immediately and see yur dctr if yu experience chest pain r severe shrtness f breath with exercise. During the first week after surgery, walk arund the huse. After the first pst-perative visit, mst patients may begin walking. If yu have significant rthpedic prblems that prevent walking, yu may benefit frm ther frms f exercise such as swimming. Walking Begin by walking five minutes a day. If yu are unable t cmplete 5 minutes withut stpping, rest fr thirty secnds and resume. Try t increase the time yu walk by a minute each day until yu are walking fr 20-30 minutes a day. Yu may break the time int mre than ne sessin (10-15 minutes in mrning and evening). As yu are able t walk mre, the pace shuld be ne that feels like mre exertin than a leisurely walk. Yu may find ther frms f exercise enjyable as yur fitness level increases. Resistance training has many benefits and is recmmended. Als attempt t increase yur activity thrughut the day by walking, using the stairs, parking further frm a building, etc. 56

Recipes and Shpping List 57

Prtein-Rich Liquid Recipes The fllwing recipes are fr liquids frtified with extra prtein. They may be used t help meet yu prtein needs fllwing surgery. They are higher in calries than mst prtein supplements (twice the calries). Limit t n mre than ne per day. High Prtein Milk (28 gm prtein, 190 cal) 1 cup skim milk 2 unces prtein pwder Sugar substitute Vanilla flavring Add ingredients t blender. Blend well and chill. Variatin: Chclate milk: add unsweetened cca pwder t recipe befre mixing. Ht chclate: head the chclate milk; sip slwly. Ygurt Shake (20 gm prtein, 170 calries) 1 cup artificially sweetened ygurt ½ cup skim milk 2 TBSP prtein pwder Add ingredients t the blender. Blend well and chill. High Prtein Eggng (25 gm prtein, 150 calries) ¾ cup skim milk ¼ cup liquid egg 2 TBSP vanilla prtein pwder ¼ - ½ tsp vanilla extract 1 tsp artificial sweetener Nutmeg t taste Add ingredients t the blender. Blend well and chill. Chc-Ng (25 gm prtein, 175 calries) Start with basic high prtein eggng recipe. Add 1 packet f sugar-free chclate. Blend well and chill. 58

Prtein Rich Liquid Recipes (cntinued) Mcha Shake (16 gm prtein, 130 calries) 8 z skim milk 2 TBSP prtein pwder ½-1 tsp instant cffee 1 tsp artificial sweetener Dash cinnamn Add ingredients t blender. Blend well and chill. High-Prtein Fruit Punch (20 gm prtein, 110 calries) 6 z. sugar-free pwdered fruit drink(such as Crystal Lite r Sugar-Free Kl Aid) 2 unces prtein pwder 4 ice cubes Add ingredients t blender. Blend well and chill. High-Prtein Cream Sup (24 gm prtein, 200 calries) 1/3 cup nn-fat dry milk 1 tsp. chicken r beef builln 3 Tbs. prtein pwder Ht water Mix first 3 ingredients and then add enugh ht water t equal 1 cup; mix well. Eat sup when it is lukewarm. 59

Sample Shpping List fr Liquid Diets Department Stre Drink shaker with sealable lid and unce markings Liquid Measuring Cup Measuring spns 1 z. sht glass r measuring cup Timer Blender r fd prcessr Grcery Stre/ Pharmacy Clear Liquid Diet Clear Liquid (Lw-carb, lw calrie) prtein supplement Sugar-free gelatin Sugar-free ppsicles Decaffeinated Cffee r Tea 100% fruit juice (apple r cranberry) Sugar-free drink mix (Crystal Lite r Kl Aid) Brth, builln Chewable Multivitamin (adult frmula) Full Liquid Diet Lw calrie, lw carbhydrate prtein shake/pwder Skim r Fat-Free milk Sugar-free pudding Ygurt (n seeds r fruit pieces) Sugar-free cca Fat-free cream sups 100% fruit juice Strained vegetable juice 60

Additinal Handuts 61

Key Pints t Remember: Yu may never be able t eat the prtins yu cnsumed prir t surgery. Fr a safe weight lss, yu need t eat a healthy, well balanced diet. Be sure t make healthy fd chices t btain the mst nutritin per serving. Chse lw calrie, nutrient-dense fds. Be patient. At first, yu will fill up after just a few bites. This is nrmal. Stp eating when yu becme full. Initial meal size shuld be apprximately 1-2 z. (2-4 Tbs.) per meal, 3 meals per day. Vlume tlerance will increase after healing (refer t meal prgressin time line fr meal prtin size). Cntinue t eat slwly, chew fds thrughly and drink in-between meals. When yu try a new fd, take ne bite t see if it is cmfrtable fr yu. Yu must take the recmmended vitamin/mineral supplements as directed every day fr the rest f yur life. Yu shuld cnsume prtein drinks r supplement with prtein pwder until yur prtein intake frm fds is adequate. Fllwing the recmmended diet rules will help yu lse weight and keep it ff. Yur dedicatin t diet, exercise, and lifestyle changes will dictate yur success after surgery. Yu can defeat the surgery, resulting in weight gain. Grazing, drinking fluid with meals, r cnsuming high calrie fds r liquids are examples f ways that the surgery can be defeated. Attend Bariatric Supprt grup meetings n a regular basis befre and after surgery. Exercise regularly and fllw dctr s rders r restrictins when exercising. Cntinue t fllw the guidelines prvided thrughut this educatin packet. Yu have been prvided the tls necessary t achieve and maintain a healthy weight lss. 62

Ntes 63

Ntes 64