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Important Testing Dates and Times
Gallbladder Ultrasound _________________ at _____________a.m./p.m. Upper GI _________________ at _____________ a.m. /p.m. ** Schedule at ProMedica Health & Wellness Center, 5700 Monroe St. (419) 291-3000 ** ** Preparation for above testing: Nothing to eat or drink after midnight **
EGD: _________________ at _____________a.m./p.m. **arrive at TOLEDO HOSPITAL at _____________a.m./p.m.
*Nothing to eat or drink after midnight*You will need a driver and for them to stay with you at the hospital until discharged.
Pre-Admission Testing _________________ at _____________a.m./p.m. *Nothing to eat or drink 12 hours prior to appointment. You may have water until 12 midnight*Arrive 15 minutes early to first appointment. (Phone # 419-291-5950)**Report to Toledo Hospital, Jobst Tower, 1st floor, 2109 Hughes Drive, Toledo OH 43606
Physical therapy: ________________ at ______________a.m./p.m. *Bring binder and the completed 3-page physical therapy questionnaire found in the exercisesection of binder (Pages 34-36) to your appointment. (Phone # 419-291-8370)*Report to Center for Health Services, 2150 W. Central Ave. Toledo, OH 43606. Located acrossfrom Toledo Hospital, 3 story red brick building, rehab department is located on 3rd floor.
2 – 2 ½ Hr. Pre-operative class: _______________ at ______________ a.m. / p.m. *Bring binder, 5700 Monroe St. Sylvania, OH 43560 (Community Education Room)
Begin liquid diet: _______________ found in surgery section of binder.
Surgery: ________________ at _____________ a.m. / p.m. **Report to Toledo Hospital at ______________a.m./ p.m.
**It is absolutely imperative that you have nothing to eat or drink after midnight the day before your surgery. Carbohydrate loading is the only exception.
**Report to Toledo Hospital, Entrance B, stop at registration desk. **Take elevator to Surgery 2nd floor.
One week post-op appointment: ______________ at _____________ a.m. / p.m. 5700 Monroe St., Suite 101, Sylvania, OH 43560
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Medical Nutrition Therapy (MNT)
Personal Weight Record MNT Visits with the Dietitian:
Date Height Weight BMI Total Weight Loss Initial Visit
Initial Visit with Bariatric Surgeon
Date Height Weight BMI Ideal Body Weight
Day of Surgery
Date Height Weight BMI Ideal Body Weight
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Post-Surgery Progress Weight Record Log:
Date Height Weight BMI Pounds Lost
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15 Steps to Weight Loss Surgery
□ 1. Attend an information seminar or view online seminar *Discuss your plan with the people in your support group □ 2. Call your insurance company asking if weight loss surgery is a covered benefit □ 3. Complete paperwork and turn in forms provided at the seminar □ 4. Appointment with the Bariatric Surgeon. Following appointment, you will receive: □ ProMedica Bariatric Patient Guide – Educational Binder □ Prescription – Chewable Prenatal Vitamin - Free at Meijer □ Orders for blood work and x-rays □ Referral to Physical Therapy – Call 419-291-8370 to make an appointment □ Review exercise tab in binder prior to appointment □ Complete questionnaire, pages 34-36 in binder and bring to appointment □ Possible Referral for Medical, Pulmonary or Cardiac Clearance □ Appointment with the dietitian to begin Medical Nutritional Therapy (MNT) □ 5. Appointment with your primary care physician for the following: □ Female patients need a updated annual Mammogram if over 40 years old □ Female patients need an updated pap smear
□ Stop Smoking □ 6. Counseling (MNT) with the Dietitian: 3 to 6 months depending on Insurance Criteria READ PAGES 1-24 IN BINDER BEFORE FIRST MNT APPOINTMENT Initial MNT visit: _______________ Fourth MNT Visit: __________________ Second MNT Visit: _______________ Fifth MNT Visit: __________________ Third MNT Visit: _______________ Sixth MNT Visit: ___________________ □ 7. Complete EMMI on-line education videos □ 8. Complete Psychological evaluation □ 9. Complete Physical Therapy appointment and begin an exercise program □10. Follow-up Appointment with the Bariatric Surgeon □11. Acquiring Insurance Approval □12. Attend Support Group □13. Scheduling the Surgery Date / Pre-op Class / Pre-admission Testing □14. The Surgery □15. Follow-up Visits for life
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Each of the steps listed above are explained in greater detail on the following pages
Step 1: Attend an Information Seminar or View the On-Line Seminar The information seminar given by one of our surgeons gives you the opportunity to learn about weight loss surgery, hear from a weight loss patient and have any questions you may have about the surgery answered. You can also view the seminar on your computer by going to promedica.org/online seminar. Discuss Your Plan with the People in Your Support System Ask yourself if you are ready to make the lifestyle change commitment that is required to be successful with weight loss surgery. It is important for you to discuss this commitment with your support system and understand the financial commitment involved with weight loss surgery. Step 2: Verify Insurance Coverage for Weight Loss Surgery Please contact your insurance company and verify that your policy does cover weight loss surgery. Ask your insurance company if the following procedures are covered at the Toledo Hospital by your insurance plan:
• Roux-en-Y gastric bypass (CPT Code 43644) • Gastric Sleeve Resection (CPT Code 43775)
PLEASE NOTE: Most Insurance Companies Request the Following Information:
• 2 to 5 year documented weight history. • Documentation of diet drugs and medically supervised diets prescribed. • Documentation of commercial diet program records (Weight Watchers, Jenny
Craig). • Exercise program records (Gym membership, YMCA). • Supporting letter from the referring physician.
***You will need to begin gathering this documentation. The insurance company will require official documentation. Copies of the doctor’s office notes detailing your weight history, weight loss attempts, prescribed weight loss drugs, and exercise programs in which you participated.
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Step 3: Complete paperwork and Turn in the Forms Received at the Seminar. Forms Can be Printed From Our Website We would greatly appreciate your efforts to respond to all the questions to the best of your knowledge. If you cannot remember exact dates, please provide approximate dates. The information you provide is very important in helping us learn more about you, your general health and your weight control issues. Our goal is to provide you with the highest quality of care tailored to meet your specific needs. As with all patient records, the information that you provide to us is confidential. Fax completed paperwork to (419)480-6607 Once your paperwork has been received, our staff will determine if you qualify for weight loss surgery according to the National Institutes of Health (NIH) guidelines. You will be called once paperwork has been evaluated, usually within 48 hours. Step 4: Appointment with the Bariatric Surgeon • At this office appointment, the surgeon will review your history and perform a
physical examination. You will have an opportunity to discuss surgical weight loss options and ask questions.
• If you have complicated medical conditions, you will be referred to a specialist for medical, cardiac or pulmonary clearance.
• At the conclusion of your visit if you are an acceptable candidate for weight loss surgery you will receive:
□ ProMedica Bariatric Patient Guide – Educational Binder □ Prescription for a chewable prenatal vitamin to begin - Free at Meijer □ Orders for blood work and x-rays □ Referral to Physical Therapy – Call 419-291-8370 to make an appointment □ Review exercise tab in binder prior to appointment. □ Complete physical therapy questionnaire, pages 34-36 and bring to appointment. □ Appointment with the dietitian to begin Medical Nutritional Therapy (MNT)
Step 5: Appointment with your Primary Care Physician (PCP) Schedule an appointment with your family physician to review your decision to have weight loss surgery. If you are a smoker or chew tobacco, discuss with your physician a prescription for a smoking cessation aide. Please have your PCP fax the following medical records to us:
• Mammogram. For women over the age of 40, a mammogram is required in the year prior to the
weight loss surgery.
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Fax report to (419)480-6607. • Pap Smear.
For women who have not undergone a hysterectomy, an updated pap smear is required prior to your weight loss surgery.
Fax report to (419)480-6607. Step 6: Counseling with the Dietitian Read Pages 1-24 in your binder prior to appointment. Your insurance company determines the number of required meetings with the dietitian. You will be scheduled for an additional review visit with the dietitian if your last visit with the dietitian has been greater than 3 months from your surgery date. You are responsible for verifying with your insurance if Medical Nutrition Therapy is a covered benefit.
• Call the customer service number on the back of your insurance card. • Ask the representative if Medical Nutrition Therapy is a covered benefit, (CPT code
97802). • They will ask you for diagnosis codes: Examples of diagnosis codes are:
Morbid Obesity E6601 Diabetes E11.9 Hypertension I10 Hyperlipidemia E78.4
• If you have coverage, we will bill your insurance company. • If you do not have coverage, we will bill you as a cash pay patient at a special rate.
Step 7: Complete Emmi On-Line Education Videos At your second dietitian visit, you will be assigned an education video called Emmi. Emmi programs are online tools that make complex medical information easier to understand.
• Watch as many times as you like, with your family and friends. • Once assigned, go to www.startemmi.com. • Your access code will be emailed to you. • Write down all your questions. You can discuss them with the bariatric surgeon.
Step 8: Complete Psychological evaluation A psychologist will evaluate you. Certain psychological problems may interfere with your ability to make lifestyle changes after weight loss surgery. It is important that you have a thorough understanding of such issues before an operation is done. You may then prepare a plan to deal with them. Psychologists cannot accurately foresee all your potential problems
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but they are available before and after the weight loss surgery to help you along your journey. Step 9: Complete Physical Therapy Appointment and Begin an Exercise Program All patients will need to complete a physical therapy evaluation at the Center for Health Services, 2150 W. Central Ave., Toledo, OH 43606. Please call 419-291-8370 to schedule your appointment. Please review the exercise tab in your binder and complete the three-page physical therapy questionnaire prior to your appointment. If you desire to lose weight and keep it off successfully, you need to exercise. The recommended schedule is 30 minutes five times a week. This may be difficult at first, but as you lose weight, it will get easier. You CANNOT depend on the surgery alone to accomplish weight loss. Regular exercise is a lifestyle change that must be made. Our physical therapist will evaluate you and recommend an exercise program individualized to each patient. Ask about our Bridge to Fitness or Script4Fitness programs here at ProMedica Wildwood Athletic Club.
Step 10: Follow-up Appointment with the Bariatric Surgeon
• After you have completed your psychological evaluation and counseling with the dietitian, you will have an appointment with the bariatric surgeon. At this office appointment, the surgeon will again review your history and perform a physical examination. You will have an opportunity to review the surgical consent, alternatives, risks, benefits of weight loss surgery and ask questions/concerns.
• Medical, cardiac or pulmonary clearances will be reviewed. • At the conclusion of your visit, a preoperative testing, consultation plan, and surgical
worksheet will be completed. These pre-operative tests are not done until insurance approval is obtained.
Step 11: Acquiring Insurance Approval Once your weight history, diet and exercise program, medical nutrition therapy, psychological therapy and initial consult or subsequent visits with the surgeon is complete, we will submit a letter of recommendation to your insurance carrier requesting approval for the surgical weight loss procedure. Your medical records are sent to your insurance company with this letter. The insurance company may need additional information before they can make a decision. As described in Step 2, having your weight and weight treatment history at this time is very important. Failure to include this information may result in a delay of the approval process.
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Some insurance companies will make the decision about your surgery within a few weeks. Some insurance carriers take several weeks or months to return a decision. We will contact you when we have heard from your insurance company. You may contact your insurance company to check on the status of your insurance approval. If your insurance company denies approval for weight loss surgery, our office staff will discuss appeal process and self-pay options with you.
Step 12: Attend Support Group You are strongly encouraged to attend support groups. Dates can be found on our website www.promedica.org/bariatric. Research shows that patients who attend weight loss surgery support group meetings lose 20-30% more weight. Step 13: Scheduling the Surgery Date / Pre-op Class / Pre-admission Testing Once your insurance approval is obtained, you will be contacted to arrange any pre-operative visits. The following appointment dates will be arranged: Surgery Date Pre-operative Studies
• Gallbladder Ultrasound if indicated • Upper GI x-ray • Chest x-ray • Upper Endoscopy if indicated • Pre-operative laboratory tests • EKG
Pre-admission testing appointment at Toledo Hospital. Instructions on the pre-operative liquid protein diet and carbohydrate loading. Pre-operative class. One-week follow-up appointment.
Step 14: The Surgery Congratulations, you made it to surgery.
Step 15: Follow-Up Visits for Life We look forward to working with you in reaching and maintaining your health and weight loss goals. Compliance to a follow-up schedule is very important. Regular follow-up visits are essential to helping you achieve your personal and weight loss goals.
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Table of Contents
Introduction - Welcome - Comprehensive Accredited Center - Contact numbers - Recommended Psychologist - Bariatric Web sites
Preparing for surgery
- Nutrition Goals before Bariatric Surgery - How to Read Food Labels - Nutrition for the First Steps of Your New Life
Medicines before and after Surgery Alcohol and Smoking
- Policy on Tobacco Products - Two Problems associated with Tobacco use and Bariatric Surgery - ProMedica Wellness Tobacco Treatment Services
Your Hospital Stay Exercise - Physical Therapy Forms – complete and bring to your appointment
- Daily Exercises - Daily Exercise Log - Aerobic Exercise Log - Exercise
Surgery
- Surgeries done at ProMedica Toledo Hospital - Benefits of Laparoscopic Surgery - Risk of Surgery - How We Choose Which Procedure a Patient Will Receive - Pre-op Liquid Diet - Your Surgery - Pre-op Shower and Bathing for Surgery - Pre-Surgery Instructions
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Day 1 of your new life • Eating for Healing – Clear Liquids
Discharge from the Hospital
• Resuming Home Medications • Discharge Diet Goals
Follow up Visits with your Bariatric Team Support Groups / Emotional Concerns after Weight Loss Surgery
Day 2 of your new life • Eating for healing – liquid protein shakes
Day 3 of your new life
• Eating for healing – full liquids Day 10 of your new life after Gastric Bypass or Day 17 of your new life after Sleeve Gastrectomy
• Eating for healing – creamy foods • Healthy eating techniques • Vitamin/mineral supplements and medicines
Day 17 of your new life after Gastric Bypass or Day 24 of your new life after Sleeve Gastrectomy
• Eating for healing – soft foods • Daily Food Logs • Vitamin/mineral supplements and medicines
Common nutritional complaints after bariatric surgery 6 weeks after surgery
• Eating for healing – soft foods • Vitamin/mineral supplements and medicines • Calcium Citrate • Exercise
4 months after surgery
• Eating for healing – soft foods • Vitamin/mineral supplements and medicines
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6 months after surgery
• Eating for healing – regular foods • Vitamin and mineral supplements
9 months after surgery
• Fiber • Vitamin and mineral supplements
1 year and beyond
• Weight loss plateau • Vitamin/mineral supplements
Vitamins/Minerals/Protein/Lactose Intolerance
• Vitamin/mineral Supplements for life • Calcium • Iron • Vitamin B-12 • Vitamin D • Protein • Lactose Intolerance
Eating Out
• Size up your servings • Tips for restaurant eating
Measuring Success Pregnancy after bariatric surgery
Forms to sign and turn in prior to surgery:
• Weight-loss surgery Pre-operative Quiz
Introduction
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Welcome Message from our Medical Staff
Congratulations on your choice to have weight loss surgery! During this process, your ProMedica Weight Loss Surgery team will be helping you to meet your weight loss goals so that you might start “A New Life, A New You”. Many people do not realize the effect patients with obesity has on the mind and body. Patients with obesity face health, social and psychological problems that are not recognized by our society. Obesity is not caused by a lack of will power as is commonly believed. The difficulties faced in everyday life like tying your shoes, getting in and out of your car and simple daily hygiene become a challenge. Life-threatening health risks like diabetes, high blood pressure, sleep apnea, heart disease, arthritis, infertility and a shortened life span are caused by obesity. Obesity can severely affect the quality of your life. This disease is so powerful that you alone cannot cure it. Many of you have struggled with why you are obese and feel defeated by your inability to change your weight. Statistics show despite diet plans, 95 percent of people will regain their weight. The only proven long-term solution to obesity and its related illnesses is weight loss surgery. Weight loss surgery, despite its risks, can drastically improve your life. You can have control and make decisions toward a new life, a new you. We offer minimally invasive surgical options using the most advanced techniques for permanently treating obesity and its related complications. Our team will talk with you about your medical, nutritional, physical, and emotional needs. Please use this guide as a way to keep this important information at your fingertips. To help you in your goals please bring this guide with you to each visit at the office and to your appointments at the hospital. This includes visits with the dietitian, physical therapist, psychologist, bariatric nurse, bariatric surgeon, and pre-admission testing appointment and pre-operative class. This patient information guide will begin the journey to understanding the role of weight loss surgery. Most importantly, it will prepare you for what to expect before and after your surgery. We look forward to answering any questions you may have and welcome you to our program.
Patrick White MD, FACS | Jose Parodi, MD, FACS | Daniel McCullough, MD, FACS
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ProMedica Weight Loss Surgery
Comprehensive Accredited Center
The Metabolic & Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) of the American College of Surgeons and the American Society for Metabolic & Bariatric Surgery have designated ProMedica Weight Loss Surgery as a Comprehensive Accredited Surgery Center for Metabolic & Bariatric Surgery. This designation is awarded to programs with a proven record of favorable outcomes for weight loss surgery and who have demonstrated a commitment to delivering the highest-quality care for bariatric surgery patients.
To earn this accreditation, ProMedica Weight Loss Surgery met the essential criteria that ensure its ability to support a bariatric surgical care program and measure up to the institutional performance requirements outlined by the MBSAQIP accreditation standards.
Accredited bariatric surgery centers provide both the hospital resources necessary for optimal care of patients with obesity and the support and resources necessary to address the entire spectrum of care and needs of bariatric patients, both before and after surgery.
“Accreditation is an important way for patients to verify that a practice has access to all the key resources necessary for optimal care,” said Dr. Patrick White, Director of ProMedica Weight Loss Surgery. “It also evaluates outcomes to verify the safety and effectiveness of the bariatric surgeons. We are proud to be acknowledged for our excellence at ProMedica Weight Loss Surgery”.
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ProMedica Weight Loss Surgery Contact Numbers Office Phone Hours- M-F 8am-4:00pm Phone: 419-291-6777 1-800-971-8203 Fax-419-480-6607 Drs. White, Parodi and McCullough - General / Bariatric Surgery Office Phone: 419-291-6777 (Phones roll over to answering service after 4:00PM).
Metabolic & Bariatric Surgery (MBS) Program Coordinator Cathy Uram, RN, CBN [email protected] PHONE TREE OPTIONS – Dial 419-291-6777 Bariatric Outreach Coordinator – Insurance and approval questions - Option # 1 Appointment Line - Scheduling and changing appointments - Option # 2 Surgery Scheduler – Scheduling or changing surgery - Option # 3 Bariatric Nurse Line – Medical questions and concerns - Option # 4 Registered Dietitians - Questions regarding your diet – Option # 5 Shannon Sorg, MS, RD, LD Christina Gardner, MFN, RD, LD Billing Questions – Option # 6 All Other Questions – Option #7 Physical Therapy - The Center for Health Services - Total Rehab - Level 3 2150 W. Central Toledo, OH 43606 Phone: 419-291-8370
When leaving a message, Please speak clearly stating your full name, date of birth, reason for the call and best number and time to reach you.
Preparation
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Recommended Psychologist: Dr. Smitley 4841 Monroe St. Suite 301 Toledo, Ohio 43623 Phone: (419)475-2535
Harbor Behavioral Health Dr. Bonnie Kauffmann 3909 Woodley Road, Suite #600 Toledo, Ohio 43606 Phone: (419)720-6115 - Carmen (567)455-5369 – Angie Sylvania Therapy and Counseling 5800 Monroe St., Bldg. A, Suite 1 Sylvania, OH 43560 Phone: (419)517-7073 or (419)276-3556 Currently are not evaluating patients having Medical Mutual Insurance Melissa R. Davies, Psy.D. 1125 Ralston Ave. Defiance, OH 43512 Phone: (419) 782-2800 Fax: (419) 782-2805 Insurances Not Accepted: Anthem, Blue Cross/Blue Shield, Cigna, United Healthcare, Medicaid or Paramount Advantage
Ross Halpern, Ph.D., L.P. & Associates 135 S. Prospect St. Ypsilanti, MI 48198 Phone: (734) 961-3030
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Bariatric Web sites www.promedica.org/bariatric
ProMedica Toledo Hospital wants to help you start your new life. This web site provides you information about our program, patient testimonials and resources to assist you along the way.
Our dietitian encourages you to look under the “weight loss resources” tab and download our patient cookbook filled with many healthy recipes you can use after surgery. Or you can access it through the direct link: https://www.promedica.org/Public%20Documents/bariatric/weight-loss-surgery-cookbook.pdf
www.obesityhelp.com
This web site allows you access to emotional support from fellow weight loss surgery patients. It contains a ProMedica Toledo Hospital message board for patients to communicate to each other. Phone apps that may be beneficial:
– Baritastic – Loseit – myfitnesspal – Mydailyplate – Caloriecounter – Waterlogged
Internet food label reading websites:
– Calorieking.com – Myfitnesspal.com – Verywell.com – My-calorie-counter.com
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Nutrition Goals before Bariatric Surgery
Bariatric surgery does not cure obesity. You will lose weight at first, but at some point after the surgery, your success will depend on your lifestyle choices. Making diet and lifestyle changes before surgery will help increase your weight loss success after surgery. Please begin working on the following goals before surgery. _____ 1. Eat four to five small meals per day. Meals should be about 3 hours apart. No night time snacking. Example: 9 am – breakfast or 6 am - breakfast 12pm (noon) – lunch 9 am – morning snack 3 pm – afternoon snack 12 pm (noon) - lunch 6 pm – dinner 3 pm – afternoon snack 6 pm - dinner
_____ 2. Avoid all sugars, sweets, desserts, and sugared drinks. Read food labels for 5 grams of sugar or less per serving.
_____ 3. Avoid fried foods, limit fats added to foods, and avoid high-fat fast foods. Read food labels for about 3 grams of fat or less per serving.
_____ 4. Eat a protein-rich food at each meal. This includes poultry, fish, lean meat, eggs, beans, tofu, and low fat dairy products. Proteins can be followed by vegetables, then fruits. Limit starches such as breads, rice, pasta, and potatoes.
_____ 5. Take a multiple vitamin/mineral supplement daily.
_____ 6. Sip 8 cups (64 ounces) liquids between meals (stop drinking 30 minutes before the meal and don’t resume till 30 minutes after the meals is done.)
_____ 7. Eliminate drinks with: • Sugar and/or calories (for life after surgery) • carbonation (for life after surgery) • caffeine (for at least 6 weeks after surgery) • alcohol (for at least 1 year after surgery).
_____ 8. Eat meals very slowly (approximately 30 minutes per meal). Stop eating when you feel full.
_____ 9. Take small bites. Chew foods well.
_____ 10. Avoid emotional eating/mindless eating.
_____ 11. Exercise by _________________________________________
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How to Read Food Labels
Serving Size
If your serving size is not the same as the one on the label, remember to count more or less for the calorie and nutrient values.
Total Fat Too much fat in the diet may play a part in heart disease, cancer and obesity. After gastric bypass surgery, too much fat can cause diarrhea. Look for foods which contain about 3 grams of fat or less per serving.
Sugars Fruits, juices, and dairy products contain natural sugars. After gastric bypass surgery, foods which are high in added sugars will likely cause dumping syndrome. Look for foods which contain 5 grams of added sugar or less per serving.
Protein Protein is needed to heal and maintain muscle mass. Most gastric bypass patients need 65 – 75 grams of protein a day. Make sure you are meeting
your personal protein goal.
Nutrition Facts Serving Size ½ cup (114 g) Servings Per Container 4
Amount Per Serving Calories 110 Calories from Fat 27 % Daily Value * Total Fat 3 g 5% Saturated Fat 0 g 0% Cholesterol 0 mg 0% Sodium 300 mg 13% Total Carbohydrate 13 g 4% Dietary Fiber 1 g 1% Total Sugars 5 g Includes 5g added Sugar
Sugar Alcohols 2g Protein 8 g Vitamin A 20% Vitamin C 60% Calcium 4% Iron 4% *Percent Daily Values are based on a 2,000 calorie diet. Your daily values may be higher or lower, depending on your calorie needs.
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Nutrition for the First Steps of Your New Life
Nutrition for Healing The first few weeks after surgery your body needs time to heal and will progress through the following nutrition phases: At first, the diet will help you meet your protein and liquid needs. Later, the diet will assist you in meeting all your nutrition needs. It is important that you follow the diet phases to allow for healing and decrease complications. The size of your stomach pouch is small, about 1 – 2 ounces. At first your intake of food will be small, so be patient. You may find that two to three tablespoons of food fill you up. This is normal. You may also find that you are able to eat more of one type of food than another. That is normal as well. Over time, you will be able to eat larger amounts of food. By one year after surgery, you may be able to eat to 6 ounces or ¾ of a cup. Long term, your capacity is likely to be 8 ounces or 1 cup. This will continue to limit the amount of food you can eat at one time.
Surgery may change your wants and desires for certain foods. You may be less interested in foods you use to love. To maintain a healthy weight and to prevent weight gain, you must develop and practice healthy eating habits. You will need to be aware of the volume of food that you can eat at one time and make healthy food choices to ensure the most nutrition in the least volume. One effect of weight loss surgery is the slow change in way you think about eating. You will begin to ‘eat to live – not live to eat.’
Creamy Foods
Soft Foods
Protein Shakes
Full Liquids
Regular Diet
Clear Liquids
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To adjust to your new stomach and promote weight loss you must learn to adjust eating/drinking habits and making changes in your food choices. These nine steps will help you change your eating patterns:
1. Eat only at meal times. Eat 4 to 5 small meals per day with meals about 3 hours apart. Your first meal should be eaten within 1-2 hour after waking up, as this is the start of you metabolic boost. If you are working out first thing in the morning, eat directly after your workout. Between meal “grazing” on small amounts of food during the day or at night will impair your weight loss and not allow you to lose enough weight.
2. Take small bites and chew food thoroughly.
The new opening from the stomach pouch is very small and can easily be blocked with small pieces of food. Blockage of this hole will prevent food from leaving the stomach pouch and could cause vomiting. As you follow the diet phases and choose foods with more texture, take small bites of food and chew them thoroughly. Use a baby spoon to portion out a smaller bite. When starting solid foods, chew each small bite of food about 30 times until it is a liquid consistency.
3. Stop eating or drinking when you start to feel full.
Eating too much makes you vomit and can lead to stretching of the opening from the stomach pouch to the intestines. Listen to your body’s signals, not the food left on your plate. Signs of fullness may not feel the same as before surgery. Here are some signs that may not be obvious, but will tell you when your pouch is nearly full:
• A feeling of pressure or fullness in the center of your abdomen, just below your rib cage.
• A feeling of nausea, vomiting, or heartburn. • A feeling of tiredness, as if you may need to lie down. • Getting the hiccups or a burp. • Feeling sweaty or like your heart is fluttering. • Sneezing.
4. Take 30 minutes for each meal.
At first, eat 2 – 4 Tablespoons of food over a 10 – 15 minute period. If you do not feel full, eat another 2 – 4 Tablespoons of food over the next 10 – 15 minutes. Plan at least 30 minutes for each meal. Many of us have a lifelong habit of eating too fast. Slow down, enjoy the food and relax. Explain to friends and family why you must eat slowly so they do not urge you to eat faster.
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ProteinCarbohydratesFats
5. Drink at least eight cups (64 ounces) of non-caloric liquids per day. To prevent dehydration, sip on sugar-free, non-carbonated, caffeine-free, non-alcoholic liquids between meals throughout the day. This includes Crystal Light®, Diet V8 Splash®, sugar-free Kool Aid®, Power Ade Zero, Fruit2O®, and vitamin water zero. Try drinking one cup of fluid every hour that you are awake and not eating. Getting all your fluids reduces the risk of blood clots after surgery, especially during the first two – four weeks after surgery. If you do not get enough fluids, you may develop
• headaches • light-headedness • a feeling of thirsty, but are unable to keep down liquids • muscle weakness • constipation
6. Never drink liquids when eating solid foods.
Avoid liquids 30 minutes before and 30 minutes after eating your meals. Combining liquids and solids may cause nausea. Drinking may also push foods through the stomach pouch faster, allowing you to eat more.
7. Eat protein rich food at each meal.
It is common to see some differences from program to program related to nutrition. However, most programs agree that the main source of nutrition should be protein (eggs, fish, meat, low-fat dairy, etc.).
Protein is an important nutrient in your diet. It is needed to maintain and repair your body. Include a protein rich food such as meat, fish, eggs, and low-fat dairy products at each meal. Protein powders or drinks can be helpful to fulfill your protein goals. There are many to choose from. Look for protein supplements that are low in calories, sugar and fat.
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8. Avoid all high-sugar and high-fat foods. High-sugar and high-fat foods are high in calories and may provide few nutrients. They will slow down your weight loss and may make you sick. Sugar may cause “dumping syndrome” in patients who have had gastric bypass. Dumping is when sugars go directly from your stomach pouch into the small intestine causing a fast heartbeat, nausea, abdominal pain, and diarrhea. Symptoms may vary among patients. Dumping lasts about 30 – 60 minutes. While it may make you feel ill, dumping syndrome can be helpful. It provides negative feedback for eating the “wrong” foods. Most patients do not experience full-blown symptoms of dumping more than once or twice. Most simply say that they have lost their taste for sweets.
9. Take daily vitamin and mineral supplements.
Vitamins and minerals are an important part of the weight loss diet. Since the diet allows only small amounts of foods, it is difficult to get enough vitamins and minerals from food alone. Also, surgery changes the way some nutrients are absorbed due to bypassing part of the stomach and small intestine. Therefore, it is necessary to take multivitamin/mineral supplements daily for the rest of your life to prevent vitamin and mineral deficiencies. Daily multivitamin with iron, calcium, and vitamin B-12 supplements will be consumed for the rest of your life. Additional vitamins and minerals may be prescribed based on your lab results.
If you ignore these recommendations your teeth will crumble, your bones will break, your nerves will be damaged beyond repair giving you persistent severe pain. This does not happen quickly…it takes 5 to 15 years…but it will happen. If you cannot follow our recommendations about vitamin and mineral supplementation, DO NOT HAVE WEIGHT LOSS SURGERY.
Ask about Free Prenatal Vitamins.
Medicines B
efore and A
fter Surgery
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Medicines before and after Surgery
Taking medicines after surgery All medications should be taken at least one hour before or one hour after eating. Medications should be no larger than the size of a baby aspirin for the first 6 weeks. If it is larger, it should be broken in half. Take ½ then wait 30 minutes and take the other ½. If you have many medications, they need to be spread throughout the day. Depending on the size of the pill, try waiting 15 minutes to 30 minutes between each pill. Do not open capsules.
Medications need to have less than 5 grams of sugar in them or you could experience “dumping syndrome.” Please read labels on all your medications. Sugar-free medications are recommended. For example, sugar-free cough drops or sugar-free cough syrup. Prescription and Over-the –counter (OTC) Medications Bariatric surgery includes a life-long commitment to a change in how you take your medications including both prescription and over-the-counter (OTC) products. It may be necessary to change to a different formulation or different medication so that your drug therapy can be most effective. Key points to remember include:
• Your surgeon will be the one determining what medications are continued (or discontinued) after surgery. Follow your physician’s orders until he tells you to change them. Do Not stop medicines on your own.
• There are varieties of medications that are not recommended for bariatric surgery patients (unless directed by your surgeon). These include (but are not limited to) aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve), and certain medications used for osteoporosis (Boniva, Fosamax, Actonel).
• “Time-release” medications may never be crushed or chewed and may require a change in your therapy. These changes will be recommended to you and may require that you contact your prescribing physician or be scheduled for a consultation with a pharmacist. By crushing a sustained release formulated medication, it changes the integrity of the timed-release nature of the drug, causing the contents to be released at one time, which can increase the risk of side effects.
• If allowable by physician, change the dose of an extended release (ER) or sustained release (SR) tablet or capsule to immediate release (IR).
• Examples of medications that are sustained or timed release are those with an abbreviation included in the table:
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Common Abbreviations for Extended-Release Products: CD Controlled dose CR Controlled-release CRT Controlled-release tablet LA Long acting SA Sustained action SR Sustained-release TD Time delay TR Time-release XL Extended-release XR Extended-release
• Notify all of your healthcare providers that you are going to have bariatric surgery. Please review your home medications with your prescribers for any changes that may be necessary.
• Remember you must always find out how to take medications prior to taking them.
Blood Thinners Blood thinners will need to be stopped before surgery. When to stop them will be determined by the surgeon. Please stop them according to the time listed below:
Coumadin: stop ______ days before surgery Plavix: stop ______days before surgery Pradaxa: stop ______ days before surgery Xarelto: stop ______ days before surgery Eliquis: stop _______ days before surgery
After a Roux-en-Y Gastric Bypass procedure, ulcers may develop at the site where your stomach and small intestine join. If you need to restart these medications after surgery you will also need to take Zantac 150 mg or Pepcid 20 mg daily to minimize the risk of an ulcer. This is somewhat less of a concern after a sleeve resection.
Birth Control / Hormone Replacement Birth control pills or estrogen supplementation should be stopped one month before surgery. You may resume these one month after surgery. These increase your risk for developing blood clots. Other methods of birth control should be used. It is recommended that you avoid becoming pregnant for 12 months after weight loss surgery.
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**NSAIDs Nonsteroidal anti-inflammatory drugs or NSAIDs should be stopped for at least seven days prior to surgery. After the Roux-en-Y gastric bypass procedure, frequent NSAID use can be very dangerous. NSAIDs increase your risk of developing ulcers at the site where the stomach and small intestine are joined. NSAIDs are among the most common pain relief medicines in the world. They include over the counter drugs such as:
• Aspirin (Bufferin, Bayer, Excedrin, Midol) • Ibuprofen (Advil, Motrin, Nuprin) • Ketoprofen (Actron, Orudis) • Naproxen (Aleve) • Alka Seltzer
Other NSAIDs are available by prescription. They include: • Celebrex • Daypro • Feldene • Indocin • Lodine • Mobic • Naproxen • Naprosyn • Relafen • Soma • Voltaren gel • Voltaren
Check with your pharmacist to be sure your prescription or over the counter medications do not contain aspirin. If you need medications for pain you may safely consume over the counter Tylenol and Tylenol Arthritis, or by prescription from your family doctor Ultram (Tramadol).
**Low dose Aspirin (81mg) may be resumed 2 months after gastric bypass. Zantac 150mg or Pepcid 20mg daily should be taken as well to protect the small intestine from ulceration.
After the Sleeve Gastrectomy procedure, NSAIDs are allowed when approved by the Surgeon.
Herbal Supplements Herbal supplement use should be stopped before surgery. Herbal supplements such as St. John’s Wort, Gingko Biloba, garlic, fish oil, etc., should be avoided since they can thin the blood. Other herbal supplements such as Kava and Valerian Root should be stopped 10 days before surgery because they lead to problems when an anesthetic is administered. Check your multivitamin as some contain herbal supplements as well.
*Stop Vitamins 7 days prior to surgery
*Stop Metformin 24 hours prior to surgery
Inform the bariatric team if you have a History of Gout.
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**Steroids No Prednisone for 30 days post-surgery. Prednisone interferes with the healing process. After Roux-en-Y Gastric bypass, prednisone increases the risk of ulcer formation at the site where the smaller stomach pouch and small intestine join. If you’re prescribed Prednisone in the future by another practitioner, you will need to take Zantac 150mg or Pepcid 20 mg to protect your pouch. (Ex: poison ivy) After Sleeve gastrectomy, Prednisone can be resumed when approved by the surgeon. *Prednisone inhalers and eye drops do not need to be stopped. Blood pressure medications Blood pressure medications that contain diuretics (water pill) are discouraged for the first month after surgery. It is difficult to maintain adequate fluid intake after surgery. Diuretics can add to post-op dehydration resulting in lightheadedness, dizziness, feeling faint, and even hospitalization.
Seasonal Allergy/ Upper Respiratory Infection Often nausea and vomiting are a result of increased mucus in the stomach pouch. This mucus can accumulate due to allergies or congestion as with the common cold. Claritin 10 mg daily is recommended to decrease mucus production and decrease nausea and vomiting. Cold and flu Tylenol products are recommended for cold and flu symptoms. For example, Tylenol Cold and Sinus. Mucinex, Benadryl, Sudafed and sugar-free cough syrup are other over-the-counter products that may be used. Flu Vaccine It is not recommended to receive the flu vaccine one month prior to surgery and one month post surgery. Gallstones If your surgeon ordered an Ultrasound of your gallbladder and it does not contain stones, you may be given a prescription at your 1-week follow-up appointment for Ursodiol to help prevent gallstone formation.
• Ursodiol 500mg daily • Ursodiol 300 mg two times a day (Medicare patients)
People who lose a large amount of weight quickly are at greater risk for developing gallstones. Ursodiol is taken daily the first 6 months. During the first 6 weeks, Ursodiol 500mg pill should be broken in half, and take each half 30 minutes apart.
Alcohol and S
moking
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Alcohol and Smoking
Alcohol Alcohol use must be stopped prior to surgery. ***You must remain alcohol-free for at least one year after surgery. The metabolism of alcohol changes dramatically after gastric bypass surgery. This has serious consequences.
1. Small amounts of alcohol cause high blood levels. • You can be legally drunk (defined as a blood alcohol level greater than
0.08 with a single glass of wine. 2. The effects of alcohol lasts longer. 3. Alcohol is high in calories. It may impede weight loss. 4. There is an increased risk of alcohol addiction.
• The risk of addiction increases for 10 years after gastric bypass surgery.
Policy on Tobacco Products ***Smoking should be avoided for many reasons.
• Smoking prevents good lung function • Smoking increases risk of anesthetic complications • Smoking increases risk of blood clots to the legs • Smoking reduces circulation to the skin which can slow healing. • Smoking causes stomach acid production.
There are Two Separate Problems associated with Tobacco use and Bariatric Surgery
1. Tobacco use prevents normal healing. (Intestine or stomach that is sewn or stapled together can fall apart)
2. Tobacco use after a gastric bypass can cause an ulcer.
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Tobacco Products • Cigarettes • Cigars • Chewing Tobacco • Dipping
Nicotine Delivery Devices
• Vapor Cigarettes • Nicotine gum • Nicotine patches
Electronic Cigarettes
• The U.S. Food and Drug Administration does not regulate electronic cigarettes. • As a result, nicotine concentration labeling on refill fluids used in these devices is
often inaccurate. • “Nicotine free” fluid may contain nicotine. • If you use these fluids, your nicotine test may come back positive.
Prior to an operation, we will do breathe tests, urine tests and blood tests to determine if you are using any of these products. If you claim to have stopped using these products and the tests are positive, you may be dropped from our program. If you undergo a gastric sleeve resection, you may use tobacco products once you have completely healed, about a month after the operation. Tobacco products rarely cause stomach problems after a sleeve resection. If you undergo a gastric bypass, tobacco products can cause ulcers and should never be used again. Vapor cigarettes, nicotine gum, or nicotine patches may be used, but it would be wise to stay away from them. Use of these products may encourage you to resume smoking.
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Summary of Tobacco Policy:
Gastric Sleeve Resection
• Before the operation – no tobacco products or nicotine delivery devices for 3 months.
• After the operation- If you desire, you may resume tobacco use after one month.
Roux-en-y Gastric Bypass
• Before the surgery - no tobacco products or nicotine delivery devices for 3 months.
• After surgery – No tobacco products. You may resume nicotine delivery devices one month after the operation but this is not recommended.
IF YOU TELL US THAT YOU HAVE STOPPED USING TOBACCO AND NICOTINE AND TESTS ARE POSITIVE, YOU MAY BE DROPPED FROM OUR PROGRAM
Ask your primary care physician to write you a prescription for a smoking cessation aide, if needed.
ProMedica Wellness Tobacco Treatment Services • Offers expert support to help you stop using tobacco products. • Respiratory therapists and registered nurses are certified to provide tobacco-
cessation treatment.
For more information about tobacco cessation options, please contact (419)291-8033.
Your Hospital S
tay
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Your Hospital Stay 2017 Average Length of Stay in the Hospital: Dr. White Dr. Parodi Dr.McCullough Nat. Average Lap Roux 1.8 days 2.5 days 1.5 days 1.9 days Lap Sleeve 1.9 days 2.3 days 1.3 days 1.5 days
About half of our patients go home the day after surgery. The rest are usually discharged on the following day. Please check with your insurance company on your benefits. You may have to pay a portion of that out of pocket. Please alert nurses if you have any nausea, muscle spasms, increased pain or shortness of breath. Pain control Your nursing team will help with pain control. Although there will always be some discomfort after an operation, keeping your pain under control is necessary for your recovery. When you are comfortable, you are better able to take part in activities such as walking, deep breathing, and coughing. These activities are very important to speed your recovery. The day of surgery, pain will be controlled with medications given through the IV or Patient Controlled Analgesic (PCA) pump. The next morning when you are able to tolerate fluids by mouth, your nurse will give you liquid or oral pain medicine. Hycet is the liquid pain medication prescribed. Norco or Percocet are the oral tablets prescribed. You will not be bothering the staff if you ask for pain medicine. Keep ahead of the pain. Do not wait for the pain to be at its worst before you ask for pain medicine. Pain medicine works best when used to prevent pain. The risk of becoming addicted to pain medicine is very low when it is used for a specific medical purpose, such as surgery. Gas pain is common after laparoscopic surgery. This pain is described as abdominal bloating pain radiating to your neck or shoulder area. A heating pad is helpful for short intervals. Monitor skin to prevent irritation or burns. Incentive Spirometer Deep breathing is important after surgery to prevent pneumonia and other respiratory complications. Use the incentive spirometer 10 times per hour after surgery while awake. Continue to use at home until resuming normal activity.
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Urinary Catheter The urinary catheter may or may not be placed once you have been put to sleep by anesthesia. If paced, it may be removed when your urinary output is good and you are up walking
Exercise after Surgery We recommend doing 10 – 15 ankle pumps at least once an hour to help decrease your risk of blood clots while in the hospital.
Your nursing team will assist you in walking the hospital hallways the day of surgery. You should walk at least four times the day after surgery. Walking helps increase blood flow, which decreases the risk of blood clots and enhances healing. When walking in the hall, pick up your green ProMedica Tennis Shoe Magnet at the nursing station. You should place your “Trophies” on your doorframe. The physicians and physician assistances will be looking for the magnets indicating that you have followed their recommendations with walking in the hallway at least four times a day.
Return to walking, biking or elliptical when you return home. Gradually return to the exercise program you were doing before surgery. Strengthening exercises can be started at any time. We suggest including stomach or abdominal exercises when cleared by your surgeon. If you have only laparoscopic incisions you do not need to worry about them falling apart with lifting or exercise. Lovenox Injection An injection of a blood thinning medication, Lovenox, will be administered in your abdomen subcutaneously prior to surgery to prevent blood clots. This medication may or may not be continued while you are in the hospital and after discharged from hospital.
EPC Cuffs You will wear EPC cuffs on your legs while in your hospital bed and up in the chair. This will help prevent blood clots.
Exercise
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Total Rehab Patient Intake, page 1 of 3 Phone number to best reach you: _____________________ Can we leave a message: Y N Past Medical History Check if you have ever been diagnosed with any of the following: Arthritis Fractures Joint Replacements Metal Implants Osteoporosis Diabetes Cancer: __________ ___________________ Surgery History: ______________________________________ ___________________
Stroke Heart Attack Pacemaker Defibrillator PVD Hypertension Lymphedema Asthma COPD Lung Problems Other: _______________
Epilepsy Bipolar ADHD Depression Migraines Headaches Hepatitis HIV MS Thyroid (Hypo/Hyper)
Problems with: Shortness of Breath Dizziness Night Pain Bladder/Bowel Control Blood in Urine/Stool Skin Rash Weight Loss/Gain Speech Vision Hearing
Current Problem Current problem that brings you to therapy: ____________________________________________ Body part(s) affected: _____________________________________________________________ Date of onset: ___________ How occurred: ___________________________________________ Has this occurred before? Yes No When? ____________ How? _____________________ Special tests for current problem: X-Ray MRI Other: _____________________________ Surgery Patients Only: Date of surgery for current problem: _______________________________ Have you previously had therapy or any other treatment for current problem? Yes No Explain: ________________________________________________________________________ Have you used a brace, splint, etc? Yes No Describe: ______________________________ Are you sensitive to heat or cold? Yes No Describe: _______________________________ Are you: Right-handed Left-handed Use both easily Male Female: Pregnant or Recently Pregnant Current Medications (include over the counter) None Separate List Provided ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________
Reason for taking: ________________________________________________________________________________________________________________________________ ________________
Allergies: None Latex Tape Bee Stings Cortisone Other: _______________________ Are you taking any blood thinners? Yes No Name: _____________ Do you smoke? Yes No
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Total Rehab Patient Intake, page 2 of 3 Rate your current overall health status: Excellent Good Fair Poor Check the activities that were DIFFICULT for you prior to the onset of this current problem: Sitting Walking Lifting Grooming Gripping Standing Running Throwing Bathing Writing Sit to Stand Jumping Carrying Objects Dressing Squatting Stairs Other: ______________________________________ Check the activities that are DIFFICULT for you now: Sitting Walking Lifting Grooming Gripping Standing Running Throwing Bathing Writing Sit to Stand Jumping Carrying Objects Dressing Squatting Stairs Other: ______________________________________ Goals for Therapy: Indicate specific activities you would like to improve or work toward: ______________________________________________________________________________ ______________________________________________________________________________ Home Environment
Social History
Do you have a history of falls? Yes No # of Falls in past 6 months: Live: Alone With Spouse With Family: ______________ Other:________________ If needed, can they provide assistance? Type: single family home multi-family home townhome apartment condo mobile home other: ________________ Indicate # of levels in the home: _____________ Stairs Inside: No Yes Number: _____ Railings: Left Right Both None Stairs To Enter: No Yes Number: _____ Railings: Left Right Both None Ramp: No Yes Describe: Bathroom on which floor(s)? Basement 1st 2nd 3rd Full Half None What floor is your bedroom? Basement 1st 2nd 3rd What floor is your laundry? Basement 1st 2nd 3rd Do you have throw rugs? Yes No Do you feel safe at home? Yes No Concerns: ________________________________
Marital Status/History: # of Children @ Residence: Employment Status / Job Requirements: Current Restrictions: Exercise / Recreational Activities: Financial barriers that might affect your care: Cultural or religious beliefs or wishes that might affect care: Easiest way for you to learn: Explanation Demonstration Printed Materials Other Who may we discuss your treatment with? Phone number(s)
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Total Rehab Patient Intake, page 3 of 3 Pain History Do you currently have pain? Yes No If No, Skip to Patient Signature If Yes, please complete the following questions. Indicate on the diagram where you currently experience pain symptoms: Front Back Describe Your Pain Aching Burning Cramping Gnawing Sharp Shooting Stabbing Tender Throbbing Other: __________________ Interferes with: Sleep Physical activity Appetite Other: ___________________ Is worse in: Morning End of Day Night Do You Have: Numbness Tingling Location: _________________________________ Changes with: Cough Sneeze Bowel Movement Symptoms are: Stable Improving Worsening Pain is: Constant Comes and goes What makes your pain better? ___________ What makes your pain worse? _____________ Use the following scale to rate the current level of your pain:
What is your acceptable level of pain? _______________________________________________
Patient Signature: ____________________________________________ Date: ______________
Clinician Signature: ___________________________________________ Date: ______________
If a PT Direct Access patient, must ask the following question: Do you want a licensed health care practitioner informed of this evaluation? Yes No If Yes, please specify: _________________________________________________________________
None Mild Moderate Severe Worst Possible ______________________________________________________________________________ 0 1 2 3 4 5 6 7 8 9 10
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Daily Exercises You can help prevent complications after surgery by being active. This lowers your chance of getting pneumonia, upper respiratory infections, blood clots and constipation.
A physical therapist will teach you the following exercises. If you experience pain with any of these exercises, please stop and tell your therapist. If you have any questions, please call Total Rehab at 419-291-8370.
Standing Heel Raise Stand with your feet shoulder width apart. Rise up on your toes. Repeat _____ times, _____ times per day.
Standing Ankle Stretch: Start standing with a chair or counter top at your side to hold onto for balance if needed. Stand with one foot in front of the other. Keeping the rear leg straight, slowly bend front knee until stretch is felt in rear leg. Hold for 20 – 30 seconds. Repeat _____ times, _____times per day.
Squats: Start standing with a chair or counter top at your side to hold onto for balance if needed. Stand with feet shoulder width apart. Keep back straight. Bend knees slightly. Hold for five seconds. Straighten both knees to return to starting position. Repeat _____ times, _____ times per day.
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Hip Flexion Place Thera band around either leg. Stand with your back to the wall. Bring the leg with Thera band (working leg) forward while keeping your trunk upright. Repeat _____ times, _____times per day.
Hip Abduction Keep Thera band around your ankle. Stand with your working leg away from the wall. Move working leg away from the body while keeping your trunk straight. Repeat _____ times, _____times per day.
Hip Extension Keep Thera band around your ankle. Stand facing the wall. Take a step backward with the non-working leg so your working leg is forward. Pull working leg backward while keeping your trunk straight. Repeat _____ times, _____times per day.
Hip Adduction Keep Thera band around ankle. Stand with working leg closest to the wall. Pull working leg across and in front of other leg while keeping your trunk straight. Repeat _____ times, _____times per day. *Repeat hip exercises on opposite leg
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Suck and Tuck: Stand with feet shoulder width apart, one foot slightly ahead of the other. Keep a straight back and align your shoulders in a straight line with your hips. Tighten stomach muscles (suck in) to rock hips back slightly. Do not hold your breath. Repeat _____ times, _____ times per day.
Shoulder Rolls: Grasp both ends of the Thera band and step with either foot onto the center of the band. If needed, wrap band around hands to take up the slack. Slowly make backward circles with your shoulders by shrugging shoulders up, back and then down. Repeat _____ times, _____ times per day.
***Note: Thera band contains latex, alert caregiver if you have a latex allergy of any type.***
Chest Pulls: Begin standing, grasp Thera band with arms straight out in front of you, about shoulder width apart. Keeping arms straight, pull Thera band apart, bringing arms out to your sides. Slowly return back to the front of your body. Return _____ times, _____ times per day.
Bilateral Shoulder External Rotation Start holding Thera band in both hands with elbows bent and by your side. Pull hands apart while keeping elbows at your sides. Repeat _____ times, _____ times per day.
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Rowing: Begin standing facing the door. Place knot in Thera band into doorway at chest level and close the door securing the Thera band into place. Grab the Thera band in both hands and step back until your arms are being pulled forward. Keeping your back straight, squeeze your shoulder blades together, and pull your elbows to your sides. Repeat _____ times, _____ times per day.
Abdominal Brace Lie on back as shown. Tighten your stomach muscles to flatten back against surface and hold for five seconds. A hand can be placed in arch of back to feel this pressure. Repeat _____ times, _____ times per day.
Supine Marching: Tighten stomach muscles. Do not hold your breath. Slowly raise one leg, keeping stomach muscles tight and back flat against the bed. Slowly lower to starting position. Repeat with other leg. Repeat _____ times, _____ times per day.
Abdominal Brace with Heel Slide Initiate the abdominal brace. Slide heel away from body while maintaining the brace position. Only extend leg out as far as can maintain brace. Alternate legs with each repetition. Repeat _____ times, _____ times per day.
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Abdominal Brace with Straight Leg Raise Initiate the abdominal brace. Straighten either leg so it rests on the surface. Raise the straight leg while maintaining your brace and then slowly lower it without allowing your back to arch. Repeat _____ times, _____ times per day.
Curl Ups: Keeping hands against thighs tighten stomach muscles. Slowly raise shoulders and head off the bed until shoulder blades are no longer touching. Do not hold your breath. Slowly lower to starting position. Repeat _____ times, _____ times per day.
Seated Hamstring Stretch: Begin seated in a chair. Straighten your knee out in front of you with your heel resting on the floor. Gently lean forward keeping your back straight and your shoulders back until a gentle stretch is felt in the back of your thigh. Hold 20 – 30 seconds. Repeat with opposite leg. Repeat _____ times, _____ times per day. ***If no stretch is felt, prop foot on small stool.
Walk: Walk with stomach muscles tightened and back straight. Begin with ____ minutes per day. Heart rate should be in ____range. Slow down or stop if it goes above ____ You should be able to carry on a conversation while walking. Try to add one – two minutes a week until you are walking about 20 minutes every other day.
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Daily Exercise Log
Date
Standing Heel Raise
Standing Ankle Stretch
Squats
Hip Flexion
Hip Abduction
Hip Extension
Hip Adduction
Suck and Tuck
Shoulder Rolls
Chest Pulls
Bilateral Shoulder Ext Rot
Rowing
Abdominal Brace
Supine Marching
Abdominal Brace with Slide
Abdominal Brace with SLR
Curl Ups
Seated Hamstring Stretch
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Aerobic Exercise Log Aerobic Exercises: Goal 30 minutes x five days/week.
Bike
Walk
Elliptical
Swim
Heart rate goal _____ beats per 10 sec to _____ beats per 10 sec or _____ to _____ per minute.
Begin aerobic exercise at a length of time that is easy for you. Five to ten minutes to start is fine. Increase your daily exercise time several minutes a week, working up to 30 minutes a day. You may do two 15-minute or three 10-minute sessions to add up to 30 minutes a day.
Check your heart rate after exercising 5 – 10 minutes to decide if exercise is a moderate level. To monitor heart rate place your index and long fingers at your wrist on thumb side. Count each beat for ten seconds. See chart on the next page for your recommended heart rate range base on your age.
Moderate Exercise (55 – 70% age adjusted heart rate maximum)
Age Heart
rate per 10 seconds 20 – 26 18 – 23 27 – 35 17 – 22 36 – 40 17 – 21 41 – 45 16 – 21 46 – 53 15 – 20 54 – 62 15 – 19 63 – 65 14 – 18
Moderate intensity exercise should feel light to somewhat hard. Examples of moderate exercise are mowing with a power mower, golfing walking with clubs, raking leaves, shooting baskets, dancing, and gardening.
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Exercise
Starting an Exercise Program Weight loss surgery is just a tool to help with weight loss. To accomplish the greatest weight loss from your surgery, you must exercise. Exercise is also a key factor in maintaining your weight loss. If you want to feel good and maintain and build muscle mass, you must exercise. Exercise helps you lose weight and increase the making of “good feeling” hormones called endorphins. Exercise also helps to keep your bone tissue dense and strong, increases strength and balance, boosts energy, and improves quality of life. Research has shown that patients who exercise three or more times per week for a minimum of 30 minutes lost an additional 12% of their excess weight in six months. The mistake that many patients make is that they do not exercise until they feel “all recovered”. Some patients do not exercise until they realize they are not on course to reach their goal weight. Patients who exercise early find it very rewarding. As the weight falls off, your ability to exercise improves on a week-by-week basis. Do not cheat your body of this important part of weight loss. Make a long-term pledge to exercise. You may find it hard to stay motivated about exercising. It is important to find an exercise that you like. Look into forms of exercise that you have never tried before. Explore yoga, dancing, roller skating, etc. Exercise does not mean that you have to be in a gym for hours a day. If it has been some time since you have exercised regularly, then it is best to start slowly. Begin with as little as five minutes a day and add five more minutes a week until you can stay active for 45 minutes per day. We recommend that you make exercise part of your daily routine. Just being an active person is not enough exercise to be able to lose the weight and keep it off.
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There are three forms of exercise: cardiovascular, strength building and flexibility. Cardiovascular exercise Cardiovascular exercise is also known as aerobic exercise. Aerobic exercise uses your large muscles and can be continued for long periods. For example:
• walking • jogging • swimming • cycling
These types of exercises drive your body to use oxygen more efficiently and deliver good benefits to your heart, lungs, and circulatory system. At least 20 minutes of cardiovascular exercise three – four days a week should be enough to maintain a good fitness level. Any movement is good, even house or yard work. However, if your goal is to lose weight, you will need to do some form of cardiovascular exercise for five or more days a week for 30 – 45 minutes or longer. Strength-building exercise Strength-building exercise is known as anaerobic exercise. Anaerobic exercise does not have cardiovascular benefits, but rather makes your muscles and bones stronger. Strength-building exercises require short, intense effort. People who lift weight or use any type of equipment that requires weights are doing strength-building exercise. Strength-building exercise increases your metabolism. Strength exercises also make your muscles larger. Your muscles use calories for energy even when your body is at rest. By increasing your muscle mass, you are burning more calories all the time. If you strength train regularly, you will find that your body looks leaner and you will lose fat. Strength-building exercises should be performed two – three times a week for best results. Always warm up your muscles for 5 – 10 minutes before you begin lifting any type of weight or before performing any resistance exercises. Flexibility exercises Flexibility exercises, which are also anaerobic, tone your muscles through stretching and can prevent muscle and joint problems later in life. A well-balanced exercise program should include some type of exercise from each category.
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Loss of Bone and Muscle Mass When the body is in a state of stress and trying to prevent malnutrition, it hoards its precious fat until any other usable fuel has been burned. The body will prefer to burn muscle mass before fat. If muscle is not regularly used for exercise, it will be used for energy. Loss of muscle mass can be prevented. It is very important during active weight loss to exercise hard every day. We recommend at least 20 minutes a day of aerobic and weight-bearing exercise. Pay attention to the upper body strength as well. Many people find, after a few weeks or months of regular exercise, that they begin to enjoy it and start to work out even more. Fairly hard exercise, for more than half an hour every day can greatly enhance fat -burning, and enhance weight loss. Research has shown that patients who exercised at least three times per week for at least 30 minutes lost 12% more of their total excess weight after surgery. Exercise also builds a healthy and beautiful body. Obese people are very strong and powerful. Muscle can be lost if it is not used. Save your muscles, keep your energy, eat your protein, and exercise. Ten Tips for Sticking with the Program: 1. Look at exercise like a medicine. You do not have to like exercise, but you need to
do it in order to stay healthy. You also have to do it in order to lose weight. Your body needs exercise every day, so give it what it needs.
2. Do research. Find out what types of classes your local gym is offering. Does your gym offer water exercise classes for people with arthritis? Is there a gentle yoga class offered at the community center? You are more likely to stick with an exercise that is tailored to your needs and that you enjoy. Explore new types of exercise.
3. Change your routine. So you love to walk, but you are bored with it. Sometimes, just changing the direction of your route can make all the difference. Find new places to go walking, change the time of day or offer to walk your neighbor’s dog.
4. Find a buddy. Without a coach, most athletes would not be where they are now. Why should you be any different? We all need someone to nudge us and encourage us to go the extra mile, especially when it comes to exercise. Find a friend, a neighbor or a personal trainer to help you.
5. Find your rhythm. Listen to music or books on tape or meditation while you exercise. Fifteen minutes on the bike can seem like an eternity without music. But with the right tunes to occupy your mind, your exercise routine will fly by.
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6. Participate in-group sports. You do not need to join a soccer team, but participating in a group activity increases the chances that you will stick to it. Choose water exercise, yoga or stretching classes. Choose places and times where there are other people who are actively involved in exercise.
7. Know what makes you give up the program. If going on vacation throws you off your fitness plan, try incorporating exercise into your vacation. If boredom makes you give up, stay interested by changing types of exercise and times.
8. Make a schedule. If you do not put exercise into your daily schedule, most likely you will do everything but exercise. Schedule specific activities on specific days, like walking 20 minutes on Monday, yoga class on Tuesday, etc…
9. Use a workout log. Write down the exercise you do and see how you have improved. It is difficult to keep up with exercise when you do not see the results. Write down the number of repetitions, the weight used, the length of walk, the time, etc.
10. Stay active between workouts. Walk as much as possible between workouts. Park farther away. Get off the bus a couple of stops early. Always keep a good pair of walking shoes in your car, should you have unexpected time to take a walk.
The Walking Workout Recent research indicates that walking is one of the best ways to take charge of your health. Besides the well-documented health benefits, the beauty of walking is you can do it at your own pace. Walking is the first type of exercise that we recommend both before and after surgery. If you are new to exercise and you are recovering from surgery, you can walk 10 – 20 minutes, four – five days a week. As you get stronger, you can increase the distance and the speed to your comfort level. As with any type of exercise, it is still important to warm up, then stretch when walking. Start by walking for just five minutes and then do a few gentle stretches. Your muscles will stretch better if you walked a little first. Consistency is probably the most important part of your walking routine. The more time you devote to walking each day, the healthier you will be. Remember that short walks are better than nothing at all. Health, like life, is a journey. All you need to do is take the first step.
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Water Fitness Many bariatric patients enjoy water exercise. Water activities can be started shortly after surgery with you bariatric surgeons approval. Water programs are non-weight bearing and gentle on painful joints. Water fitness can improve strength, flexibility, cardiovascular health, decrease body fat, facilitate rehabilitation after surgery, improve functional living and even enhance other sports skills. Water classes today offer more versatility than ever, but how do you find the right class for your goal, interests, needs and skills? Most importantly, you should feel comfortable in the environment. If the water is too cold or you do not feel at ease in your class, then this is not the right class for you. Water exercise, like any other type of exercise, should be done in a relaxing environment. If this is not the case, it is a sign to look for something else.
*Ask About the Bridge to Fitness Program ProMedica Weight Loss Surgery and ProMedica Wildwood Athletic Club are proud to offer the Bridge to Fitness program for bariatric patients, before and after surgery.
Bridge to Fitness is an exercise program designed to meet the needs of patients by encouraging a commitment to physical activity.
The goal is to improve and enhance the quality of life by providing a sense of physical and emotional well-being.
The Bridge to Fitness program provides general conditioning and fitness education. A professional clinical exercise specialist leads classes, offering:
• Aquatic exercise- combining range of motion, toning, cardio, and stretching in the therapy pool
• Gentle cardiovascular and strengthening exercise
Exercise classes are open to all physical fitness levels and tailored to meet individual needs, allowing patients to move at their own pace.
Wildwood Athletic Club, 2865 N. Reynolds Rd., Toledo, Ohio 43615
• Mondays, 7 P.M.- Aquatic exercise • Wednesdays, 7 P.M.- Aquatic exercise • Thursday, 6:30 P.M. - Total body conditioning: gentle cardio and strengthening exercises • NEW!! – Option of 2 aqua classes (Monday and Wednesday), 1 land and 1 aqua, or all 3 classes! • Cost: $25 for 2 Days a week • Cost: $40 for 3 Days a week • Must pay in advance. No refunds. • No make-up sessions. No classes on holidays or support groups.
To Register: Contact Wendy Bahmer at 419-578-7066 or [email protected]
Surgery
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Two Types of Surgical Procedures Performed at ProMedica Toledo Hospital
Drs. White, Parodi and McCullough perform two types of bariatric procedures for weight loss. Roux-en-Y gastric bypass and gastric sleeve resection. These two operations account for 94% of the bariatric operation done in the United States. The vast majority are done laparoscopically or with robotic technique. Rather than a large incision, or cut in the body, required for traditional surgery, six tiny incisions are used.
The Benefits of Laparoscopic Surgery include: • Less pain • Minimal blood loss • Low risk of infection • Faster recovery time • Cosmetically appealing • Prompt return to work • Small risk of hernias
Resolution of “Health Problems”/ Bariatric Operations are: • A good way to lose weight. • A great way to resolve Type II Diabetes Mellitus. 80% of patients can stop all their diabetic medications and almost all patients
can stop insulin injections.
• Other Health Problems often resolved: Hypertension High cholesterol Acid Reflux Lower extremity joint pain Infertility and menstrual irregularities Stress incontinence Leg swelling Pseudo tumor cerebri
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Roux-en-Y Gastric Bypass Normal Stomach 1500mls Pouch 15 – 30mls
Roux-en-Y gastric bypass (RYGB) is the operation most performed worldwide to induce weight loss. Most patients will lose about 75% of their excess weight in the 12 - 18 months post-surgery. A weight loss of 60 – 70% is generally maintained. During surgery, a small pouch is created at the top of the stomach using staples. The volume of the pouch is less than one ounce. This pouch is then attached to a limb of
the small intestine so that food bypasses the stomach and the first part of the small intestine.
There are several reasons why the operation works:
• Patients feel full with smaller amounts of food. • Hormonal changes suppress the appetite. • The intestines “burn off” an extra 500 calories/day. • In an occasional, massively obese patient (BMI greater than 65) a gastric bypass is
found to be technically impossible at the time of surgery. Such patients undergo a sleeve resection.
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Gastric Sleeve Resection Normal Stomach 1500 mls Banana stomach 60-100 mls Gastric sleeve resection is preferred in patients who have serious small bowel problems, such as Crohn’s disease. Patients who smoke or need to take NSAID pain medications (Aleve, Motrin and Meloxicam for example) may also be best served with a sleeve resection. This operation removes the left side of the stomach leaving a thin tube or “sleeve” down the right side. In short-term follow-up studies, weight loss with the sleeve resection is slightly less
than with gastric bypass. Long-term studies are pending. Sleeve resections cause weight loss because the stomach is smaller. Thus, you feel full with smaller amounts of food. The main source of ghrelin is removed. Ghrelin is a hormone that stimulates your appetite. Less ghrelin means less appetite.
Risks of Bariatric Operations: • Leaks may occur along suture or staple lines. Such leaks may result in infection. • Dumping syndrome can occur when the stomach contents move through the small
intestine too fast. You experience nausea, weakness, sweating, faintness, and diarrhea after eating. This usually results from eating sweets. Such poor tolerance to sweets is seen frequently after gastric bypass, but infrequently after a sleeve resection.
• Nutritional deficiencies may occur. Iron, calcium, vitamin, and protein levels must be monitored.
• As with any major operation, blood clots may form in a leg and be a source of a pulmonary embolus.
• Injury to the spleen may lead to spleen removal. • Acid Reflux can be a problem after sleeve resection. • Pneumonia. • Heart problems. • Infection.
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How We Choose Which Procedure a Patient Will Receive How do we decide which operation to do for a specific patient?
• We consider the patient’s health problems, habits, and desires. For Example:
The diabetic state is improved dramatically by both operations but the gastric
bypass has a more profound effect. If a patient has poorly controlled Type II diabetes mellitus, then bypass is preferred.
Reflux usually resolves after a gastric bypass but may persist or worsen after a sleeve resection. Barrett’s esophagus is an absolute contradiction to a sleeve resection. Thus, when reflux is severe, gastric bypass is preferred.
Patients who undergo a gastric bypass lose more weight. For lower weight patients (BMI <50) the difference is slight. For heavier patients (BMI >50) the difference becomes significant and gastric bypass is preferred.
Patients who plan to use tobacco products or daily NSAID’s after bariatric surgery should undergo a sleeve resection. Tobacco and NSAID use induces anastomotic ulcers in bypass patients. Low-dose aspirin may be resumed two months after the gastric bypass.
In patients who have small bowel problems (i.e. Crohn’s disease, large hernias or severe adhesions) sleeve resection is preferred. Manipulations of the small bowel can thus be avoided.
Absorption of iron and calcium is compromised after bypass and supplementation is necessary. If patients are unwilling to take supplements, they should consider sleeve resection. Supplementation is still prescribed after a sleeve, but deficiencies are less frequent.
If none of these factors is present, we tell the patient that there is no definite advantage to either procedure. The patient can choose what they want to have done.
Are there any other factors that patients consider when making a choice about which procedure to undergo?
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• Reversibility
The gastric sleeve resection is irreversible. The left side of the stomach is removed. It can be changed to gastric bypass if reflux is severe or weight loss is inadequate.
Gastric bypass is reversible • Obstruction
Bowel obstructions from internal hernias occur in about 1% of patients who undergo gastric bypass usually one to three years post-surgery.
Obstructions do not occur after sleeve resections. • Long Term Data
Twenty-year data on thousands of patients who have undergone gastric bypass is available.
Sleeve resection data goes back about eight years.
What about lap-bands? • They have proven ineffective and dangerous and are now rarely done. We have never
placed a band, but we have removed them. Such patients can undergo a bypass or sleeve resection at the time of band removal.
• We prefer to revise band patients to gastric bypasses. What operations did we do in 2017?
• Gastric Bypasses 164 • Gastric Sleeve Resections 200
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Comparing Weight Loss Operations: Gastric Bypass Gastric Sleeve Resection Early diabetes Effective Effective Poorly controlled diabetes Preferred Severe reflux Preferred Barrett’s esophagus Preferred Contraindicated BMI < 50 Effective Effective BMI > 50 Preferred Tobacco use Preferred Chronic NSAID use* Preferred Crohn’s disease Preferred Severe adhesions complex hernias
Preferred
Unwilling to take supplements Preferred Reversible Yes No Bowel obstructions Yes (1%) No Long term follow-up data Yes No
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Pre-op Liquid Diet
Start Date: _________________ (One week prior to surgery) This one-week liquid diet will allow you to start your weight loss before surgery. The main purpose of losing weight before weight loss surgery is to reduce body fat in the abdomen region, especially in and around the liver. By reducing the size of the liver, the operating time for laparoscopic surgery is shortened and the procedure is safer. In some instances, a bariatric surgeon may postpone surgery if the patient's liver is too large. Consume four protein shakes per day. Consume protein shakes that meet our acceptable guidelines:
• Around 200 calories or less • 25-30 grams of protein • 5 grams of carbohydrate or less • 5 grams of sugar or less • 3 grams of fat or less
For a list of acceptable shakes, please see the “Day 2” tab within this guide. If you are diabetic, your blood sugar may lower while on the liquid diet. Please use a protein shake that contains some carbohydrate to prevent frequent low blood sugars. This can include Boost Glucose Control or Ensure Active High Protein. These shakes will not be allowed after surgery, so please only buy enough to get you through the one-week liquid diet. We encourage you to monitor your blood sugar several times a day when starting the liquid diet and follow up with your Primary Care Physician / Endocrinologist for your medication adjustment if needed. Do not eat any solid foods. The shake counts as your entire meal. Please do not consume any foods with your shake or between shakes.
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Consume fluids between meals. Please consume sugar-free, non-carbonated, caffeine-free, non-alcoholic beverages between meals. You may consider:
• Crystal Light, Sugar-free Kool-Aid, or other sugar-free drink • Propel or Powerade Zero • Broth or Bouillon: Chicken, Beef, or Vegetable • Sugar-free jello • Sugar-free popsicles (25 calories or less) • Caffeine-free coffee or tea • Strained low-fat tomato soup • Strained low-fat cream of chicken soup • Strained low-fat cream of mushroom soup
Sample Menu
8 AM Breakfast: Protein Shake 10 AM: Decaf coffee 12 (noon) Lunch: Protein Shake 1:30 PM: Strained cream of chicken soup 3 PM Afternoon snack: Protein Shake 4:30 PM: Sugar-free jello 7 PM Dinner: Protein Shake 9 PM: Strained low-fat tomato soup 11PM: Sugar-free Popsicle
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Your Surgery
• Your surgery is scheduled at ProMedica Toledo Hospital on ______________at ________ a.m./p.m.
• Park in P2 garage located on ProMedica Parkway. • Valet Parking is available for a fee. • Report to Entrance B information desk and you will be directed to admitting (If
needed) or the surgery waiting room located on the second floor. You will be admitted to the hospital for one – two days.
Please note: This surgery is considered an elective case. Sometimes elective surgery cases are rescheduled to another date because of emergency surgery or changes in the surgeon’s availability. Please keep this in mind when arranging for time off with work and arrangements with family. This is your date unless you are notified otherwise by the office. The hospital does the pre-certification usually one – two days before your surgery. If you would feel more comfortable, you can contact your insurance company to make sure this has been taken care of for you. If there are any changes to your insurance or your primary care provider, please notify us. This may affect your coverage for surgery and/or office visits.
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Pre-Op Shower and Bathing for Surgery Preop showering and bathing is necessary to reduce the number of microscopic organisms you normally have living on your skin before your surgery is performed. You will need to take a shower the night before and the morning of your surgery.
What you will NEED:
• Hibiclens antiseptic antimicrobial skin cleanser (No prescription Necessary) • Substitutions for Hibiclens: Safeguard, Lever 2000 or Dial Antibacterial • Towel and wash cloth • Shampoo (Your usual brand)
What to do:
• Wash from the cleaner parts of the body towards the dirtier parts. From head to
toe with the groin and genitalia last. • KEEP ANTIMICROBIAL CLEANSER OUT OF EYES OR EARS • Wash your hair with your usual shampoo • Be sure to lather the chest, belly, groin and thighs well • Rinse well and towel dry • Put on clean bedclothes and sleep on clean sheets
IMPORTANT: DO NOT APPLY ANY LOTIONS OR POWDER TO YOUR SKIN BECAUSE THEY ENCOURAGE THE RE-GROWTH OF ORGANISMS. DO NOT SHAVE THE AREA TO BE OPERATED ON: SMALL NICKS IN THE SKIN CAN CAUSE GROWTH OF ORGANISMS. Organisms can multiply on your skin in a matter of a few hours, even when you are clean and free of lotions and powders, so you will need to take a second shower in the morning before surgery. Follow the same steps as listed above, being sure to put on clean clothing. If you are not able to shower, you may wash at the sink, being sure to rinse well.
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Pre-Surgery Instructions
Your surgery will be at ProMedica Toledo Hospital. • Please arrive two hours before your scheduled surgery time. _______________ • You may brush your teeth the morning of surgery but do not swallow any water.
Please wear your dentures or partial plate, however you will remove these just prior to surgery. You are responsible for the safekeeping of your valuables.
• Make up, nail polish, and jewelry (including body piercings) should not be worn to the hospital. For acrylic nails, you need to remove the nail polish.
• Please bring your eyeglasses and a case. • If you received a red plastic bracelet, please remember to bring it with you the
day of surgery. • If you have a CPAP/BIPAP machine- Bring it with you to the hospital. • Wear comfortable clothes to the hospital.
Illness before surgery If you develop a cold, persistent cough, fever, skin breakdown, or any changes in your condition during the days before your surgery please schedule an appointment with your family physician. You will need to be evaluated. Notify your bariatric surgeon of this evaluation and any action taken. You need to be in the best possible shape for anesthesia. Surgery scheduling can be adjusted. The night before surgery All patients will be on a liquid diet the day before surgery. You may drink clear liquids up until midnight the night before surgery. Nothing to eat is allowed after midnight including chewing gum, mints, lifesavers or orange juice. CARBOHYDRATE LOADING 8 to 4 HOURS PRIOR TO SURGERY The last drink you should have prior to surgery is 16 ounces of one of the following: Gatorade (not G2), PowerAde, Apple or Cranberry Juice Example: If you are the 7:30am case – drink 16 ounces prior to bed or you may choose to get up at 3am – whatever works for you. If you are the 10:30 Case – drink 16 ounces at 6am
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• THIS IS THE ONE TIME, YOU WILL BE ASKED TO DRINK A SUGAR
BEVERAGE OR 100% FRUIT JUICE THAT IS NOT DILUTED. • MAKE SURE THIS BEVERAGE IS COMPLETED 4 HOURS PRIOR TO
SURGERY. • NOTHING TO DRINK 4 HOURS PRIOR TO SURGERY OR SURGERY WILL
BE CANCELED. No bowel preparation is needed.
Surgery Times Do Change! You may be called and requested to arrive earlier or later than originally scheduled. Please have patience with us if you experience delays. We will attempt to keep you informed of any change but feel free to ask at the reception desk for updated information. Medications the morning of surgery The surgeons will review what medications they wish you to take the morning of surgery with a sip of water.
• Take all heart, blood pressure, thyroid and anti-depressant medications the morning of surgery with a sip of water.
• Do not take Insulin, sugar pills or water pills unless otherwise instructed. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________
Anesthesia General anesthesia will allow you to be sound asleep during the operation. Once you are settled on the operating table, you will be connected to several monitors. You will breathe pure oxygen for a few minutes. Then you will be given a quick acting sedative through your IV. An anesthetic gas and other medication will keep you asleep.
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Your anesthesiologist will discuss the specific risks of general anesthesia with you before surgery. The Operation Once you enter the operating room, your team of professionals will do everything they can to make you comfortable. After you are asleep, a tube called a urinary catheter will be placed into your bladder. The surgical procedure on average will last about two – four hours. The length of the operation depends on the number of extra procedures needed (release of adhesions, gallbladder removal, repair of hiatal or incisional hernias) and the difficulty of finding working space within your abdomen. When your surgery is done, you will be moved to the recovery room. Recovery Room While in the recovery room, you will be closely monitored. Recovery room nurses will remain with you at all times. Your family members will be notified of your arrival to the recovery room however they will not be able to visit you until you are taken to your hospital room. When your initial recovery is complete and all your vital signs are stable, you will be ready to be transferred to a private room on REN 5E Acute or REN 5W Acute in the Renaissance tower 5th floor where specially trained bariatric nurses will care for you. You will not be discharged from Post Anesthesia Care Unit (PACU) until a bed is available on the Bariatric Designated Floor. If there is a long delay in transferring you to the bariatric floor and PACU discharge criteria is met, the PACU team will get you up. When arriving to the bariatric floor, you will be expected to walk from the stretcher to the bed with assistance.
The time from the start of surgery until you are in your hospital room can be six hours or more. Your visitors should use Entrance B, Parking Garage P2 when visiting you in the hospital.
Day 1
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Eating For Healing – Clear Liquids
Immediately after surgery, you will not eat food or drink liquids. Sugar-Free Clear Liquids Once your diet is advanced to sugar-free clear liquids you can sip on the following liquids for your meals:
• Broth or Bouillon: Chicken, Beef, or Vegetable • Sugar-free jello • Diluted 100% clear fruit juice*
* All juices must be 100% juice with no added sugar. Dilute 50% with water. Choose clear juices such as apple, grape or white grape juice.
Eat four to five small meals per day Eat four to five meals per day about 3 hours apart. At first, eat 2 – 4 Tablespoons (1 – 2 ounces) of food over a 10 – 15 minute period. If you do not feel full, eat another 2 – 4 Tablespoons of food over the next 10 – 15 minutes. Stop eating/drinking when you are full, even if you have consumed less than 2 ounces. Do not consume more than ½ cup (4 ounces) per meal. Always measure out your portions. Medicine cups (1-ounce portions) are available for you to use in the hospital. Please be sure you are consuming no more than 4 medicine cups or ½ cup per meal. Meet your fluid needs of 48 to 64 ounces per day You may sip on water or other sugar-free, non-carbonated, non-alcoholic, caffeine free beverages throughout the day while on clear liquids. If you are served something other than your planned diet, do not eat it. Call your floor nurse to have your meal changed.
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Sample Menu for sugar-free clear liquids
Breakfast: 1 – 2 ounces sugar-free jello 1 – 2 ounces diluted fruit juice
Lunch: 1 – 2 ounces chicken broth
1 – 2 ounces sugar-free jello
Dinner: 1 – 2 ounces diluted fruit juice 1 – 2 ounces beef broth
Evening: 1 – 2 ounces chicken broth
1 – 2 ounces sugar-free jello
Discharge from
H
ospital
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Discharge from the Hospital
Specific Recovery Instructions When you get home, take things easy for a while. Your body is still healing from the stress of major surgery. The first several weeks after your surgery, you may feel weak and tire easily after activity. However, try to be as active as possible. Plan to walk as much as you can tolerate without becoming too tired. Start with short walks, increasing the distance each day. The more physically active you are, the more recovery is enhanced and the more energy you will have. By the time of your six-week office visit you should be walking regularly for 30 – 40 minutes a day. If you have problems walking due to joint pain, water exercises are recommended. You can start water activities when your surgeon clears you. You may travel short distances in a car as soon as you feel strong enough to make the trip. Do not drive a motor vehicle until you are off all prescription pain medicines, usually about one week after your surgery. Avoid sitting and standing without moving for long periods. Change positions frequently while sitting and walk around instead of standing still. This will help prevent blood clots from forming in your legs. Avoid lifting anything heavier than 20 – 30 pounds, or doing push or pull motions (i.e. vacuuming) during the first two weeks. Do not do any heavy work for the first two weeks. Climbing stairs is encouraged. Remember you may feel tired, less energetic, and sore for several weeks following the operation. This is a major procedure and you will be losing weight as well as healing wounds. Pain Medications You may take the prescribed pain medication to help with pain control. If recommended, please cut the pill in half. Take ½ of the pill, wait 30 minutes then take the other ½ of the pill. Do not take more than two whole tabs (four ½ pills) every four hours. Norco or Percocet do not need to be cut in half. Liquid pain medication is always an option if desired.
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Resuming Home Medications Changes in your home medications may be made when you are discharged from the hospital. These are some examples: 1. NSAIDs (Aspirin, Motrin, Ibuprofen, Aleve, Naproxen)
• These should be stopped for life after Gastric Bypass. • Can be resumed after Sleeve Resection when approved by surgeon. • Aspirin 81 mg may be resumed in 2 months. Remember to take Zantac
150mg or Pepcid 20mg daily if you are a gastric bypass patient. 2. Diuretics (Lasix, Hydrochlorothiazide)
• In the first few weeks after bariatric surgery, we worry that you may become dehydrated. It is difficult to drink enough.
• Diuretics increase the urine output and may contribute to dehydration. • These medications should be stopped or decreased. • Some blood pressure medicines are combination drugs. An example is
Lisinopril plus Hydrochlorothiazide. If you are on this type of drug we may give you a new prescription for Lisinopril alone.
3. Vitamins, Calcium, Iron – Stop • These are essential in the long run but not in the immediate post-op period. • Chewable vitamins will be resumed at one week post-op. • If Vitamin D or B12 were started pre-operatively, they will be resumed at
one week post-op. • Calcium and iron are not started until 6 week post-operatively.
4. Diabetic Medications • In general, the diabetic state rapidly improves after a bariatric operation. • Therefore, in most cases, fewer medications are needed to control the blood
sugar. • We cannot predict with accuracy, however, exactly how much insulin or
metformin, for example you will need. • We usually reduce the insulin dose by about 65% and decrease the doses or
number of oral medications that you take. • We then depend on you to check your blood sugars and further adjust the
medications to keep a blood sugar of around 125 to 150.
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• The “fine tuning” of your medications will be done by your primary care physician once you have stabilized.
Time off Work You usually are off work for about 2-4 weeks while you continue to recover at home. This time off does vary depending on the type of work you do, your general health, how badly you need your work for financial reasons, your general motivation, the surgical approach (laparoscopic versus open), and your energy level. We would caution you not to rush back to full-time work too quickly. The first few weeks are a precious time to get to know your new digestive system, rest, exercise, and to meet with other post-operative patients in support group meetings. Personal Hygiene Most patients like to have someone home with them the first few days after surgery for moral and physical support. Due to the nature of abdominal surgery, you may need some help with toileting. Flushable baby wipes tend to be gentler for personal hygiene, as well as a peri-bottle. You can also use a small sports-top water bottle. A long sponge stick can be very helpful. Hormonal changes Estrogen is a hormone found in the body that regulates menstrual cycles. Estrogen is stored in fat cells. As you lose fat cells, menstrual cycles may be altered. You may or may not have periods. Periods may be heavier. Pre-menstrual syndrome (PMS) symptoms may be worse as well. Incision Care Your incision needs minimal care. If sutures were used, they dissolve, so there is no need to remove any stitches. You may notice some tape on your incision. This tape is called “Steri-Strips®.” They will fall off on their own. Leaving the incisions open to air, whenever possible, helps prevent infection. It is important to keep your incision clean and dry to promote faster healing. After showering, you should pat the incision area dry. After about three weeks, the incision will be ready for soaking in a tub or swimming. Despite the greatest care, any incision can become infected. If your incision becomes reddened, swollen, leaks pus, has red streaks, has yellow/green, puss-like and/or
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odorous drainage, feels increasingly sore, or you have a fever above 101.5° F, call your surgeon right away. Please do not use any antibiotic ointment or other ointment on your incision.
→The bottom line: Unless otherwise prescribed shower, wash your incision with soap, rinse and dry thoroughly. If your incision is oozing or catching on clothing, you may cover with a very light dressing, otherwise leave open to air. Your surgeon will tell you if you should care for your incision differently.
Drainage tube (if present) If you have the drainage tube inserted at the time of surgery you will need to drain the small bulb at least three times a day or when the bulb is ½ full. Write down the amount of liquid emptied on the JP output sheet. Call your doctor if the color of drainage changes from pink to green or brown. Do not soak in a bathtub or swim while you have this drain. Normal drainage in the tube will change in color from bloody to pink to a clear yellow. Call your doctor if:
• You have a fever greater than 101.5° F or chills. Check temperature two times a day for 10 days
• Heart racing • Increased belly pain not controlled with pain medication • Persistent vomiting or diarrhea • Shortness of breath, new leg swelling or new leg pain • Redness, swelling, drainage or pain at incision site
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Discharge Diet Goals
Goal Reason Strategies No vomiting To avoid tearing the
staple line. • Eat slowly. • Sip fluids. • Do not use straws. • Avoid carbonated drinks.
Get enough fluids
To avoid becoming dehydrated.
• Sip small amounts of water or sugar-free, noncarbonated, caffeine-free, non-alcoholic drinks.
• Aim for 8 cups (64 ounces) of these fluids daily. Minimum of 48 ounces in the first 2 weeks.
Get enough protein.
To heal the surgical wounds and minimize the loss of muscle and other lean tissue.
• Choose protein shakes or powders that are high in protein but low in fat and sugar.
• Aim for ultimate goal of 65 – 75 g protein per day.
Avoid stretching the stomach pouch.
The purpose of surgery was to make your stomach smaller.
• Eat four to five small meals per day. • Limit the amount that you can eat to less
than ½ cup at a time.
Avoid dumping syndrome.
After having sweets or fats, the stomach content can immediately go into the small intestine. This can cause nausea, vomiting, or diarrhea.
• Avoid concentrated sweets, such as sugar, candy, honey, jam, jelly, cake, cookies, or pies.
• Limit foods to less than 5 grams sugar per serving.
• Avoid greasy/high fat foods such as fried foods, bacon, sausage, or fatty meats.
• Limit foods to less than 3 grams fat per serving.
Follow-up Visits
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Follow-up Visits with Your Bariatric Team
Follow-up visits with your bariatric team are very important. You will be scheduled for the following visits:
1 week – with the Bariatric Surgeon or Physician Assistant/ Dietitian • You will receive:
A 3 month and 6 month lab order An Emergency medical alert card Prescription for Ursodiol if indicated Prescription for a chewable Prenatal Prescription for Prenatal with iron to be started in 5 weeks
*5 or 6 weeks – Visit with Surgeon or a nutrition class with the Dietitian
3 months – No appointment
• Have your lab work completed • Call (419)291-6777 for results 2 weeks after blood work
**Don’t forget to have your labs done one week prior to your 6-month appointment**
* 6 months - Appointment with the Physician Assistant (P.A.)
• You will receive: A 9 month lab order if your 6 month labs are abnormal A 1 year lab order
9 months- No Appointment
• Have your lab work completed • Call (419)291-6777 for results 2 weeks after blood work
**Don’t forget to have your labs done one week prior to your 1-year appointment**
* 1 year – with the Bariatric Surgeon / Bariatric Nurse • You will receive:
Annual lab order Plastic Surgery Information
*Annual Appointments –with Physician Assistant or Surgeon
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Lifetime follow up is suggested to be successful with your weight loss!
Changes will be made to your vitamin/mineral regimen based on these lab results. Your weight loss will be assessed at each visit. Diet and exercise lifestyles will also be assessed at each visit. We are committed to helping you achieve a healthy weight loss. Additional visits with the dietitian and psychologist may be needed. We will assist you with making these appointments if needed. PLEASE ALWAYS REMEMER TO:
• Stop all Vitamins and Calcium 24 hours prior to blood work • Have blood work one week prior to 6 month, 1 year and
annual appointments • Fasting for 12 hours is only necessary if the surgeon has
ordered a Lipid Panel – This is usually the case with your 6 month and annual blood work
Support G
roups/
Em
otional Concerns
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Support Groups ProMedica Weight Loss Surgery Support Group is committed to providing all pre-operative and post-operative patients with the knowledge they need to be successful in their personal bariatric journeys. These meetings are a wonderful opportunity for you to make new friends who share similar experiences and feelings.
Support group meetings provide you with peer support. It is reassuring to hear others’ viewpoints on common concerns and get additional information from group leaders and guest speakers. The meetings also allow you to learn about surgery first hand from others who have had weight loss surgery.
Additionally, support group meetings are great for problem solving. Research has shown that patients who attend support groups regularly are more successful with their weight loss. Family and friends are always welcome to attend.
Evening Support Groups First Monday of the month from 6:00 pm- 8:00 pm unless it falls on a holiday or the week of a holiday
Day Support Groups Third Friday of every other month beginning January from 10:00 am to 11:30am unless it falls on a holiday week then it would be the fourth Friday.
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Support Group Rules 1. Confidentiality:
Because confidentiality is essential, we expect that each person will respect and maintain the confidentiality of the group. What is said in the group is not to be repeated or discussed at any other time or place. “What is said here – stays here” Who attends the group is also confidential.
2. Sharing:
Everyone is encouraged to share his or her stories with the group. Keep your contributions to 3 minutes to ensure that all members have a chance to speak. We are here to share our own feelings and experiences; we try not to give advice.
3. Respect:
All attendees will be respectful of others by allowing one person to speak at a time. We avoid interrupting: if we do break in, we return the conversation to the person who was speaking. Silence cell phones while in group. If you must answer a call, please leave the room before doing so.
4. Acceptance:
We try to accept people, just as they are, and we avoid making judgments. We do not discuss group members who are not present.
5. Focus:
We give supportive attention to the person who is speaking and avoid side conversations.
6. Freedom of Speech: We have the right to ask questions and the right to refuse to answer. We have the right to speak and the right to remain silent.
7. Present Awareness: We try to be aware of our own feelings and talk about what is present to us now, rather than what life was like for us in the past.
8. Promptness: We begin and end our meetings on time.
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Emotional Concerns after Weight Loss Surgery
Emotional Concerns Bariatric surgery has both physical and emotional effects. Please do not take these changes lightly. All patients need to think about this before and after surgery. You may feel:
• depressed • helpless • angry • frustrated • happy • excited • joyful • disappointed
For a short time, the instant sense of loss of food often causes distress. A rapid decrease in estrogen levels may cause symptoms of depression. Over a long time, you may have changes in body image. Bariatric surgery is not a fix for your everyday problems with your spouse, friends, family members, job, or social life. This surgery will allow you to begin to gain control over one aspect in your life – your weight. Although you have chosen to have weight loss surgery to resolve your obesity, weight loss also changes your lifestyle. Obesity was comfortable to you, simply because it was your way of life. Now, that life is gone. When the reality of your new life confronts you, it is natural to begin a longing for your old way of life. This shows itself in several stages. These stages include denial, anger, bargaining, depression, and acceptance. Different people go through these stages differently. It is natural for some patients to experience denial before they have surgery, because they focus on the positive. They seem to understand the risks and complications, but often do not recall hearing about the emotional and physical stress that follows. After surgery is performed, some patients try to bargain for extra space in their stomach pouches. They overeat, have painful consequences, and may become angry for getting into the situation. This anger may also surface when other discomforts or
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complications develop throughout the recovery period. These feelings are difficult to accept or express openly, and depression may follow. Feelings of sadness and crying spells can be common. These emotional reactions to surgery are completely understandable. They cannot be eliminated, but must be experienced and worked through. Adapting to the changes taking place in your body and your relationship to food can take many months. The final stage of acceptance will occur when you feel at peace with the changes brought about by surgery. In the past, one of the best methods for you to cope with life stress may have been for you to eat. This method will no longer be useful, especially while your new stomach pouch is at its smallest. One of the keys to success of this surgery is to learn to replace those comforts with healthy activities. You will need to learn to learn different ways to cope with stress. There are many things that you can do to help yourself through the recovery and adjustment period. One of the most important aspects is to recognize and understand the experience of loss. Expect to have ups and downs as the weeks go by. If you are feeling teary and depressed, have a good cry. Do not suppress your emotions. They will surface again anyway. Going for a walk or adding other physical activities will help you manage this changing phase of your life. The understanding that bariatric surgery, and weight loss, will not solve your personal or relationship problems will also ease your adjustment and acceptance. You cannot expect a perfect body or a perfect life after the weight loss. In fact, many new problems will develop because of the many new opportunities. These will need to be recognized and attended to. Try to be as positive as possible. As new challenges pop up, recognize them and develop a problem solving approach. Adjust your expectations. Set realistic goals and stay occupied with work, hobbies and exercise. You will also feel more positive if you look your best. Pay attention to hygiene, hairstyle, clothes – women may want to experiment with make-up. Take a walk, listen to music, meditate or pray. Do things you always wanted to do. Enjoy the process of rediscovery. Talk to your spouse, family doctor, friends, and other patients for support. We are here to support you through these changes with personal consultations, support groups and workshops.
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Counseling Occasionally, personal change or relationship problems will persist after surgery. These should be addressed in professional counseling. Emotional counseling may be needed during the phase of adjusting to your new body and the many changes that follow surgery. We can help recommend counselors who are qualified and experienced in working with people who have had weight reduction surgery. Do not hesitate to request this. Major changes can cause new problems to emerge or old ones to intensify. Our experience has shown us that in the period of stress, starvation and weight loss that occurs following surgery, mild to severe depression is common. You and your support person should look for the signs of depression: persistent sadness, anxiety, loss of interest or pleasure in activities (including sex), restlessness, irritability, feeling restless, irritable or excessive crying, feeling guilty, worthless, helpless or hopeless, changes in sleep patterns, decreased energy, fatigue, “feeling slowed down,” thoughts of death and suicide, difficulty concentrating, remembering or making decisions and persistent physical symptoms that do not respond to usual treatment. With treatment, patients can improve and return to normal quickly. Unfortunately, most depressed people do not recognize their depression. You and your support person need to be aware of the risks of depression in the recovery period and should discuss possible treatment. Professional counseling can be a positive step toward a healthy adjustment. Family and Friends You can expect your family and friends to have different reactions to your surgical experience and to the weight loss that follows. Although you hope your loved ones will be supportive and helpful during your ups and downs, this may not always be the case. First, your partner or spouse is used to you and your weight. This may result in a resistance to the change, taking the form of disagreement, mood swings or refusal to support your dietary or exercise regimen. Keep communication channels open; recognize signs of distress in your partner. These changes will require your partner to relate in new ways to you. This takes time, effort and patience. If you are experiencing serious ongoing problems in your relationships, short-term professional counseling may be helpful.
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Friends and extended family members also must adjust. Many of them will be positive and genuinely delighted for you. They will stick with you through highs and lows and relate to you as the lovable, unique person they have grown to appreciate. Others have become secure in your obesity and will have difficulty adjusting to the new body you are developing. If they are also obese, they will be constantly reminded of their continuing problem as you lose weight. They may be quick to point out sagging skin, wrinkles, and other disadvantages. They may envy your courage or physical health. Be open about your appreciation of them and their concerns for you. Talk with them about their own feelings. Body Image Keep in mind that as your body undergoes changes in weight and size, it is likely you may not see your body as others may view it. It takes time for your mind to catch up with what your body is doing. As you lose weight, you may actually be surprised when you see your reflection in a store window or mirror. You may not feel like this person is you. It is normal to feel like you are still the same size as you were before, but there are some definite ways to help you work through this. Here are some examples:
• Take a picture of yourself every few weeks during your weight loss and compare the changes.
• Try on clothes in a smaller size. You will be surprised how quickly you will change sizes.
• Have someone point out a person in a public place who is about the same size as you. This helps you have a new frame for reference.
• Take measurements of yourself every few weeks and record the results. • Save an outfit from your pre-operative size and try it on every few weeks or
whenever you need a lift. • Accept compliments graciously. Do not minimize or qualify your weight loss.
You have worked hard for the outcome. Simply say, “thank you.”
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The Internet We greatly encourage support, both before and especially after surgery. Group support and being connected to other patients is vital to a successful surgical result. The Internet is a way to help fill the void between group meetings. For this reason, we encourage you to use the Internet. You should be cautious about what you experience on the Internet. Try to stay on chat groups recommended by our staff. We urge you to ask us directly if you have any questions about the surgical process. Please feel free to contact our staff with any concerns or questions – we will either have the answer or do our best to find it for you. Support Group Meetings We consider group support meetings to be mandatory. We know realistically we cannot make you attend these meetings, but they are for your education, support, and nutritional and medical advice. Benefits of group meetings:
• Provide peer support • Allow you to learn about surgery firsthand from others who have had weight
loss surgery • Let you share your experiences • Provide guest speakers to expand your knowledge on related topics • Great for problem solving.
These support groups are a wonderful opportunity to make new friends and be with people who share what you are experiencing. It can be reassuring to hear others’ viewpoints on common concerns and to get additional information from the group leader or guest speaker. Research has shown that patients who attend support groups regularly are more successful with their weight loss and mental adjustment than people who do not. You will find these meetings helpful in many ways. Family and friends are welcome to attend with you.
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Stress Eliminators • Love yourself. Add yourself to your list of “loved ones.” Make taking care of
your physical, emotional, social, and physical needs a priority. • Listen to music. Let the rhythms drain away your stress. • Breathe deeply. Inhale through your nose, exhale through your mouth slowly,
and imagine that you are inhaling calmness and exhaling stress. • Laugh often. Have a giggle. Watch a comedy on video, listen to a tape or read
the Sunday funnies. Laughter is the best medicine. • Speak up for yourself. People who feel they have some control over some
aspects of their lives are less subject to stress. If you do not like the way, something is going, say so politely. In order for change to occur, you must take action.
• Let go. Learn the difference between what you can and cannot control. Stop worrying about things that are beyond your control. Use that energy to make the changes that you can. Focus on your own happiness.
• Manage your time. To avoid feeling rushed, plan out how much time you will need to accomplish tasks, to get ready to go places, to travel, to eat, etc.
• Get a hug. Humans are social beings and we require some safe, nurturing physical contact.
• Practice meditation. Spend at least 15 minutes a day relaxing your mind. Sit comfortably, breathe calmly, listen to some soft music and just clear your mind.
• Treat yourself with compassion. Give yourself permission to make mistakes, to play without feeling guilty, to change your mind and to set aside time only for you.
Day 2
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Eating For Healing – Liquid Protein Shakes
Adding liquid protein shakes The 2nd day after surgery your diet will advance to include protein shakes. Protein is necessary for wound healing, fighting infection, maintaining muscle mass, preventing hair loss, and maintaining good health. Therefore, you will consume a protein shake for each of your four meals. There is a variety of protein shakes available on the market. However not all protein shakes contain good quality protein. Here is a list of acceptable high quality protein shakes.
Drink Serving Size Calories Protein Sugar CHO Fat Where to Buy Premier Protein Drink
11 ounces ready to drink
160 30 1 g 4-5 g 3 g Grocery stores Sam’s Club Costco
Pure Protein Shake
11 ounce ready to drink
150 35 g 1 g 1 g 1 g Grocery stores
Atkins Lift
16.9 ounces Ready to drink
90 20 g 0 g 2 g 0 g Grocery stores
Syntrax Nectar
1 scoop mixed with 8 ounces water
90-100 23 g 0 g 0 g 0 g Walmart Vitamin Shoppe
Isopure Zero Carb Protein drink
20 ounces 160 40 g 0 g 0 g 0 g GNC Vitamin Shoppe
Unjury Powder
1 scoop mixed with 8 ounces water
or 1 scoop mixed with 8 ounces skim milk
90-100 180
20-21 g 28 g
1 – 4 g 4 g 0 g ProMedica Home Medical Equipment www.unjury.com call 1-800-517-5111
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Drink Serving Size Calories Protein Sugar CHO Fat Where to Buy
100% Gold Standard Whey
1 scoop mixed with 8 ounces water
or 1 scoop mixed with 8 ounces skim milk
120 210
24 g 32 g
1 g 3 g 1g Vitamin Shoppe GNC Bassett’s Health Claudia’s Abundant Life Rite Aid Bally Fitness
Sip a liquid protein shake for your meals. You will consume a protein shake for each of your meals. Please consume the entire shake. However, your stomach will only hold about 4 ounces or ½ cup over a 30 minute time period. Therefore, if your protein shake is 1 cup or 8 ounces it should take you about one hour to consume it. Other protein shakes may be appropriate. We would like them to be:
• ~200 calories or less • > 15 grams of protein, but best if 25 – 30 grams of protein • ~5 grams of carbohydrate or less • 5 grams of sugar or less • 3 grams of fat or less • Contains “whey” protein or “whey protein isolate”
Meet your fluid needs of 64 ounces per day You may continue to consume sugar-free, non-carbonated, non-alcoholic, caffeine free liquids between meals. Small sips throughout the day and evening will help you to consume the liquids you need. Please do not use straws. Please count your protein shakes as part of your fluids.
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Sample menu for protein shakes
Breakfast: Protein shake Lunch: Protein shake Afternoon Snack: Protein shake Dinner: Protein shake
If you would like to change the flavor of your protein shakes, you may do so by adding sugar-free syrups. Sugar-free syrups, such as DaVinci Sugar-free Syrups, are zero calorie syrups that come in many different flavors.
Day 3
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Eating for Healing - Full Liquids
The 3rd day after surgery your diet will advance to include full liquids. Full liquids include:
• Sugar-free pudding • Low-fat, low sugar yogurt
Kroger CARBMaster yogurt or activia light yogurt Greek lite
• Hot creamy cereals Oatmeal (made with fat free milk)- should be thin, liquidly consistency
o Plain (can add sugar substitute and/or cinnamon) o Quaker Oats Weight Control Oatmeal o Lower sugar instant oatmeal
Cream of wheat (made with fat free milk) Cream of rice (made with fat free milk) Grits (made with fat free milk) Malt-o-meal hot wheat cereal (made with fat free milk)
• Low-fat creamed soups made with milk, strained (no “chunks”) 98% fat-free creamed soups
• Protein shakes and/or unflavored protein powder
Eat four to five small meals per day. Eat four to five meals per day. At first, eat 2 – 4 Tablespoons (1 – 2 ounces) of food over a 10 – 15 minute period. If you do not feel full, eat another 2 – 4 tablespoons of food over the next 10 – 15 minutes. Stop eating when you are full, even if you have consumed less than 2 ounces. Always measure out your portions. Consume no more than ½ cup per meal. Fluids Drink 8 cups (64 oz.) of water or other sugar-free, non-alcoholic, non-carbonated, caffeine-free beverage between meals each day. Do not drink 30 minutes before your meal; do not consume any liquids with your meal, then wait 30 minutes after your meal to drink fluids. Please do not use straws. Remember to count your protein shake as part of your total fluid intake. Protein Protein is important for wound healing, to minimize muscle loss, and to prevent hair loss. Your protein goal is 40 grams of protein per day while on full liquids. To ensure you are meeting your protein goals:
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• Drink a protein shake as a meal. Please drink the entire shake slowly over time. • If you are not using protein shakes, then you must use unflavored protein
powders to mix in with your foods. You may purchase an unflavored protein powder called Beneprotein powder at ProMedica Home Medical Equipment.
Medicine All pills should be taken one hour before or after eating. Take one pill at a time. Exercise By this time after surgery, you should be stretching and using theraband exercises. Sample Menu #1 for full liquids Nutrition Facts: This day provides ~ 43 grams of protein
Breakfast: 8-ounce vanilla Unjury protein shake
Lunch: 2-4 ounces low-fat cream of chicken soup (strained)
Afternoon Snack: 2-4 ounces low sugar oatmeal
Dinner: 2 – 4 ounces cream of wheat
Sample menu #2 for full liquids Nutrition Facts: This day provides ~ 43 grams of protein
Breakfast: 2 – 4 ounces Protein Power Oatmeal (see recipe on next page) Lunch: 2 – 4 ounces Protein Power Pudding (see recipe on next page) Afternoon Snack: 2-4 ounces of low sugar yogurt with one scoop Beneprotein Dinner: 2 – 4 ounces Protein Power Chocolate Milk (see recipe below)
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Full Liquid Diet Recipes Here are a couple of recipes you may wish to include in your diet to give you more variety. Protein power chocolate milk ½ cup skim milk 1 packet Swiss Miss Sensible Sweets Light hot cocoa mix 1 scoop unflavored protein powder 4 ice cubes Put all ingredients into blender. Blend on high for 45 seconds. Makes one serving. Nutrition Information per serving: Calories 95, Protein 12 grams Protein Power Crystal Light ½ cup Crystal Light (powder mixed with water) 1 scoop unflavored protein powder 2 Tbsp Cool Whip free 4 ice cubes Put all ingredients into blender. Blend on high 45 seconds. Makes one serving. Nutrition Information per serving: Calories 50, Protein 6 grams Protein Power Oatmeal ½ cup evaporated skim milk ¼ cup quick oats Add evaporated skim milk to quick oats. Microwave at 50% for three – four minutes. Nutrition Information: Calories 230, Protein 11 grams Protein Power Pudding 1 package (4 serving size) pudding, no sugar added, any flavor 2 cups skim (or fat free) milk 4 scoops unflavored protein powder Put milk in blender. Add pudding mix and protein. Blend on medium speed for 45 seconds or until well mixed. Pour into small bowls. Refrigerate until set. Makes four servings. Nutrition Information per serving: Calories 95, Protein 10 grams
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Peach Creamsicle Shake 6 ounces Crystal Light peach tea 2 Tablespoons sugar-free instant vanilla pudding mix 1 scoop vanilla protein powder 6 packets Splenda Ice Cubes Thoroughly mix the ingredients in a blender. Makes one shake to be consumed over one hour. Nutritional Information varies depending on protein powder used. **All recipe nutrition information is based on using Beneprotein powder as the unflavored protein powder. This contains 25 calories, 6 g protein per scoop. You may substitute another protein supplement. To determine the nutrient content of the new recipe, simply subtract the nutrient contribution of Beneprotein powder and add in the information from the label of the product used.
Day 10 G
astric Bypass
Day 17 S
leeve
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Eating for Healing – Creamy foods The 10th day after your gastric bypass surgery or the 17th day after your sleeve gastrectomy surgery, your diet will advance to include creamy foods. Creamy foods include: • Scrambled eggs • Soft cooked eggs (not hard cooked) • Egg substitute/Egg beaters • Low-fat or fat free cottage cheese • Low fat ricotta cheese • Low sugar custard • Protein shakes and/or unflavored protein powder You may continue to consume foods from the full liquid phase. Eat four to five small meals per day Eat four to five meals per day. At first, eat 2 – 4 Tablespoons (1 – 2 ounces) of food over a 10 – 15 minute period. If you do not feel full, eat another 2 – 4 Tablespoons of food over the next 10 – 15 minutes. Always measure out your portions. Do not consume more than ½ cup per meal. Drink fluids between meals. Drink 8 cups (64 oz) of water or other sugar-free, non-alcoholic, non-carbonated, caffeine-free beverage between meals each day. Remember to have “dry meals”. Do not drink 30 minutes before your meal, do not consume any liquids with your meal, then wait 30 minutes afterward your meal to drink fluids. Please do not use straws. Remember to count your protein shake as part of your total fluid intake. Protein Protein is important for wound healing, minimizing muscle loss, and preventing hair loss. Your protein goal is 50 grams of protein per day while on semi-soft foods. To ensure you are meeting your protein goals:
• Drink a protein shake as a meal. Please drink the entire shake slowly over time. • If you are not using protein shakes, then use unflavored protein powders to mix
in with your foods. You may purchase an unflavored protein powder called Beneprotein powder at ProMedica Home Medical Equipment.
Medicine All pills should be taken one hour before or after eating. Take one pill at a time.
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Exercise By this time after surgery, you should be walking 10 – 15 minutes, five days a week, more if tolerated. Creamy foods diet sample menu Nutrition Facts: This day provides ~70 grams of protein Breakfast: 1 scrambled egg Lunch: 8 ounce protein shake Afternoon Snack: 1 soft-cooked egg Dinner: ¼ - ½ cup low-fat cottage cheese Creamy Foods Diet Recipes
Pineapple smoothie 2/3 cup pineapple juice, 100% ½ cup low-fat cottage cheese Put all ingredients into blender. Blend on high for 45 seconds. Makes one serving. Nutrition Information per serving: Calories 187, Protein 15 g Cottage Cheese Mousse 1 small sugar-free pudding mix (4 serving size) 16 ounces fat free cottage cheese 4 ounces Cool Whip Free Blend cottage cheese until smooth. Add pudding and mix well. Empty into large bowl. Fold in Cool Whip. Makes four servings. Nutrition information per serving: Calories 120, Protein 14 g.
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Fudgesicles 1 small box (4 servings) sugar-fee chocolate pudding mix 1 ½ cups fat-free or skim milk ½ cup plain low-fat yogurt Combine the chocolate pudding mix with the milk and mix. Add yogurt. Pour into ½-cup containers and chill, or freeze into popsicles. Makes four servings. Nutritional information per serving: Calories 11, Protein 3 g. Pumpkin Moose 1 small box (4 servings) sugar-free instant vanilla pudding 2 cups skim or fat-free milk ½-cup solid pack pumpkin 1-teaspoon pumpkin pie spice ½ cup Cool Whip Free Cinnamon (optional) Prepare pudding according to package directions, substituting the skim milk. With a spoon, fold solid pack pumpkin, pumpkin spice and Cool Whip Free into the pudding. Refrigerate until set. Before serving, top the pudding with a dollop of Cool Whip Free and cinnamon, if desired. Makes five servings. Nutritional information per serving: Calories 130, Protein 4.5 g.
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Scrambled Eggs in a Cup 1 egg 1 Tablespoons skim or fat-free milk 1 Tablespoons low fat shredded cheese Salt and pepper, to taste Spray a microwave safe cup with cooking spray. Put eggs and milk in cup and mix. Microwave 20-40 seconds on high. Stir. Microwave 15-30 seconds longer. Top with cheese. Add salt and pepper to taste.
Soft cooked eggs Begin with the eggs at room temperature and cover them completely with cold water in a saucepan. Heat the eggs and water on stovetop until water boils; remove from heat and cover pan. Let the eggs and water stand for 2-4 minutes.
Low Sugar Custard 2 large eggs 2 large egg whites 2/3 cup Splenda 2 teaspoons vanilla 2 cups 1% milk 1 cup evaporated low fat or skim milk Fresh nutmeg, grated or ground Preheat oven to 325 degrees. In a medium bowl, whisk eggs, egg whites, Splenda and vanilla; set aside. In a small saucepan, bring milk and evaporated milk to a low simmer. Whisk a small amount of the hot milk mixture into the egg mixture, to temper the eggs; whisk in the remaining milk. Strain mixture into a large measuring cup with a pouring lid or bowl. Pour, or ladle, the mixture into 6-ounce custard cups or ramekins, and sprinkle with nutmeg. Set the cups in a large baking dish and place the baking dish into the preheated oven. Pour hot water into the baking dish, until the water level is halfway up the sides of the custard cups. Bake for 45 – 55 minutes, or until edges of custard has set and center jiggles slightly when shaken. Refrigerate and allow custard to cool before serving.
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Almost Rice Pudding 1 ½ cups fat-free cottage cheese 1 cup fat-free or skim milk ½ cup fat-free half and half ½ cup Splenda ¾ cup egg substitute or 3 eggs Cinnamon (to taste) Nutmeg or pumpkin pie spice (to taste) Combine all ingredients in a blender. Blend. Pour the mixture into eight 6 ounce ramekins or one 8 inch soufflé dish. Place ramekins or soufflé dish in another pan which contains 1 inch of water (be sure not to cover the smaller dishes with the water). Bake at 350 degrees in the oven. Pudding is done when a knife can be inserted into the center and pulled out clean.
Vanilla Butterscotch Protein Shake 8 ounces cold water 2 scoops vanilla protein powder 1 tablespoon sugar-free butterscotch pudding 1 tablespoon sugar-free vanilla pudding 4 – 5 ice cubes Combine all the ingredients in a blender. Allow time for mixture to settle before serving (should have a custard-like texture and taste). Vanilla Frosty 1 – 2 scoops vanilla protein powder 2 – 4 ounces low sugar, low fat yogurt (any flavor) 10 – 12 ice cubes ¾ cup water or soy milk
Blend all the ingredients in a blender until mixture has the consistency of a Wendy’s frosty.
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Healthy Eating Techniques • Choose only one allowed eating place in your home. It should be a place where you
can sit down and eat comfortably. At work, avoid eating at your desk. This will help you develop a “set” eating environment in which to enjoy your meals.
• When you are eating, only eat. Do not watch television, read or engage in any other activity. This will help you focus on your meal and keep you from overeating.
• Use smaller plates when you eat. Portions look larger on a smaller plate and can
help you feel more satisfied with your meal.
• Keep food in the kitchen only. Avoid dishes of candy, nuts, etc. in other rooms of the house.
• Learn to leave some food behind on your plate at each meal. Cancel your membership to the “CLEAN PLATE CLUB”.
• Do not put serving dishes on the table. You are more likely to take extra helpings if the food is in front of you.
• Eat slowly. This gives the body a chance to realize it is satisfied before you have overeaten. Three suggestions: - Use baby spoons or cocktail forks to encourage smaller bites. - Put your eating utensil (or finger food) down between each bite. Do not pick it
up until the previous bite is well chewed and swallowed. - Stop and take a short break midway through your meal. A two to three minute
break will help you realize when you have had enough.
• Sip your liquids. Try using a child’s sippy cup or a water bottle with a pull up tab. Do not drink from straws.
• Shop with a list. Do not go to the grocery store hungry.
• Avoid situations in which you are likely to overeat, such as buffets and “all you can
eat” specials. • Focus on healthy food choices as part of a healthy lifestyle. This should include
exercise as allowed by your physician. Even activities such as taking the stairs and walking the dog can be good for you.
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Vitamin/Mineral Supplements and Medicines
Take: • A chewable prenatal vitamin one time a day.
or
• A chewable complete vitamin two times a day. Take one in the morning and one in the evening. Please avoid “gummy” vitamins, as these do not contain iron. Examples: Flintstones Complete chewable tablets or Centrum kids chewable tablets or
• One Daily Plus Iron Vitamin Small easy to swallow vitamin for those patients not liking the taste of the chewable vitamins.
- Take one tablet two times a day
**Coffee and tea inhibit the absorption of calcium and iron. Please consume these beverages 2 hours away from your vitamin and mineral supplements.
• Ursodiol 500 mg every day (If indicated)
or Ursodiol 300 mg two times a day (Medicare patients if indicated)
Do not take if gallbladder removed or diagnosed with gallstones before surgery.
Your bariatric surgeon will check for vitamin/mineral deficiencies. Additional supplements, like iron, may be prescribed based on your lab results. Please consume: _____________________________________________________________________
_____________________________________________ ________________________
Day 17 G
astric Bypass
Day 24 S
leeve
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Eating for healing - Soft foods
The 17th day after your gastric bypass surgery or the 24th day after your sleeve gastrectomy surgery, your diet will advance to include soft foods. You will follow this diet for approximately six months after surgery. Eat four to five small meals per day. Continue to eat four to five small meals per day. Try to keep a consistent schedule for meals and snacks. Three meals and an evening snack are recommended. Add one new solid food item at each meal. All new foods should be soft, cooked, or canned. Chew well so food is almost liquid before you swallow.
At first, eat 2 – 4 Tablespoons (1 – 2 ounces) of food over a 10 – 15 minute period. If you do not feel full, eat another 2 – 4 Tablespoons of food over the next 10 – 15 minutes. Stop eating when you are full, even if you have consumed less than 2 ounces. Always measure out your portions. Do not consume more than ½ cup of food at a meal. Protein At least half of your meal should be a protein source. This can include meat, fish, eggs, and low-fat dairy products. Eat the high protein foods first, before any other food. Your protein goal is at least 65 – 75 grams per day. You can obtain your protein goal by eating foods and using protein shakes/powders. Keep daily food records to monitor protein intake to ensure you are meeting your goal. Utilize the Daily Progress Log handout in this packet to help you keep track. Once you are able to meet your protein goal through just foods, you can stop consuming the protein shakes/powders. Normally, if you are eating less than a ½ of a cup of food at a meal you will still need to use protein shakes to meet your protein goal. Drink fluids between meals. Drink at least 8 cups (64 oz) of water or other sugar-free beverages between meals. Avoid beverages that have alcohol, caffeine, and carbonation. Please do not use straws. Be sure to do mindful eating. Pay careful attention to your body’s feeling of fullness. Stop eating when you start to feel full. It is better to have one place to eat (such as the kitchen table) and to avoid reading or watching TV while you eat. This helps you to enjoy your food, to concentrate on eating slower and to realize when your stomach is full.
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Exercise By this time after surgery, you should be walking, bicycling, or doing elliptical at least 10 – 15 minutes, five days a week, more if tolerated. If you have problems with your weight-bearing joints, water exercises are recommended. The mistake that many patients make is that they do not exercise until they feel “all recovered” or try to start exercising when they realize they are not on course to reach their goal weight. Patients who exercise early after surgery find it very rewarding. As the weight falls off, the capacity for exercise improves dramatically with significant improvements on a week-by-week basis. Do not cheat your body of this important aspect of weight loss. Make a long-term pledge to exercising. Medicine All pills should be taken one hour before or after eating. Take one pill at a time.
Sample Menu #1 Soft Foods Nutrition Facts: This day provides ~90 grams of protein
Breakfast: ½ cup scrambled eggs (1~ 2 large eggs)
Morning 1/3 cup low-fat cottage cheese Snack: 2 Tablespoons canned peaches in their own juice
Lunch: Chicken or tuna salad ½ cup canned chicken or tuna, packed in water
1 Tablespoon Miracle Whip Light Afternoon Snack: ½ cup chili (made with lean ground beef or lean ground turkey)
Dinner: 3 ounces boneless, skinless chicken breast 2 Tablespoons mashed potatoes
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Sample Menu #2 Soft Foods Nutrition Facts: This day provides ~85 grams of protein
Breakfast: ½ cup scrambled egg topped with salsa (1 egg)
Morning Egg Salad (made with 1 egg and 1 tsp Miracle Whip Light) Snack: 1/2 slice toasted bread
Lunch: Quesadilla, pan cooked using cooking spray 1 small tortilla 2 ounces canned chicken or cooked cubed chicken 1 ounce low-fat cheese
Afternoon Snack: ½ cup Greek light yogurt Dinner: 3 ounces baked ham steak
Cooked broccoli florets with 1 ounce low-fat cheese
Sample schedule to get 4-5 meals while consuming 64 ounces of fluids in between meals. 6:30am-7 am – Breakfast 7:30am-9 am – 12 ounces water 9:30am-10 am – Morning snack 10:30am – 12N – 12 ounces water 12:30pm-1pm – Lunch 1:30pm-3:00pm – 12 ounces water 3:30pm-4 pm – Afternoon snack 4:30pm -6 pm – 12 ounces water 6:30pm-7 pm – Dinner 7:30pm-9:30 pm – 16 ounces water
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Foods Recommended:
Protein ** Most of your meal should be protein foods.
• Canned tuna or chicken, packed in water or in pouches • Eggs, egg beaters • Cheese, reduced fat • Cottage cheese, reduced fat • Ricotta cheese, reduced fat • Yogurt, low-fat, low sugar
Kroger Carb Master • Skim, 1%, or ½% milk • Protein shakes • Low-fat deli meats • Peanut butter, creamy, low-fat or natural (< 1 Tbsp per day) • Skinless chicken, cooked until tender and cut into small pieces • Skinless turkey, cooked until tender and cut into small pieces • Lean pork, cooked until very tender and cut into small pieces • Lean ground beef (this may be more difficult to digest for the first six months,
use lean ground turkey if needed) • Lean ham • Fish, steamed or poached • Crab, scallops, oysters, shrimp (avoid fried) • Tofu or soy products such as veggie burger patty, veggie sausage links • Beans and lentils such as kidney beans or fat-free refried beans
Vegetables
• Canned or cooked tender vegetables without peels or seeds • Red beets • Squash/Yams • Potatoes, mashed or baked without skins • Potatoes, instant mashed • Spinach, canned or well cooked
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Foods Recommended: Fruits ** Limit total fruit consumption to no more than 1/4 cup (2 oz) per day.
• Canned peaches or pears, packed in own juice or water (not canned in syrup) • Applesauce, unsweetened • Banana • Ripe melon
Starches ** Limit total starches to no more than two servings per day.
• Cream of wheat, oatmeal, malt-o-meal with added protein powder • Toasted bread (avoid soft-doughy breads) • Melba toast • Pita/flat bread • Flour tortillas • Low sugar cold cereals soaked in milk until soggy
Foods Not Recommended: “Sticky” foods
• Soft bread (it can make a dough ball that could plug up the stomach pouch) • Sticky or sweet rice • Spaghetti and other pasta • Macaroni and cheese • High fat cheese, melted cheese • Raisins, prunes, and other dried fruits
Crunchy Foods
• Granola and other cereals with nuts • Raw vegetables, salad, pickles, and relish • Nuts and seeds • Popcorn • Chips • Coconut • Whole raw fruits, fruits with coarse skins and fibers such as oranges
98
Foods Not Recommended: Tough Foods
• Tough and chewy meat, especially steak • Dry meats
High-Sugar High-Fat Foods
• Regular mayonnaise, sour cream, cream cheese, salad dressing • Whole and 2% milk • Ice cream, cakes, cookies, pies, and other desserts • Dried fruits like raisins • Bacon • Olives • Sausage • Gravy • Sugar, honey, corn syrup, molasses • Maple syrup
Foods with seeds, peels and husks
• Strawberries and other berries with seeds • Corn
Beverages
• Juice • Carbonated drinks (soda pop, beer) • High sugar drinks (Kool-Aid, lemonade, sweet tea) • Caffeinated coffee/tea
Slider foods **Slider foods are processed soft simple starches that slide right through the stomach pouch without providing you a sense of fullness.
• Pretzels • Crackers (saltines, graham, Ritz, etc.) • Filled cracker snacks such as Ritz Bits • Cheese puffs or cheese crackers • Tortilla chips with salsa • Potato chips • Sugar-free cookies
99
DAILY Name ________________________________________________ PROGRESS LOG Date _________________________________________________
Drink fluids Goal eight glasses per day
Relax
Exercise
Take your vitamins/minerals
Food item Grams of protein
Bre
akfa
st
Mor
ning
sn
ack
Lunc
h
Afte
rnoo
n sn
ack
Din
ner
Total Protein Goal 65 – 75 grams/day
100
DAILY Name ________________________________________________ PROGRESS LOG Date _________________________________________________
Drink fluids Goal eight glasses per day
Relax
Exercise
Take your vitamins/minerals
Food item Grams of protein
Bre
akfa
st
Mor
ning
sn
ack
Lunc
h
Afte
rnoo
n sa
nck
Din
ner
Total Protein Goal 65 – 75 grams/day
101
DAILY Name ________________________________________________ PROGRESS LOG Date _________________________________________________
Drink fluids Goal eight glasses per day
Relax
Exercise
Take your vitamins/minerals
Food item Grams of protein
Bre
akfa
st
Mor
ning
sn
ack
Lunc
h
Afte
rnoo
n sn
ack
Din
ner
Total Protein Goal 65 – 75 grams/day
102
DAILY Name ________________________________________________ PROGRESS LOG Date _________________________________________________
Drink fluids Goal eight glasses per day
Relax
Exercise
Take your vitamins/minerals
Food item Grams of protein
Bre
akfa
st
Mor
ning
sn
ack
Lunc
h
Afte
rnoo
n sn
ack
Din
ner
Total Protein Goal 65 – 75 grams/day
103
DAILY Name ________________________________________________ PROGRESS LOG Date _________________________________________________
Drink fluids Goal eight glasses per day
Relax
Exercise
Take your vitamins/minerals
Food item Grams of protein
Bre
akfa
st
Mor
ning
sn
ack
Lunc
h
Afte
rnoo
n sn
ack
Din
ner
Total Protein Goal 65 – 75 grams/day
104
DAILY Name ________________________________________________ PROGRESS LOG Date _________________________________________________
Drink fluids Goal eight glasses per day
Relax
Exercise
Take your vitamins/minerals
Food item Grams of protein
Bre
akfa
st
Mor
ning
sn
ack
Lunc
h
Afte
rnoo
n sn
ack
Din
ner
Total Protein Goal 65 – 75 grams/day
105
DAILY Name ________________________________________________ PROGRESS LOG Date _________________________________________________
Drink fluids Goal eight glasses per day
Relax
Exercise
Take your vitamins/minerals
Food item Grams of protein
Bre
akfa
st
Mor
ning
sn
ack
Lunc
h
Afte
rnoo
n sn
ack
Din
ner
Total Protein Goal 65 – 75 grams/day
106
Vitamin/Mineral Supplements and Medicines
Continue to take: • A chewable prenatal vitamin one time a day.
or A chewable “complete” vitamin two times a day. Take one in the morning and
one in the evening. Please avoid “gummy” vitamins as these do not contain iron. or
One Daily Plus Iron Vitamin Small easy to swallow vitamin for those patients not liking the taste of the chewable vitamins.
o Take one tablet two times a day
**Coffee and tea inhibit the absorption of calcium and iron. Please consume these beverages 2 hours away from your vitamin and mineral supplements.
• Ursodiol 500 mg every day (If indicated)
or Ursodiol 300 mg two times a day (Medicare patients if indicated)
Do not take if gallbladder removed or diagnosed with gallstones before surgery.
Your bariatric surgeon will check for vitamin/mineral deficiencies. Additional supplements, like iron, may be prescribed based on your lab results. Please consume: _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
__________________________________________________________________
107
Common Nutritional Complaints after Bariatric Surgery
Problem Possible Cause Prevention/Treatment Burping and hiccups
• Swallowing air when eating and drinking
• Chew with mouth closed • Avoid using straws to drink • Eat slowly • Avoid carbonated beverages
Bad Breath • Body in ketosis • Get 64 ounces of fluid per day • Brush teeth and tongue regularly • Sugar-free breath mints (check to
ensure < 5 grams of sugar alcohols) Diarrhea • Lactose intolerance
• Fatty food intolerance • Dumping syndrome
• Keep food diary to track foods/beverages consumed and onset of symptoms
• Lactaid pills are helpful if lactose intolerant
• Avoid sugary and fatty foods Constipation • Pain medications after
surgery • Decreased fiber intake • Iron Supplements
• Get 64 ounces of fluid per day • Exercise regularly • Stool softener (i.e. Colace) • Saline fleets enema • MiraLAX 17 grams/day • Benefiber
Hunger/snacking • Is it physiological or psychological hunger?
• Emotional eating
• Regular meal times emphasizing high protein foods
• Get 64 ounces of fluid per day • Increase fiber intake after nine months • Avoid caffeine (may cause delayed
hunger) • Regular exercise
Hair loss • Stress of surgery • Rapid weight loss • Usually between three –
nine months after surgery
• Ensure adequate protein intake • Take vitamin/mineral supplements • Take Biotin 5,000 micrograms – a hair
and nail vitamin • Special shampoos for hair loss
108
Problem Possible Cause Prevention/Treatment Dizziness • Low blood pressure
• Dumping syndrome • Skipping meals
• Discuss with primary care physician if blood pressure meds need adjusting
• Avoid sugary and fatty foods • Avoid drinking with meals • Avoid skipping meals • Include protein and complex carbohydrates at
each meal Dumping syndrome
• Dehydration • High fat or sugary
foods • Drinking with meals • Eating too much
• Get 64 ounces of fluid per day • Avoid sugary and fatty foods • Do not drink with meals • Wait 30 minutes after a meal to resume
drinking • Small bites, chew slowly • Stop eating when full
Fatigue • Recovering from surgery
• Too little sleep • Inadequate fluids • Depression • Anemia • Low blood sugars
• Get eight hours sleep per night • Get 64 ounces of fluid per day • Meet protein goals of 65 – 75 g per day • Take recommended vitamin/mineral
supplements • Have iron/blood sugar level checked
Frothing • Over eating/drinking • Food too dry • Dehydration
• Eat slowly with small bites and stopping when full
• Measure food, no more than ½ cup • Eat moist foods • No pasta, rice or bread for four months • Get 64 ounces of fluid per day
Food Stuck • Eating too much • Eating too quickly • Not chewing enough • Food too dry or tough
• May need to go back to warm liquids (like broth or herbal tea) for 24 hours until food passes
• Use baby spoon/cocktail fork to make sure bites are smaller than a dime
• Measure food, no more than ½ cup
109
Problem Possible Cause Prevention/Treatment Nausea • Post nasal drip due to
allergies • Hormonal changes
causing increased sense of smell
• May need to take medicines to assist in drying up the post nasal drip such as Claritin
• To decrease smells use a mug with a lid to consume your protein shakes
• Consume warm water with lemon or herbal peppermint tea to help decrease nausea
Vomiting • Usually related to eating behaviors and food choices
• If can’t keep anything down, may be due to a stricture
• Eat slowly, chewing well • Avoid overeating • Avoid sugary and fatty foods • Do not drink with meals • Wait 30 minutes after a meal to resume
drinking
6 Weeks
110
Eating for healing - Soft foods
At six weeks after surgery, your diet will continue to include soft foods. You may now include soft ripe fruits that have been peeled and small amounts of lettuce leaves into your diet. Your vitamins/minerals will also change at this time. Eat four to five small meals per day. Continue to eat four to five small meals per day. Try to keep a consistent schedule for meals and snacks. Three meals and an evening snack are recommended. Chew well so food is almost liquid before you swallow. Always measure out your portions. Do not consume more than ½ cup at a meal. Protein At least half of your meal should be a protein source. This can include meat, fish, eggs, and low-fat dairy products. Eat the high protein foods first, before any other food. Your protein goal is 65 – 75 grams per day. Keep daily food records to monitor protein intake. Utilize the Daily Progress Log handout in this packet to monitor your diet. Continue to use protein shakes/powders to meet your protein goal if you can not meet the goal through just eating foods. Choose solid foods over soft, mushy or liquid foods. Solid foods fill up your stomach pouch and sit in your stomach pouch longer than soft, mushy, and liquid foods. Choose poultry, fish, whole fruits over soups, yogurt. Drink fluids between meals. Drink at least 8 cups (64 oz) of water or other sugar-free beverages between meals. Avoid beverages that have alcohol, caffeine, and carbonation. Be sure to do mindful eating. Pay careful attention to your body’s feeling of fullness. Stop eating when you start to feel full. It is better to have one place to eat (such as the kitchen table) and to avoid reading or watching TV while you eat. This helps you to enjoy your food, to concentrate on eating slower and to realize when your stomach is full. Medicine All pills should be taken one hour before or after eating. Take one pill at a time.
111
Exercise Walking, bicycling or swimming should be increased to 30 – 40 minutes, five days a week. Strengthening exercises should be performed three days a week.
Sample Menu Soft Foods
Breakfast: 1 Omelet: ½ cup egg beaters 1 ounce low-fat cheddar cheese
Morning snack: 1/3 cup low-fat cottage cheese
2 Tablespoons ripe skinless pear
Lunch: Turkey tortilla wrap: 2 ounces lean turkey lunchmeat 1 ounce mozzarella cheese, made with skim milk 1 small tortilla 1 lettuce leaf 1 tsp Miracle Whip Light
Afternoon Snack: 1 low fat string cheese with peeled apple slices
Dinner: Broiled or barbequed Shish-ka-bob skewer:
3 ounces of cubed lean meat, poultry, or shrimp Onion and green peppers
112
Foods Recommended:
Protein ** Most of your meal should be protein foods.
• Canned tuna or chicken, packed in water or in pouches • Eggs, egg beaters • Cheese, reduced fat • Cottage cheese, reduced fat • Ricotta cheese, reduced fat • Yogurt, low-fat, low sugar • Skim, 1% or ½% milk • Protein shakes • Low-fat deli meats • Lean beef jerkey • Peanut butter, creamy, low-fat or natural (< 1 Tbsp per day) • Skinless chicken, cooked until tender and cut into small pieces • Skinless turkey, cooked until tender and cut into small pieces • Lean pork, cooked until very tender and cut into small pieces • Lean ground beef (this may be more difficult to digest for the first six months,
use lean ground turkey) • Lean ham • Fish, steamed or poached • Crab, scallops, oysters, shrimp (avoid fried) • Tofu or soy products such as veggie burger patty • Beans and lentils
Vegetables
• Cooked tender vegetables without peels or seeds like green beans, carrots • Red beets • Squash/Yams • Potatoes, mashed or baked without skins • Potatoes, instant mashed • Spinach, canned or well cooked • Lettuce, salad • Seedless cucumbers, without skins
113
Foods Recommended:
Fruits ** Limit total fruit and juice consumption to no more than 1/4 cup (2 oz) per day. • Canned peaches or pears, packed in own juice or water (not canned in syrup) • Applesauce, unsweetened • Banana • Ripe melon • Soft ripe fruits without skins or peels; like plum, peach, pear, apple
Starches ** Limit to two servings per day.
• Cream of wheat, oatmeal, malt-o-meal with added protein powder • Toasted bread • Melba Toast • Pita/ flat bread • Flour Tortillas • Low sugar cold cereals
Foods Not Recommended: “Sticky” foods
• Sweet or sticky rice • Spaghetti and other pasta • Macaroni and cheese • High fat cheese • Raisins, prunes, and other dried fruits • Soft doughy breads
Crunchy Foods
• Granola and other cereals with nuts • Raw vegetables, pickles, relish • Nuts and seeds • Popcorn • Chips • Coconut • Whole raw fruits with coarse skins and fibers such as oranges
114
Foods Not Recommended: Tough Foods
• Tough and chewy meat • Dry meats • Steak
High-sugar High-fat foods
• Regular mayonnaise, sour cream, cream cheese, salad dressing • Whole and 2% milk • Ice cream, cakes, cookies, pies and other desserts • Dried fruits like raisins • Bacon • Olives • Sausage • Gravy • Sugar, honey, corn syrup, molasses • Maple syrup
Foods with seeds, peels and husks
• Strawberries and other berries • Corn
Beverages
• Juice • Carbonated drinks (soda pop, beer) • High sugar drinks (Kool-Aid, lemonade, sweet tea) • Caffeinated coffee/tea
If you are going to have 1 cup of caffeinated coffee or tea, add 2 8oz. glasses of water to your daily intake. Remember do not take your vitamins within 2 hours of coffee/black tea.
115
Foods Not Recommended:
Slider foods **Slider foods are processed soft simple starches that slide right through the stomach pouch without providing you a sense of fullness.
• Pretzels• Crackers (saltines, graham, Ritz, etc.)• Filled cracker snacks such as Ritz Bits• Cheese puffs or cheese crackers• Tortilla chips with salsa• Potato chips• Sugar-free cookies
116
Vitamin/Mineral Supplements and Medicines
At six weeks after surgery, please take: • One prenatal vitamin daily or A chewable “Complete” vitamin two times a day. Take one in the morning
and one in the evening. Please avoid “gummy” vitamins, as these do not contain iron. or
One Daily Plus Iron Vitamin Small easy to swallow vitamin for those patients not liking the taste of the chewable vitamins.
- Take one tablet two times a day
• 500 mg of calcium citrate with vitamin D taken three times per day for a total of at least 1500 mg per day.
• This should be taken two hours away from iron supplements (including the iron in prenatal vitamins) to avoid interference with iron absorption.
• DO NOT take calcium that is calcium carbonate as it is not readily absorbed after gastric bypass surgery.
• Please refer to the calcium handout for different products available on the market.
• 1000 mcg sublingual (under the tongue) Vitamin B-12 daily or 1000 mcg/1cc intramuscular shot every two – four weeks or 500 micrograms nasal spray into one nostril once a week (Nascobal) • Ursodiol 500 mg every day (If indicated) or Ursodiol 300 mg two times a day (Medicare patients if indicated)
Do not take if gallbladder removed or diagnosed with gallstones before surgery.
• 1500 – 5000 micrograms Biotin daily (optional for hair loss). **Coffee and tea inhibit the absorption of calcium and iron. Please consume these beverages 2 hours away from your vitamin and mineral supplements.
117
Follow up visits with your bariatric surgeon are very important. Your bariatric surgeon will check for vitamin/mineral deficiencies.
Additional supplements like Vitamin D and Iron may be prescribed based on your lab results. Please consume:__________________________________________________
118
Calcium Citrate
Calcium and Vitamin D are important nutrients for keeping our bones strong. Calcium Citrate is the most absorbable form of calcium following gastric bypass surgery. Vitamin D plays a significant role by helping our bodies absorb calcium. When choosing calcium supplements make sure they are calcium citrate based and contain Vitamin D. Calcium is best taken in divided doses of no more than 600 mg at a time, and should be taken separately from iron supplements to avoid interference with iron absorption.
CHEWABLES
Product Calcium (mg)
per unit
Vitamin D (IU)
per unit
Amount per day for 1500
mg
Where available
Bariatric Advantage Calcium Citrate Chewy Bites
500 mg
500 IU 3 per day (1 chew 3 times/day)
ProMedica Home Medical Equipment Bariatricadvantage.com Jaks Pharmacy- Bowling Green, Ohio
Celebrate Soft Chews- Caramel, Chocolate or Berry
500 mg 500 IU 3 per day (1 chew 3 times/day)
ProMedica Home Medical Equipment Celebratevitamins.com
LIQUID
Product Calcium (mg)
per unit
Vitamin D (IU)
per unit
Amount per day for 1500
mg
Where available
Wellesse Calcium and Vitamin D
500 mg 500 IU 3 TBSP (1 TBSP 3 times/day)
ProMedica Home Medical Equipment Meijer’s Wal-Mart Rite Aid Walgreens
119
TABLETS Product
Calcium
(mg) per unit
Vitamin D (IU)
per unit
Amount per day for 1500 mg
Where available
Citracal Maximum
315 mg 250 IU 5 caplets (2 caplets 2 times/day + 1 caplet 1 time/day)
Grocery stores and drug stores
Citracal Petites
200 mg 250 IU 7 ½ tablets (2 ½ tablets 3 times/day)
Grocery stores and drug stores
120
Exercise Exercise is an important part of your program after weight loss surgery. Exercise at a moderate level for 30 minutes five days a week has been shown to result in a greater weight loss after surgery. To prevent weight regain 150 – 250 minutes of moderate exercise a week may be needed. Regular exercise helps the body use fat as a fuel source. Strengthening and walking exercises will help keep muscles and bones strong. Exercising before surgery can decrease problems after surgery.
Include both strengthening and aerobic exercise such as walking, bicycling, swimming or elliptical in your exercise program. Begin aerobic exercise at a length of time that is easy for you. Five to ten minutes to start is fine. Increase your daily exercise time several minutes a week, working up to 30 minutes a day. You may do two 15-minute or three 10-minute sessions to add up to 30 minutes a day.
Check your heart rate after exercising 5 – 10 minutes to decide if exercise is a moderate level. To monitor heart rate place your index and long fingers at your wrist on thumb side. Count each beat for ten seconds. See chart on the next page for your recommended heart rate range base on your age.
Moderate Exercise (55 – 70% age adjusted heart rate maximum)
Age Heart
rate per 10 seconds 20 – 26 18 – 23 27 – 35 17 – 22 36 – 40 17 – 21 41 – 45 16 – 21 46 – 53 15 – 20 54 – 62 15 – 19 63 – 65 14 – 18
Moderate intensity exercise should feel light to somewhat hard. Examples of moderate exercise are mowing with a power mower, golfing walking with clubs, raking leaves, shooting baskets, dancing, and gardening. Strengthening exercises with Thera band or weight lifting is recommended three days per week.
4 Months
121
Eating for healing - Soft foods
At four months after surgery, you will continue to eat soft foods. You may now include rice, pasta, and soft breads into your diet. Eat four to five small meals per day. Continue to eat four to five small meals per day. Try to keep a consistent schedule for meals and snacks. Three meals and an evening snack are recommended. Chew well so food is almost liquid before you swallow. Do not consume more than ½ cup of food at a meal. Protein At least half of your meal should be a protein source. This can include meat, fish, eggs, and low-fat dairy products. Eat the high protein foods first, before any other food. Your protein goal is 65 – 75 grams per day. Keep daily food records to monitor protein intake. Use the Daily Progress Log handout in this packet to monitor your diet. Use protein shakes/powders as needed to meet your protein goal. Fluids Drink at least 8 cups (64 oz) of water or other sugar-free beverages between meals. Avoid beverages that have alcohol, caffeine, and carbonation. Do not use straws. Be sure to do mindful eating. Be aware of your body’s feeling of fullness. Stop eating when you start to feel full. It is better to have one place to eat (such as the kitchen table) and to avoid reading or watching TV while you eat. This helps you to enjoy your food, to concentrate on eating slower and to realize when your stomach is full. Medicine All pills should be taken one hour before or after eating. Take one pill at a time. Exercise Have a plan for winter or bad weather day exercise. You need to have an indoor program such as mall walking, treadmill, stationary bike or videotapes to maintain an exercise program year round in Northwest Ohio.
122
Sample Menu Soft Foods
Nutrition Facts: This day provides ~ 90 grams of protein
Breakfast: 1/3 cup low-fat cottage cheese 2 Tablespoons unsweetened applesauce with cinnamon
Morning snack: ½ cup tuna salad (made with Miracle Whip Light)
Lunch: Sandwich
1 slice bread 2 ounces lean sliced luncheon meat 1 ounce low-fat cheese 1 lettuce leaf 1 tsp low-fat Italian dressing
Afternoon Snack: 1 hard cooked egg Dinner: Spaghetti
3 ounces meatballs 2 Tablespoons pasta 2 Tablespoons tomato sauce
123
Foods Recommended: Protein ** Most of your meal should be protein foods.
• Canned tuna or chicken, packed in water or in pouches • Eggs, egg beaters • Cheese, reduced fat • Cottage cheese, reduced fat • Ricotta cheese, reduced fat • Yogurt, low-fat, low sugar
• Dannon light’n fit Carb and Sugar Control • Kroger Carb Master
• Skim, 1% or ½% milk • Protein shakes • Low-fat deli meats • Lean beef jerkey • Peanut butter, creamy, low-fat or natural (< 1 Tbsp per day) • Skinless chicken, cooked until tender and cut into small pieces • Skinless turkey, cooked until tender and cut into small pieces
Protein
• Lean pork, cooked until very tender and cut into small pieces • Lean ground beef (this may be more difficult to digest for the first six months) • Lean ham • Fish, steamed or poached • Crab, scallops, oysters, shrimp (avoid fried) • Tofu or soy products such as veggie burger patty • Beans and lentils
Vegetables
• Cooked tender vegetables without peels or seeds like green beans, carrots • Red beets • Squash/Yams • Potatoes, mashed or baked without skins • Potatoes, instant mashed • Spinach, canned or well cooked • Lettuce
124
Foods Recommended: Fruits ** Limit total fruit and juice consumption to no more than 1/4 cup (2 oz) per day.
• Canned peaches or pears, packed in own juice or water (not canned in syrup) • Applesauce, unsweetened • Soft ripe fruits without peels and skins, like apple, peach, plum, nectarine,
melon, banana
Starches ** Limit to two servings per day. • Cream of wheat, oatmeal, malt-o-meal with added protein powder • Bread and toasted bread • English Muffin • Melba Toast • Pita/flat bread • Flour Tortillas • Rice • Spaghetti and other pasta • Macaroni and cheese made with low-fat cheese • Low sugar cold cereals soaked in milk until soggy
Foods Not Recommended: “Sticky” foods
• High fat cheese • Raisins, prunes, and other dried fruits
Crunchy Foods
• Granola and other cereals with nuts • Raw vegetables, pickles, relish • Nuts and seeds • Popcorn • Chips • Coconut • Whole raw fruits, fruits with coarse skins and fibers such as oranges
Tough Foods
• Tough and chewy meat • Dry meats
125
• Steak
High-sugar High-fat foods • Regular mayonnaise, sour cream, cream cheese, salad dressing• Whole and 2% milk• Ice cream, cakes, cookies, pies, and other desserts• Dried fruits like raisins• Bacon• Olives• Sausage• Gravy• Sugar, honey, corn syrup, molasses• Maple syrup
Foods with seeds, peels and husks • Strawberries and other berries• Corn
Foods Not Recommended: Beverages
• Juice• Carbonated drinks (soda pop, beer)• High sugar drinks (Kool-Aid, lemonade, sweet tea)• Caffeinated coffee/tea
♦ If you are going to have 1 cup of caffeinated coffee or tea, add 2 8oz.glasses of water to your daily intake. Remember do not take your vitaminswithin 2 hours of coffee/black tea.
Slider foods **Slider foods are soft simple processed carbohydrates that slide right through the stomach pouch without providing you a sense of fullness.
• Pretzels• Crackers (saltines, graham, Ritz, etc.)• Filled cracker snacks such as Ritz Bits• Cheese puffs• Cheese crackers• Tortilla chips with salsa• Potato chips• Sugar-free cookies
126
Vitamin/Mineral Supplements and Medicines
At four months after surgery, please take: • One prenatal vitamin daily or A chewable “Complete” vitamin two times a day. Take one in the morning
and one in the evening. Please avoid “gummy” vitamins as these do not contain iron.
or One Daily Plus Iron Vitamin Small easy to swallow vitamin for those patients not liking the taste of the chewable vitamins.
- Take one tablet two times a day.
• 500 mg of calcium citrate with vitamin D taken three times per day for a total of at least 1500 mg per day.
This should be taken two hours away from iron supplements (including the iron in prenatal vitamins) to avoid interference with iron absorption. DO NOT take calcium that is calcium carbonate as it is not readily absorbed after gastric bypass surgery. Please refer to the calcium handout for different products available on the market.
• 1000 mcg sublingual (under the tongue) Vitamin B-12 daily or 1000 mcg/1cc intramuscular shot every two – four weeks or 500 micrograms nasal spray into one nostril once a week (Nascobal) • Ursodiol 500 mg every day (If indicated) or Ursodiol 300 mg two times a day (Medicare patients if indicated)
Do not take if gallbladder removed or diagnosed with gallstones before surgery.
• 1500 – 5000 micrograms Biotin daily (optional for hair loss). **Coffee and tea inhibit the absorption of calcium and iron. Please consume these beverages 2 hours away from your vitamin and mineral supplements.
127
Follow up visits with your bariatric surgeon are very important. Your bariatric surgeon will check for vitamin/mineral deficiencies.
Additional supplements like Vitamin D and Iron, may be prescribed based on your lab results. Please consume:_________________________________________________
6 Months
128
Eating for healing – Regular foods The return to regular foods in an exciting time. Until this stage, your food choices have been limited. You have been slowly adding back in foods. Now, at six months after surgery, you are ready to move into the eating program you will keep for the rest of your life. Eat four small meals per day. Continue to eat four small meals per day. Try to keep a regular schedule for meals. It should take 20 – 30 minutes to eat each meal. Do now swallow until food is chewed to a paste consistency. Eat slowly until you are comfortable full, then stop. Limit your food intake to ½ cup to ¾ cup of food per meal. Choose foods based on their nutrient content Use your knowledge of how to read food labels to select healthy low-fat and low sugar foods. Select protein foods first. Keep striving to meet your protein goal. Eating enough protein will help you maintain your muscle tissue, keep your immune function working properly and help your body make healthy new cells. Fluids Drink at least 8 cups (64 oz) of water or other sugar-free beverages between meals. Avoid beverages that have alcohol, caffeine, and carbonation. Your stomach is small. A beverage may take up room you need for nutritious foods. Drink your fluids between meals. Be sure to do mindful eating. Pay careful attention to your body’s feeling of fullness. Stop eating when you start to feel full. It is better to have one place to eat (such as the kitchen table) and to avoid reading or watching TV while you eat. This helps you to enjoy your food, to concentrate on eating slower and to realize when your stomach is full.
Medicine All pills should be taken one hour before or after eating. Take one pill at a time. Exercise Try new exercise options such as yoga (both stretching and strengthening), spinning, running, exercise classes or sports such as tennis or golf. Walking shoes will need replaced at least every three to five hundred miles, or once a year. If heel shows compression, shoes need replaced.
129
Food Group
Foods Recommended
Foods Not Recommended
Beverages Sugar-free, non-carbonated, non-alcoholic, caffeine free drinks such as Crystal Light, Sugar-free Kool-Aid, Powerade zero.
Carbonated soft drinks, sweetened beverages such as Hi-C, fruit punch
Milk Skim, 1% or ½% milk, fat-free buttermilk, sugar-free cocoa, low sugar low-fat yogurt
Chocolate milk, whole or 2% milk, sweetened cocoa mixes, sweetened eggnog, sweetened condensed milk, regular fruited yogurt
Fruits and Juices All fresh, unsweetened canned and frozen fruit
Canned and frozen fruit with sugar added (or in syrup), candied fruit, juice
Vegetables All except “not recommended” foods
Glazed or candied vegetables
Starches/Breads ** Limit to 2 – 4 servings per day
Regular and reduced calorie breads, rolls, unsweetened cereals. Any low fat cream or broth-based soups. White or sweet potatoes, peas, rice, noodles, macaroni, spaghetti, dried beans and peas
Sweet rolls, sweet or iced breads, iced doughnuts, sweetened cereals, chips
Meats and Substitutes
All lean meat, fish, poultry, eggs or egg substitutes, low-fat cheeses, peanut butter, soy nuts/edamame
Fried and/or fatty meats, glazed meats
Fats Margarine, vegetable oils, mayonnaise, salad dressing, gravy, liquid or powdered non-dairy creamer.
**Limit to three servings per day
Saturated fats: butter, bacon, vegetable shortening, cream sauces, sour cream, cream cheese
130
Food Group
Foods Recommended
Foods Not Recommended
Desserts Sugar-free jello, sugar-free pudding
Frosted cake, pie, cookies, pastries, sherbet, regular pudding and jello, ice cream
Miscellaneous Artificial sweetener such as saccharin, Stevia, aspartame/Nutrasweet, acesulfame K/Sweet One, Splenda, sugar-free jelly/jam, all natural fruit spread, salt, pepper, spices, herbs, vinegar, cocoa powder, dill pickles, mustard, catsup, (in moderation), horseradish, sugarless gum, flavorings (such as extracts)
Sugar, honey, candy, regular jam and jelly, preserves, syrup, molasses, sweet pickles
131
Vitamin/Mineral Supplements At six months after surgery, please take:
• One prenatal vitamin daily or A chewable “Complete” vitamin two times a day. Take one in the morning
and one in the evening. Please avoid “gummy” vitamins, as these do not contain iron. or
One Daily Plus Iron Vitamin Small easy to swallow vitamin for those patients not liking the taste of the chewable vitamins.
- Take one tablet two times a day. • 500 mg of calcium citrate with vitamin D taken three times per day for a
total of at least 1500 mg per day.
This should be taken two hours away from iron supplements (including the iron in prenatal vitamins) to avoid interference with iron absorption. DO NOT take calcium that is calcium carbonate as it is not readily absorbed after gastric bypass surgery. Please refer to the calcium handout for different products available on the market.
• 1000 mcg sublingual (under the tongue) Vitamin B-12 daily or 1000 mcg/1cc intramuscular shot every two – four weeks or 500 micrograms nasal spray into one nostril once a week (Nascobal) • 1500 – 5000 micrograms Biotin daily (optional for hair loss).
**Coffee and tea inhibit the absorption of calcium and iron. Please consume these beverages 2 hours away from your vitamin and mineral supplements.
If Prescribed You May Now STOP Ursodiol after taking for 6 months
Follow up visits with your bariatric surgeon are very important.
Your bariatric surgeon will check for vitamin/mineral deficiencies.
Additional supplements like Vitamin D and Iron, may be prescribed based on your lab results. Please consume:_______________________________________________
9 Months
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Fiber Eventually after gastric bypass surgery you will notice a return in your appetite. At this time, we encourage you include fiber back into your diet. The way it works is easy to understand: When fiber mixes with liquids in your stomach, it swells and takes up more space, making you feel full. High fiber foods also move more slowly through your digestive tract than other foods, helping you feel fuller longer. It is also helpful in treating chronic constipation. The fiber in foods produces a soft, bulky stool that passes through the bowel more easily and shortens the time it takes the body to rid itself of waste products.
.
Dietary fiber is only found in foods of plant origin such as legumes (dried beans), whole grains (breads and cereals), and fruits, and vegetables. Information on the amount of fiber in a serving can be found on the food label. Food labels give the serving size and the amount of dietary fiber in that food item. Aim for 20 – 35 grams of fiber a day. Add fiber to your diet gradually and be sure to drink ~ 8 cups or 64 ounces of fluids a day.
Look here for the grams(g) of fiber in a serving size of a selected food item. This example is for one potato.
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Tips for Adding Fiber to Your Eating Plan • Check the Nutrition Facts on the labels and choose products with 4 or more grams
(g) Dietary Fiber per serving • Eat whole grain breads and cereals. Look for choices with 100% whole wheat, rye,
oats, or bran as the first or second ingredient. • Have brown or wild rice instead of white rice or potatoes. • Enjoy a variety of grains. Good choices include barley, oats, kamut, and quinoa. • Bake with whole wheat flour. You can use it to replace some white or all-purpose
flour in recipes. • Add dried beans and peas to casseroles or soups. • Eat fruits and vegetables with peels or skins on. • Compare food labels of similar foods to find higher-fiber choices. • Drink plenty of fluids. Set a goal of at least 8 cups per day. You may need even
more with higher amounts of fiber. Fluid helps your body process fiber without discomfort.
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Vitamin/Mineral Supplements
At nine months after surgery, please take: • One prenatal vitamin daily or A chewable “Complete” vitamin two times a day. Take one in the morning
and one in the evening. Please avoid “gummy” vitamins as these do not contain iron.
or One Daily Plus Iron Vitamin Small easy to swallow vitamin for those patients not liking the taste of the chewable vitamins.
- Take one tablet two times a day.
• 500 mg of calcium citrate with vitamin D taken three times per day for a total of at least 1500 mg per day.
This should be taken two hours away from iron supplements (including the iron in prenatal vitamins) to avoid interference with iron absorption. DO NOT take calcium that is calcium carbonate as it is not readily absorbed after gastric bypass surgery. Please refer to the calcium handout for different products available on the market.
• 1000 mcg sublingual (under the tongue) Vitamin B-12 daily or 1000 mcg/1cc intramuscular shot every two – four weeks or 500 micrograms nasal spray into one nostril once a week (Nascobal) • 1500 – 5000 micrograms Biotin daily (optional for hair loss).
**Coffee and tea inhibit the absorption of calcium and iron. Please consume these beverages 2 hours away from your vitamin and mineral supplements.
Follow up visits with your bariatric surgeon are very important. Your bariatric surgeon will check for vitamin/mineral deficiencies.
Additional supplements like Vitamin D and Iron, may be prescribed based on your lab results. Please consume:______________________________________________
1 Year
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Weight Loss Plateaus What is a plateau? The rate of weight lost after surgery is depends on many factors. These factors include gender, age, exercise level, caloric intake, muscle mass and the amount of excess weight to lose.
There may be times when the scale does not decrease for a few days or even a few weeks. This can be very discouraging. When the scale does not decrease for a long period such as a month, it is called a plateau.
Medical science cannot always explain why plateaus occur. Your body may be simply adjusting to the chemical and biological changes that occur during weight loss. Even though you may not be losing pounds during a plateau, your weight may be redistributing itself. Many people notice their clothes are fitting better, they feel “lighter”. It is possible to lose inches without losing pounds. You may want to measure your progress by tracking body measurements, especially hips, thighs, and waist.
Exercise affects plateaus When you begin to expand your exercise program, your weight loss may actually slow down initially. This may be because you are adding muscle tissue. Muscle weighs more than fat. Muscle also requires more water to function than fat tissue does, which means you see a slight increase in water weight.
Exercise and activity are important for your overall weight loss. You not only burn calories by increase your overall metabolism with exercise. You should include exercise as a part of your healthy lifestyle.
If you notice your weight loss has reached a plateau and you are not at your goal weight yet:
Make sure you are following the nutrition program • Eat four meals per day, no grazing. • Choose foods with 5 grams of sugar or less per serving • Choose foods with 3 grams of fat or less per serving.
Exercise • Start or continue with regular exercise • Include aerobic exercise such as swimming, biking or walking.
At times, weight loss may seem like a slow process. This can be especially true during a plateau. Take a step back and look at your continued weight loss over time. Congratulate yourself on your progress so far.
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The Eight Rules of Weight Loss
There are eight rules that we have found helpful for weight loss success. All successful patients who have had the gastric bypass have these things in common.
1. Consumption of an adequate amount of liquid, preferably water. You shouldconsume a minimum of 1 ½ - 2 liters of liquid each day. This can only bedone slowly, sipping fluids throughout the day. Never drink more than twoounces of liquid over a 10 – 15 minute period. On very hot or humid days, orwhen exercising, you should drink additional glasses of water. This isnecessary in order to prevent dehydration.
2. Only eat at mealtimes. Between meals grazing on small amounts of foodthroughout the day will decrease your weight loss.
3. Your primary source of nutrition should be protein.
4. Never drink liquids when eating solid foods. Liquids should be avoided for aperiod of 30 minutes before and 30 minutes after eating meals.
5. Avoid foods and liquids that contain sugar. Sugar may cause dumpingsyndrome in patients who have had the gastric bypass procedure. Dumping,in short, is when sugars go directly from your stomach pouch into the smallintestine causing a racing heart, nausea, abdominal pain and diarrhea.
6. Stop eating and drinking when you begin to feel full. Listen to your body’ssignals. Do not look at the food that is left on your plate. Overfilling yourstomach pouch will cause your pouch to stretch and may prevent weight losssuccess or cause long-term problems.
7. It is essential that you have a regular exercise program. Our researchindicates that this will increase your overall weight loss by 12% in sixmonths. The first recommendation for aerobic exercise was at a moderateintensity. As you lose weight, consider increasing intensity up to range of 70– 80% of age adjusted maximum, with primary care physician’s approval.
8. Attend support group meetings and workshops. They will help you stayfocused and motivated and help you work through the changes that weightloss brings.
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Vitamin/Mineral Supplements
At one year after surgery please be sure you are taking: • One prenatal vitamin daily or A chewable “Complete” vitamin two times a day. Take one in the morning
and one in the evening. Please avoid “gummy” vitamins, as these do not contain iron.
or One Daily Plus Iron Vitamin Small easy to swallow vitamin for those patients not liking the taste of the chewable vitamins.
- Take one tablet two times a day.
• 500 mg of calcium citrate with vitamin D taken three times per day for a total of at least 1500 mg per day.
This should be taken two hours away from iron supplements (including the iron in prenatal vitamins) to avoid interference with iron absorption. DO NOT take calcium that is calcium carbonate, as it is not readily absorbed after gastric bypass surgery. Please refer to the calcium handout for different products available on the market.
• 1000 mcg sublingual (under the tongue) Vitamin B-12 daily or 1000 mcg/1cc intramuscular shot every two – four weeks or 500 micrograms nasal spray into one nostril once a week (Nascobal) • 1500 – 5000 micrograms Biotin daily (optional for hair loss).
**Coffee and tea inhibit the absorption of calcium and iron. Please consume these beverages 2 hours away from your vitamin and mineral supplements.
Follow up visits with your bariatric surgeon are very important.
Your bariatric surgeon will check for vitamin/mineral deficiencies. Additional supplements like Vitamin D and Iron, may be prescribed based on your lab results. Please consume:_________________________________________________
Vitamins / M
inerals / Protein /Lactose Intolerance
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Vitamin/Mineral Supplements for Life Vitamins and minerals are an important part of the gastric bypass diet. It is necessary to take supplements for the rest of your life to prevent vitamin and mineral deficiencies. Continue to take your vitamin and mineral supplements:
• One prenatal vitamin daily or A chewable “Complete” vitamin two times a day. Take one in the morning
and one in the evening. Please avoid “gummy” vitamins, as these do not contain iron.
or One Daily Plus Iron Vitamin Small easy to swallow vitamin for those patients not liking the taste of the chewable vitamins.
- Take one tablet two times a day
• 500 mg of calcium citrate with vitamin D taken three times per day for a total of at least 1500 mg per day.
This should be taken two hours away from iron supplements (including the iron in prenatal vitamins) to avoid interference with iron absorption. DO NOT take calcium that is calcium carbonate, as it is not readily absorbed after gastric bypass surgery. Please refer to the calcium handout for different products available on the market.
• 1000 mcg sublingual (under the tongue) Vitamin B-12 daily or 1000 mcg/1cc intramuscular shot every two – four weeks or 500 micrograms nasal spray into one nostril once a week (Nascobal) • 1500 – 5000 micrograms Biotin daily (optional for hair loss).
**Coffee and tea inhibit the absorption of calcium and iron. Please consume these beverages 2 hours away from your vitamin and mineral supplements.
Follow up visits with your bariatric surgeon are very important. Your bariatric surgeon will check for vitamin/mineral deficiencies. Additional supplements like Vitamin D and Iron, may be prescribed based on your lab results. Please consume:____________________________________________
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Calcium
Calcium and Vitamin D are important nutrients for keeping our bones strong. Calcium Citrate is the most absorbable form of calcium following gastric bypass surgery. Vitamin D plays a significant role by helping our bodies absorb calcium. When choosing calcium supplements make sure they are calcium citrate based and contain Vitamin D. Calcium is best taken in divided doses of no more than 600 mg at a time, and should be taken separately from iron supplements to avoid interference with iron absorption. When you do not absorb enough calcium from the food and supplements that you eat, your body takes calcium out of your bones and teeth. In eight to twelve years, the teeth will begin to crumble and you will be prone to fractures. It is very hard for your body to put the calcium back into the bones and teeth. Therefore, the only efficient way to avoid problems is to religiously take your supplements. Chewables:
Product Calcium (mg)
per unit
Vitamin D (IU)
per unit
Amount per day for 1500
mg
Where available
Bariatric Advantage Calcium Citrate Chewy Bites
500 mg 500 IU 3 per day (1 chew 3 times/day)
ProMedica Home Medical Equipment Bariatricadvantage.com Jaks Pharmacy- Bowling Green, Ohio
Celebrate Soft Chews- Caramel, Chocolate or Berry
500 mg 500 IU 3 per day (1 chew 3 times/day)
ProMedica Home Medical Equipment Celebratevitamins.com
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Liquid:
Product Calcium (mg)
per unit
Vitamin D (IU)
per unit
Amount per day for 1500
mg
Where available
Wellesse Calcium and Vitamin D
500 mg 500 IU 3 TBSP (1 TBSP 3 times/day)
ProMedica Home Medical Equipment Meijer’s Wal-Mart Rite Aid Walgreens
Tablets:
Product
Calcium
(mg) per unit
Vitamin D (IU)
per unit
Amount per day for 1500 mg
Where available
Citracal Maximum
315 mg 250 IU 5 caplets (2 caplets 2 times/day + 1 caplet 1 time/day)
Grocery stores and drug stores
Citracal Petites
200 mg 250 IU 7 ½ tablets (2 ½ tablets 3 times/day)
Grocery stores and drug stores
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Iron Iron helps carry oxygen throughout your body. The United States Recommended Daily Allowance (USRDA) for iron is 10 milligrams for males and 18 milligrams for females. After your surgery, your iron level may become low. This is because you may not be able to get enough iron from the foods that you eat. Therefore, your iron level will be checked often. If you are found to have a low value, there are steps you can take to help correct it.
• Make foods rich in heme-iron a priority at meal times. There are two types of iron in foods, heme and nonheme iron. Meat, poultry, and fish contain heme iron, which is more easily absorbed by the body than nonheme iron. Nonheme iron is found mainly in plant foods, such as breads and vegetables.
• Take a look at your multivitamin. Your doctor will evaluate it to see if you need a higher iron-containing vitamin.
• If your vitamin is relatively high in iron, you may need to add a separate iron supplement. Options include: One pill Ferro-Sequel two times per day (100 mg elemental iron) 324 mg Ferrous Fumarate one time per day (106 mg elemental iron)
• Brand names: Feostat, Ferrets, Hemocyte, Ircon, Nephro-Fer, Femiron, Fumasorb, Ferrimin 150, Ferrocite
325 mg Ferrous Sulfate two times per day (130 mg elemental iron) Bariatric Advantage chewable 60 mg iron two times per day (120 mg
elemental iron)
• Take your iron supplements on an empty stomach to help increase absorption. Avoid foods that hinder iron’s absorption; such as coffee, tea and bran; for at least two hours before and after taking iron supplements.
• Consume Vitamin C at the same time as your iron containing foods and supplements to increase the absorption of iron. Foods high in vitamin C include citrus fruits such as oranges and grapefruit, cantaloupe, peppers, broccoli, tomatoes, and strawberries.
• Iron supplements should be taken separately from calcium supplements to
avoid interference of absorption.
• Constipation is a common side effect when taking iron supplements. You can decrease this side effect by increasing your fluid and fiber intake. You may also wish to take a daily stool softener.
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• Deficiency usually occurs in young women as a result of menstruation. • The main consequence of iron deficiency is anemia – that means lack of red
blood cells. • People who are anemic feel tired and sluggish. Dizziness or light-headedness
can occur, especially when you stand. • Mild deficiency can be treated with the pills discussed above. • Severe deficiency can be treated by intravenous infusions of iron usually with
a medication called Venofer.
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Vitamin B-12 (Cyanocobolamine) Vitamin B-12 helps the body produce new cells. The United States Recommended Daily Allowance (USRDA) recommends 3 mcg (micrograms) per day. Animal foods are good sources of vitamin B-12. It is also found in some plant foods.
Absorption of Vitamin B-12 Vitamin B-12 requires intrinsic factor, a substance produced in the lower part of the stomach, for absorption. Although food no longer passes through this section of the stomach, intrinsic factor meets up with vitamin B-12 in the small intestine. This change in the process is most likely less efficient than before, resulting in less vitamin B-12 absorption.
Vitamin supplement We recommend 1000 mcg vitamin B-12 sublingually every day. Sublingual is put under the tongue and is absorbed directly into the blood stream. Intrinsic factor is not needed for sublingual absorption.
You may also do a 1000 mcg intramuscular shot every two – four weeks instead. The frequency of the shot depends on lab results.
A third option is a nasal spray, Nascobal 500 micrograms – one spray into one nostril once a week.
Deficiency Lab tests will determine if you are receiving enough vitamin B-12. Vitamin B-12 injections will be given every two weeks if lab results indicate that you are below normal levels. A prolonged vitamin B-12 deficiency can result in permanent nerve damage- permanent, sometimes severe pain in the legs.
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Vitamin D Vitamin D is found in many foods such as fish, eggs, fortified milk, and cod liver oil. The sun also contributes significantly to the daily production of vitamin D, and as little as 10 minutes of exposure is thought to be enough to prevent deficiencies in fair skin people. Vitamin D is important for bone health. Deficiency In adults, vitamin D deficiency can lead to osteomalacia. This results in muscular weakness in addition to weak bones. People who are obese are at increased risk for vitamin D deficiencies. One study revealed that 99% of obese people were vitamin D deficient before undergoing any weight loss procedure. If you are diagnosed with a vitamin D deficiency you will be put on vitamin D supplements.
• For a very low level you will be given a prescription for 50,000 international units of Vitamin D once or twice a week for three months.
• If your level is moderately low you will be given 1,000 – 10,000 international units daily for three months.
These supplements are in addition to your calcium with vitamin D supplements.
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Protein Protein is important for everyone, but it is especially important for those who have had weight loss surgery. Protein is essential for healing after surgery. It is also needed to decrease muscle mass loss during rapid weight loss. Lack of protein in your diet may result in poor healing, hair loss, and an overall decrease in energy.
Protein needs vary from person to person as well as type of surgical procedure, open versus laparoscopic. Since you will be consuming smaller meals after surgery, it is important to make wise food choices. You will need to choose foods high in protein, such as meat and dairy products. Try to include one serving of these at each meal and snack. Your goal is to consume at least 65 – 75 grams of protein per day. The nutrition label, which is printed on all packaged foods, will tell you exact protein content.
Look here for the grams of protein in a serving size of
a selected food item.
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Listed are various examples to help you make wise choices. Food/Beverage Serving Size Protein Calories
MEAT, FISH, POULTRY Lean ground sirloin 3 oz 21 grams 230 Roast 3 oz 19 grams 200 Pork Chop 3 oz 18 grams 129 Red snapper 3 oz 14 grams 38 Shrimp, boiled 3 oz 21 grams 85 Tuna, canned in water ½ cup 28 grams 90 Salmon 3 oz 20 grams 125 Perch 3 oz 22.5 grams 100 Flounder 3 oz 32 grams 100 Lobster ½ cup 10 grams 43 Haddock 3 oz 16.5 grams 95 Baked ham 3 oz 26 grams 130 Chicken, dark 3 oz 26 grams 150 Chicken, white 3 oz 28 grams 137 Turkey 3 oz 25 grams 120 Peanut butter, creamy 1 TBSP 4 grams 95 STARCHES Fat-free refried beans ½ cup 9 grams 135 Barley ½ cup 13 grams 100 Kidney beans ½ cup 7 grams 110 SOUPS Bean, pea or lentil soup ½ cup 4 grams 30 Minestrone soup ½ cup 3 grams 30 MILK, CHEESE, YOGURT
Cottage cheese ½ cup 14 grams 80 Skim mozzarella cheese 1 oz 6 grams 80 Fat-free American cheese 1 slice 7 grams 35 Fat-free shredded cheddar ¼ cup 9 grams 35 Skim milk ½ cup 4 grams 45 Yogurt, light ½ cup 4 grams 45 Greek yogurt, light ½ cup 10 grams 60 Egg, large size 1 egg 7 grams 65 Egg white 1 egg white 3 grams 20 Egg substitute ¼ cup 7 grams 50 Tofu ¼ cup 5 grams 95
1 oz = 2 Tbsp 2 oz = ¼ cup 3 oz = 1/3 cup 4 oz = ½ cup 8 oz = 1 cup
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Lactose Intolerance
Lactose is the type of sugar in milk and dairy foods. To digest lactose, people need to have a specific enzyme in the small intestine. This enzyme is called lactase. After the Roux-en Y gastric bypass you have trouble digesting lactose. You may have diarrhea, bloating, stomach pain, and gas symptoms. Limiting or avoiding milk and dairy products can help ease these symptoms. Taking lactase supplements before having milk and dairy products may also help. Foods recommended:
Lactose free milk and nondairy foods
Lactose-free milk such as Lactaid. Unsweetened Almond milk or light soy milk.
Low-lactose dairy foods
Some people with lactose intolerance can safely eat dairy foods that contain a little lactose (less than 1 gram lactose per serving). You may wish to try:
• 1 – 2 ounces aged cheese, such as Swiss, cheddar or parmesan • 2 tablespoons cream cheese • ⅓ cup cottage cheese • ½ cup ricotta cheese
Try these foods one at a time, in small amounts. Stop eating them if symptoms return or get worse.
Lactase enzymes Lactaid Fast Act chewables can be taken any time you consume dairy products.
Eating O
ut
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Eating Out Making healthy choices when dining out is easy once you get the hang of it. Here are some tips to help you along the way:
• Plan ahead. Consider the place where you will be dining and think aboutwhat you will order before you get there. If high fat or high sugar foodstempt you, avoid looking at the menu.
• Get “known” for eating healthy. Your friends and relatives will then makea greater effort to agree to eat in restaurants that offer those foods.
• Choose restaurants with low-fat or low sugar options.• Avoid “all you can eat” restaurants.• Avoid situations where high fat or high sugar foods will tempt you.• Look for these words in the menu description: steamed, poached, in
broth, in its own juice, garden fresh, roasted and grilled.• Make your choices and order first.• Try ordering two side dishes or appetizers rather than an entire meal. For
example: shrimp cocktail and a side salad; chili and a bowl of steamedvegetables, vegetable beef soup and a grilled chicken breast.
• Enjoy socializing. Focus on your family and friends more than the food.• Share your meal with someone else.• Carry sugar-free mints or candies with you for a sweet treat after your
meal.• Eat slowly.• Leave food on your plate – a little or a lot.• To give the appearance of eating more than you have, push the food
around on the plate.• Take home extras for another meal or two.• Order food without sauces and dressings or ask for them on the side.
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Size Up Your Servings Measure food portions so you know exactly how much food you are eating. When a food scale or measure cups are not handy, you can still estimate your portions using the following.
3 ounces of meat is about the size and thickness of a deck of playing cards or an audiotape cassette.
A medium apple or peach is about the size of a tennis ball.
1 ounce of cheese is about the size of four stacked dice.
1 cup of mashed potatoes or broccoli is about the size of your fist.
1 teaspoon of butter or peanut butter is about the size of the tip of your thumb.
1 ounce of nuts equals one handful.
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Choose Avoid
Mexican • Lean chicken, lean beef, shrimp orvegetable fajitas with salsa
• Flour or corn tortillas (baked)• Gazpacho• Chicken tostada or chicken
enchilada (plain)• Salad bars (avoid high fat
toppings)
• Fried tortillas or tortilla chips• Extra cheese• Sour cream and guacamole• Refried beans and fried rice• Milkshakes made with whole milk
or ice cream
Fast Food • Plain hamburgers (withoutmayonnaise based sauces &cheese) with only bottom bun
• Small chili without cheese• Grilled chicken sandwiches
without high fat sauces and onlythe bottom bun
• Sandwiches made with lean roastbeef, turkey or ham (no mayo, oilor extra cheese) without the toppiece of bread
• Cheeseburgers, double burgers• French fries, potato chips• Fried/breaded fish or crispy chicken
sandwiches• Apple pies (even baked), ice cream• Sandwiches made with salami,
bologna or pastrami
Tips for Restaurant Eating
Choose Avoid
Asian • Lightly stir-fried or broiledchicken or fish dishes
• Lightly stir-fried or steamedvegetable dishes
• Tofu items (not fried)• Fortune cookies
• Egg rolls, fried rice, fried noodles,Lo Mein dishes
• Breaded and deep fried meats• Dishes with lobster sauce• Chicken wings• Crab puffs
Italian • Chicken dishes with tomato, clamor garlic sauce
• Minestrone soup• Salad with olive oil and vinegar
• Dishes with cheese or cream sauces• Breaded meats• Sausage• Garlic bread• Cheesecake, ice cream or pastries
Measuring S
uccess
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Measuring Success How do you measure success? There are many definitions of success. For one person, it may be a decrease in medications for diabetes. For another, it may be the ability to ride the rides at Cedar Point. During follow-up visits, we look to see if you are losing weight at the expected rate. The following graph shows you a typical weight loss trend.
You may measure your weight loss in several ways. The most common is to weigh yourself on a scale. However, their may be periods where this can be frustrating, so add at least one more method to help you see the wonderful changes. You could:
• Take measurements of your chest, hips, thighs and arms on a monthly basis. • Take photographs at regular intervals • Document the decrease in medications • Make a list of all the things that are getting easier to do (such as tying shoes) • Try on a piece of clothing that was tight at your heaviest weight.
Pregnancy A
fterB
ariatric Surgery
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**Pregnancy after Bariatric Surgery
Many women plan to become pregnant after bariatric surgery for weight loss. Severely overweight and obese women have a greater risk for hypertension, diabetes, high birth weight babies and other complications. Weight loss has been shown to reduce these risks. Timing a pregnancy after bariatric surgery After bariatric surgery, a woman should wait until her weight loss is completed and she is maintaining a steady weight before conceiving a child. We do not recommend becoming pregnant for 18 months to two years after surgery. A woman who does become pregnancy before the 18 months to two-year period should contact her bariatric surgeon and obstetrician immediately. Pregnancy within this period may entail higher risks for a low birth-weight baby and miscarriage. Weight gain Weight gain during pregnancy is about 15 – 25 pounds. Nutritional Needs A pregnant woman who is 18 months to two years out from having bariatric surgery has similar needs as a pregnant woman who has not had surgery. Depending on the amount of food you are able to eat at each meal, you may need to consume 6 small meals to obtain adequate calories for baby’s growth. It is important to obtain adequate vitamin/minerals. We want you to take:
• One prenatal vitamin per day • One chewable multivitamin with iron per day. • 500 – 600 mg of calcium citrate with vitamin D three times per day. • 1000 mcg sublingual (under the tongue) Vitamin B-12 daily or 1000 mcg
intramuscular monthly shot. • DHA/ARA supplement if desired (is available as part of prenatal vitamins)
Alcohol Pregnant women should avoid alcoholic beverages. Alcohol has been linked to mental retardation, learning disabilities, and birth defects.
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Caffeine Excessive amounts of caffeine may increase the chances of low birth weight babies. Also, caffeine can be passed into the breast milk of lactating mothers. It is advisable to take in only a small amount of caffeinated products such as coffee, tea, and some soft drinks. Food Safety Pregnant women may be more at risk to certain food-borne illnesses. Therefore, it is best to avoid raw or undercooked meat, poultry, eggs, and seafood. Also, swordfish, king mackerel, tilefish, and shark may contain toxic contaminants and should be avoided. Washing hands and cooking surfaces, refrigerating foods promptly, and cooking foods completely ensures further food safety. Listeria Listeria can cause miscarriages and other problems during pregnancy. To avoid listeria contaminated foods please:
• Do not eat hot dogs, luncheon meats, bologna, or other deli meats unless they are reheated until steaming hot.
• Do not drink raw (unpasteurized) milk. • Do not eat soft cheese such as Feta, queso blanco, queso fresco, Brie,
Camembert cheeses, blue-veined cheeses, and Panela unless it is labeled as made with “pasteurized milk”.
Glucose Tolerance Test Please be advised that if you do experience dumping syndrome with a high sugar content of food you will not be able to have the glucose tolerance test done. Other methods should be used to test your glucose tolerance.
Forms to S
ign
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Weight Loss Surgery Pre-Operative Quiz
The answers you give to these questions will help the bariatric staff know how much you know about bariatric surgery. Any questions you answer wrong will be reviewed with you. Please circle True or False for each of the statements.
1.) There is more than one weight loss surgery offered for patients with obesity.
True False
2) A few months after surgery, you do not have to worry about your diet and can eat whatever you want.
True False
3) You are certain to permanently lose weight after surgery. True False 4) This surgery will commit me to a life-long need for follow up visits and blood work.
True False
5) The benefits of bariatric surgery depend on how well I follow the bariatric program recommendations for lifestyle change.
True False
6) After weight loss surgery, I need to exercise in order to have the greatest amount of weight loss.
True False
7) After weight loss surgery, I will need to take vitamin/mineral supplements for the rest of my life.
True False
8) After the Roux-en-Y surgery, I must avoid non-steroidal anti-inflammatory drugs (Motrin) and tobacco products (smoking) which can cause ulcers.
True False
9) Weight loss surgery will cure my depression. True False 10) Bariatric surgery is a simple procedure without risk. True False
__________________________________________ _________________________ Patient’s Signature Date/Time _______________________________________ ________________________ Bariatric Staff’s Signature Date/Time
