€¦ · Web viewGastric Sleeve and Gastric Bypass do not constitute a cure for morbid obesity; they are great tools that we need to teach you how to apply. The most important part

Copyright© 2014 Dr. Jose T. Luna

NutritionalGuidelines AfterBariatric Surgery


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Introduction

In order to succeed in the weight loss process and maintain your perfect weight you will have to change your nutritional lifestyle permanently. The goal of bariatric surgery is to help you change your eating habits in order to promote a healthy loss of weight and it`s maintenance.Surgery itself is only a part of treatment. Gastric Sleeve and Gastric Bypass do not constitute a cure for morbid obesity; they are great tools that we need to teach you how to apply. The most important part of treatment is your adherence to a healthy diet. This is what determines your ability to keep your weight under control – following a diet after the surgery as well as for the rest of your life.This diet is different from any other diet that you might have followed in the past. It will progress through a series of stages; you will be eating much smaller portions compared to what you are probably used to, and you will have to eat and drink regularly according to the schedule. Nevertheless, you will have to learn to listen to your body in order to determine whether it got in a starvation mode. If you overeat it can cause stomachache and/or vomiting. After surgery most of the patients get full by eating very small portions. Eventually you will learn when to stop in order to get full and not overdo it. A permanent change of eating habits is necessary in order to insure both an adequate nourishment and successful weight loss on the long run. The surgery will help you make the changes. If your body does not get an adequate nutrition, it becomes vulnerable to fatigue, depression, infections and other diseases that can affect your organism, compromise your health, and even put your life in danger.It is important not to be obsessed with the calorie or nutritional value, since it is not a regular diet.The key is to get well-nourished through a well-balanced diet. The surgery is going to restrict the amount of food one can eat, but not the choices you make.


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It is very important to attend all the appointments with your nutritionist and surgeon. Patients that keep their regular meetings with the doctors are more successful in losing weight and staying healthy.


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What to expect

Common Symptoms Post Surgery• Nausea and Vomiting


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You may experience nausea the first day after surgery. Pay attention to the precise timing of symptoms and identify the reason, thus avoiding discomfort in the future. The most common cause of nausea and vomiting is accelerated food intake, including liquids. Make sure to chew very slowly and thoroughly when you start the solid food stage; lack of proper chewing is a common cause of these symptoms. If you are experiencing discomfort while progressing from one stage to another, continue with the previous stage without progressing for 3-5 days until you feel more confident to move on.

• Gastro Esophageal Reflux Reflux is the partial return of stomach contents into the esophagus, this symptom is typical for gastric sleeve patients and appears when you eat food or drink rapidly. To prevent gastro esophageal reflux you have to drink and eat staying straight, avoid lying down immediately after eating as this promotes reflux; if you want to rest you have to wait for at least half an hour after your last intake to prevent symptoms. This symptom is rare for Gastric Bypass patients, but it can also appear.

• Dumping Syndrome Dumping Syndrome is unique to patients undergoing gastric bypass. High intake of carbohydrates and simple sugars is the reason for this phenomenon that causes several unpleasant side-effects. The intestine gets a load of carbohydrates that causes a cascade of hormonal changes, and this in turn causes diarrhea, abdominal pain, nausea, dizziness, tachycardia, fainting, sweating, and fatigue. These symptoms appear within the first half hr. after a high sugar intake. A small percentage of patients have this syndrome later for up to 3 hours after ingestion, these patients tend to develop hypoglycemia, sweating, tachycardia, and fatigue. You should avoid high intakes of sugars at one time; if these symptoms appear call your doctor.

• Dehydration


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Besides the substantial restriction because you have decreased your stomach capacity, there is an inflammatory process in the gastric remnant tissue that reduces even more the ability to meet your nutritional requirements. The inflammatory process is more noticeable in the first weeks after surgery, and there is a possibility of dehydration if you do not intake the appropriate amounts of liquids. Patients who live in hot climate are under increased risk of getting dehydrated and their water needs are even greater. Try to drink lots of liquids, small portions but frequently; this will prevent early satiety, nausea and vomiting. Learn to notice satiety and stop fluid intake once feeling full; continue when satiety has ceased.

• Constipation Drastic changes in your diet will affect your digestive habits; the absence of need to defecate in the first weeks is common, remember that your diet is based on full liquids for this short period of time and no solid matter may form along the intestine. Normal digestive habits return in three weeks post-op. Consult your doctor if symptoms persist.

• Diarrhea You received broad-spectrum antibiotics during hospitalization and in the first week post-op. The optimal functioning of our gut bacterial flora is compromised by the presence of these antibiotics; this also affects the optimal intestinal function. Taking Lactobacillus Prophylaxis prior and after surgery reduces the risk of diarrhea in the postoperative period.

• Fatigue It is one of the most common symptoms after a bariatric procedure. Remember that your caloric intake drastically decreases, therefore our body energy needs will not be met and you will feel tired early in the day. It is common for this symptom to last for 1–2 months and you should regain vitality after this period.

• Lactose Intolerance


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This phenomenon is typical for patients undergoing gastric bypass: changes in bacterial flora to subsequent exposure to antibiotics produce alterations in the metabolism of lactose. Avoid dairy products that cause symptoms such as constipation, flatulence and abdominal pain. Try to use Lactobacilli supplementation and consult your physician.


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Dietary Evolution

Stage 1: Clear Liquids Days 1 to 3 Post-op

The day after surgery you will be put on a clear liquid, non-carbonated and sugar-free diet. You will be required to drink at least 64 ounces (2 liters) of fluids per day in order to avoid dehydration. It might be necessary to drink even more during the hot weather. In the first few days drink your liquids with calm until you determine the amount of fluids that can be tolerated. Your first consumption will be ground ice only; make sure to drink it slowly as it will be your first intake experience after the surgery.


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Begin with little sips. Avoid using a straw; this will prevent gas entering into your stomach. The amount of clear liquids you are allowed to drink is not limited. At the beginning it will be easier to tolerate water rather than juices. If you take medication in a form of pills they will have to be crushed or changed to a liquid form.

Water Ground ice Jell-o sugar free Isopure protein cocktails with electrolytes and zero carbohydrates Gatorade low in sugar

Stage 2: Full Liquid Diet Days 3 to 17 Post-op

During the first two weeks after your discharge from the hospital you will have to drink liquids only. Solid foods could cause pressure on the sutured line of the stomach and stretch the new stomach pouch. This might cause vomiting and pain. Liquid diet will also give enough time for the stomach tissue to heal. To insure an adequate intake of protein, calcium and other nutrients, the liquid diet has to be based on foods that contain protein.Calorie daily intake: 500 – 600 CalType of exercising: walkingTime: 30 minutesCalorie expenditure with exercise: 50 – 100 Cal

Food Allowed

Liquids included in Stage 1

Chicken Broth

Fish Broth Greek Yoghurt

Protein Cocktail Low fat milk and/or lactose free milk


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Recommendations1. Use your kitchen scales to weigh and measure food portions.2. Take 100g (3.5 ounces) of chicken/fish in its own broth and blend it.

After thorough blending strain it and remove the solids, consume pure liquid. This type of processing will make the nutrients contained in chicken/fish remain in its prepared broth.

3. Start your protein supplement; remember that your daily need of protein is 70–100 g.

4. Consume approximately 64 ounces (2 liters) of fluids daily.5. Have a minimum of 5 liquid meals per day (including the protein

supplement).6. Start taking your vitamins, preferably chewable and/or liquid.

Example of a Meal Schedule

Breakfast Snack Lunch Snack Dinner


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* 4 oz. Greek Yogurt

* Protein shake* Multivitamins

*Protein shake

*B-complex (Sublingual or liquid)

*Jell-o with protein added,

unflavored

*Chicken broth 3.5 oz. (100 g of solids blended and strained)*Fish broth,

tilapia 3.5 oz. (100 g of solids

blended and strained)* Vit. D + calcium

*Protein shake *Jell-o with protein

added, unflavored

*Chicken broth 3.5 oz. (100 g

of solids blended and

strained)Fish broth,

tilapia 3.5 oz. (100 g of solids

blended and strained).

*Greek Yogurt

Stage 3: Blended or Pureed Diet Days 17 to 30 Post-op

At this point you can start eating pureed and soft foods that require minimum chewing. Solid food is not allowed at this stage; slowly, day by day start introducing moist and soft textured foods into your diet. This stage includes all kinds of fluids from the previous stage: clear and

Notes

1. * An asterisk implies one option, it doesn`t mean that all of the offered options have to be applied at the same time.

2. Chicken or fish broth has to be made from 100g (3.5 ounces) of solids blended with 120 ml of prepared broth (liquid) and strained.

3. You are not obligated to finish the portion of broth if you cannot; remember that during the first post-op months your stomach tissue remains inflamed, so do not get discouraged, it is totally normal.

4. You can finish the meal later or have it as a snack.5. Do not forget to include your drinks 30 minutes before or after each meal.


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full liquids. Again preference will be given to the nourishment rich in protein, but low in sugar and fat. In a few more weeks after surgery the capacity of the new gastric pouch will increase. Stop eating as soon as you feel satisfied, and always eat foods rich in protein first.Calorie daily intake: 550 – 650 CalType of exercising: WalkingTime: 30 minutesCalorie expenditure with exercise: 50 – 100 Cal

Liquids from the stage 1 – 2 Pureed salmon Pureed tuna Pureed tilapia Scrambled eggs (no yolk) Bean broth (do not eat solid beans, only blended and

strained) Lentil broth (do not eat solid lentils, only blended and

strained) Cottage cheese Pureed salmon

Recommendations

1. During this stage food requires minimum chewing: scrambled eggs, cottage cheese etc.

2. Continue drinking liquids slowly as at stage 2; increase the amount to a minimum of 6 to 8 cups per day.

Food Allowed


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3. Drink protein supplement (also as an appetizer) between meals.4. Keep taking chewable or liquid vitamins. 5. Eat slowly, taking very little bites.6. Bread, rice, pasta, fruit and raw vegetables should not be

consumed during Stage 3.7. It is important to have a meal schedule. Keep a diary of what you

eat, use Bariatricapp in your advantage.8. If you do not feel hungry have only a few bites of food in order to

keep your nutritional schedule completed.9. Eat and chew slowly, beware of your limits.10. Stop eating once you feel full, you can finish your meal later.11. Do not force yourself to eat a whole dish at one time; your

stomach capacity is still considerably restricted.

Meal Calories Fat Carbohydrates Protein

Breakfast

4 oz. Greek Yogurt(DANONE brand

Greek Light)53 Cal 0 g 5.3 g 8 g


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Snack

Protein shake (1 scoop) Isopure brand,

unflavored110 Cal 0 g 0 g 26 g

Lunch

Tuna (Dolores brand, canned in water)

pureed 3.5 oz. (100 g)150 Cal 6 g 0 g 24 g

Snack

Bean soup(120 ml) 106 Cal 3 g 14.5 g 6 g

Dinner

Fish broth, tilapia 3.5 oz. (100 g blended in

120 ml of broth, strained)

131 cal 1.9 g 0 g 26 g

Total Calories500

Fat4.9 g

Carbohydrates19.8 g

Protein90 g


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This graphic shows that out of the total amount of calories 75% come from protein, 20% from carbohydrates and only 5% of calories come from fat.

Stage 4: Solid Food Days 30 to 60 Post-op


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You can start Stage 4 in 4 weeks after surgery assuming that you can tolerate foods from Stage 3 with no difficulty. If not stop progressing in your diet and continue Stage 3. As you are progressing to a normal diet, you will have to make your food choices very carefully. At this point it is safe to start experimenting with certain kinds of solid foods that have different textures. Make sure that what you eat is very tender and chew it thoroughly; you should be able to eat regular food now.It is important to eat slowly and chew every bite at least 20 times, until it feels pureed in your mouth. Stop eating once you feel full, as after 4 weeks post-op your stomach capacity restriction is still significant; remember that your stomach tissue is still in the healing process and can be somewhat inflamed, which causes certain restriction also.Continue eating small portions and always give priority to foods with high level of protein.Do not forget taking your multivitamins and protein supplements.

Calorie daily intake: 500 – 700 CalType of exercising: WalkingTime: 30 minutesCalorie expenditure with exercise: 50 – 100 Cal

Food Allowed

Salmon 3.5 oz ( 100 g) Tuna 3.5 oz ( 100 g) Tilapia 3.5 oz ( 100 g) Beans Egg White Chickpeas Lentils Turkey Breast Chicken Breast



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Breakfast

2 scrambled eggs (egg whites only, 40 g) 70 Cal 5 g 0 g 6 g

Snack

Protein shake (1 scoop )

Isopure unflavored105 Cal 0 g 0 g 26 g

Lunch

Salmon filet 3.5 oz. (100 g)

150 Cal 6 g 0 g 24 g

Snack

4 oz. of Greek Yogurt (OIKOS Greek) 90 Cal 1.5 g 12 g 8 g

Dinner

Tilapia fish broth (3.5 oz. or 100 g of fish

blended in 120 ml of broth)

131 Cal 1.9 g 0 g 26 g

TotalCalories

551Fat

14.4 gCarbohydrates

12 gProtein

90 g


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This graphic shows that out of the total amount of calories 66% comes from protein, only 9% from carbohydrates and 25% of calories come from fat.

Stage 5: Days 60 to 120 Post-op


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In 60 days post surgery you must increase your calorie rate. At this stage your wounds are healed enough to be physically more active. Depending on your individual characteristics and health status you will begin an exercise program focused on your cardiac training. In order to maintain an adequate calorie expense, you have to continue exercising in the same rhythm for at least 15 minutes, preferably 30 minutes. Along with the increase of your calorie rate, your food intake and nutritional needs will grow as well. As your food options became more various, now you can also increase the percentage of calories coming from carbohydrates, not forsaking though an adequate protein consumption of 70 – 100 g per day. This stage is indispensable for your metabolic balance: gradually your body starts adjusting, and increased physical activity will promote a stable, continuous and healthy weight loss. In those days when you are not physically active lower your carbohydrate intake; you can consume carbohydrates in the days of increased physical activity only.

Calorie daily intake: 600 – 750 CalType of exercising: walking, jogging, Zumba, rope jumping, running, riding bicycle. Time: 30 – 45 minutes in intervals of 15 minutesCalories expenditure with exercise: 100 – 250 Cal

Foods from the previous stages Whole eggs Dry cranberries Raisins Dates Strawberries Raspberries

Food Allowed


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Breakfast

2 scrambled eggs (egg whites only, 40 g) 70 Cal 5 g 0 g 6 g

Snack



Lunch

Sirloin grilled steak 3.5 oz. (100 g)

165 Cal 4.7 g 0 g 31 g

Snack

Nuts and peanuts(50 g)

203 Cal 28 g 8.9 g 9.7 g

Dinner



131 Cal 1.9 g 0 g 26 g

TotalCalories

727Fat

21.9 gCarbohydrates

37 gProtein

89 g


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From this diagram you can conclude that the amount of calories coming from carbohydrates increased. Note that although you consumed 89 gr of protein, it makes only 50% of the total amount of calories. The fact that the percentage of calories coming from fat is 29% doesn`t imply any health risk, as all the fats in this diet are healthy, with high contents of Omega -3, -6, -9 Fatty Acids.


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Stage 6: 4 to 12 Months Post-opAt this point you are entering in a new stage of your long journey to a new healthy life style. By this time you have already lost a significant percentage of the excess weight. The following months are indispensable for a continuous weight loss process, although there is a risk of regaining weight during the very last months of this stage. Weight regain might take place only if you do not follow your diet plan and indications regarding your physical activity. During these 8 months your weight loss process will slow down, but do not get discouraged. You will notice that while you haven`t lost much weight, your sizes went down, you will notice changes in your physical appearance, your neck will become thinner, your cheeks will deflate, your hips will get slimmer and your stomach will become smaller. If you follow your diet program and continue being physically active this stage will not constitute any difficulty for you.You will notice that your food intake ability has increased comparing to the first stages of your diet. This could make you return to your old nutritional habits that could cause a plateau in your weight loss process or even regaining of a few pounds by the end of this stage. Do not get frustrated, you still have time to correct mistakes and reach the goal. You will have an opportunity to increase the variety of food options, increase the amount of carbohydrates with complex sugars and avoid simple sugars. The consumption of carbohydrates will have to be limited and allowed only on the days of increased physical activity. You still need to continue your daily protein intake of 70 – 100 g, multivitamins, B-complex sublingual, calcium citrate + Vitamin D (Bypass patients only). These food supplements incorporated into your strict diet will provide you with adequate nourishment and satisfy your daily metabolic needs. You have already lost enough weight to increase your calorie rate and reach your daily goal of a balanced calorie intake and burning. If you have problems with your joints give preference to exercises that make less pressure on them, like swimming or riding bicycle; yoga can help increase your flexibility.Note that during Stage 6 the variety of foods has increased. Your diet includes fruit, greens and seeds; make it a habit to incorporate them in your meals daily but limit its intake when you are not physically active, especially fruits that contain lots of carbohydrates. Remember that the priority always belongs to the foods with high content of protein. Adding red meat to your diet is important at this stage, but you have to be very careful as it can cause certain discomfort especially during the first


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intake. It is recommended to start with ground beef from the sixth month on, since by this time your stomach will be better prepared.Calorie daily intake: 700 – 900 CalType of exercising: walking, swimming, jogging, Zumba, rope jumping, spinning, running, bicycle riding. Time: 30 – 60 minutes in intervals of 30 minutesCalorie expenditure with exercise: 200 – 350 Cal

Foods from the previous stages Red meat (6th month) Apple, banana, grapes Asparagus, broccoli, lettuce Peanuts, almonds, pecans Cereal, rice Pasta ( limited)


Food Allowed


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Breakfast

2 whole scrambled eggs 185 Cal 14 g 1 g 13 g

Snack



Lunch

Chicken breast3.5 oz. (100 g)

150 Cal 6 g 0 g 24 g

Snack

Dry cranberries and raisins 3.5 oz. (100 grs).

151 cal 0 g 37 g 0 g

Dinner



131 Cal 1.9 g 0 g 26 g

TotalCalories

722Fat

21.9 gCarbohydrates

38 gProtein

89 g

Stage 7. 12 - 24 Months Post-op

On this long path of dieting after the surgery you have come to a point


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when there is an ease of consuming food that seemed to be impossible to eat before, including the intake of alcohol and some types of junk food. It is quite common that at this point the patient has returned to old habits that do not contribute to general well-being, the increase of intake capacity tends to give confidence to get out of the routine and eat start eating junk food again. At this stage you have lost enough weight, the bariatric patient tends to lose between 50% - 70% of excess weight by this time. It is rare that a patient loses 100% of their excess weight, this will depend on the individual characteristics of the person, do not compare yourself with others, every individual is different and will have different results, remember this is not a competition. The key to continue weight loss process (if it is still required) is in following a healthy, simple and low carbohydrate diet, high in protein and moderate in fat. You’ve already lost enough weight and have been exercising for over a year, the new challenge of this stage is to increase caloric expenditure by increasing the time of your work out and by continuing the diet featured in the previous stages, taking into account that if your calorie expenditure is greater, the calorie intake has to increase accordingly.

Calorie daily intake: 900 – 1200 CalType of exercising: running, walking, swimming, jogging, Zumba, rope jumping, spinning, bicycle riding, muscle conditioning Time: 60 minutes in intervals of 30 minutesCalorie Expenditure with exercise: 300 – 500 Cal


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Secrets to Success

How you should eat

WHAT you are eating after the surgery is as important as HOW you are eating. The moment you sit down at the table you need to change your way of thinking: do not get distracted but focus on every bite, even in the way you chew.


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Avoid

• Eating fast • Using straw • Carbonated drinks • Beverages containing caffeine • Alcoholic beverages • Talking while eating • Fluid intake while eating • Eating while doing other activities • Skipping meals (your diet program) • Filling up your plate with food • Red meat in the first 4–6 months

New habits

• Chew 20–30 times per mouthful. • Acquire small plates, forks and spoons, this will limit the portions you can consume including child-sized. • Eat small portions and weigh them.


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• Keep a record of every meal you eat in Bariatricapp; this will help to have an objective control over your nutritional goals and how to accomplish them. • Cook your own food and measure the portions, this will help you have a specific idea of what you eat, keep a record of it in your application. • Look for foods allowed during each STAGE depending on their nutritional value, always seek the sources of significant amounts of protein. • Rest your body, it needs rest; sleeping from 7 to 8 hrs. daily helps to increase energy levels and promotes optimal recovery. • Set a time each week to weigh yourself; do not obsess over the scale. Weighing yourself weekly helps keep track of your surgical outcome, write it in your application.

Make plans • Plan your meals and make food choices days in advance. • Your diet plan starts with shopping for groceries, keep the pantry with the necessary food and have an inventory of your purchases. This will help to get a sense of the nutritional choices and avoid unnecessary purchases of food without nutritional value. • Cook your own food so that you are aware of the portions and quality of food.


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“The Plateau” The Plateau is a stage that occurs between the first and the second postoperative months, i.e. 30–60 days. It is characterized by the absence of weight loss, commonly lasts between 1–2 weeks. It is common for the patient to feel disappointed, to believe that the purpose of the procedure and nutritional education is lost. "The Plateau" is a part of the weight loss process and patient`s experience. Do not get discouraged, this stage is also characterized by the loss of sizes as you begin to notice changes in your body image.

Nutritional Supplements The amount of food you are able to consume will be insufficient to meet the needed nutritional requirements; therefore it must be compensated with nutritional supplements depending on the surgical procedure. The supplementary food needs after the gastric sleeve and the gastric bypass are different. It is recommended that the gastric sleeve patients continue taking their supplements for at least 2 years after the surgery, the supplementation for the gastric bypass patients is for life. Recent studies have shown that the pre- and post-op intake of lactobacilli decreases subsequent gastrointestinal symptoms, ask your doctor about the nutritional requirements and follow the rules according to these guidelines.

Supplement Gastric Sleeve Gastric Bypass


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Red Meats Red meat has to be avoided in the first 4–6 months post-op. Usually patients make attempts to eat red meat prior to this stage. In that case it is common to have abdominal pain, nausea and vomiting. We recommend starting with ground beef, as it is softer, easier to chew and less aggressive to the recently healed stomach. Alcohol It is important that you avoid alcoholic beverages until your stomach heals completely by the end of the first 6 months post-op. You should avoid all kinds of carbonated drinks including beer. Calorie levels in distilled liqueur like whiskey, vodka and tequila are high; this type of liquor can cause an upset stomach, nausea and vomiting. The gastric bypass patient is highly susceptible to the effects of alcohol after the surgery; because alcohol directly enters into your intestine, absorption is almost immediate, thus increasing toxicity in your body, not to mention that the side effects appear sooner and are more intense. The patient should be aware that the best decision is to avoid alcoholic beverages of any kind to prevent symptoms that caused discomfort.

Drugs

Chewable Multivitamin Yes Yes

B Complex (Sublingual) Yes Yes

Vitamin D + Calcium Citrate No Yes

Iron/ Zinc No Yes

Vitamin A, E No Yes


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If you take medication for previous health-related conditions, talk to your doctor about what type of treatment you are in. There are drugs that must be removed prior to your surgery enough time in advance to avoid complications. To maintain a low level of gastric acidity and in order to reduce gastritis and acid reflux symptoms after surgery, you should start with Omeprazole 20 mg every 12 hrs. during 1 month prior to the surgery and for 2 months after the surgery.


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Nutritional Follow Up

It is extremely important that you are aware that bariatric surgery is a tool to help you modify your eating habits; if you believe that surgery will work by itself you are making a mistake. Any patient undergoing bariatric surgery requires monitoring by a multidisciplinary team that includes the physical, nutritional and psychological aspect, if you are not willing to work on these 3 areas, you have high chances of failure, this means that you can experience nutritional deficiencies and insufficient weight loss after the surgery.

You will have to consult your Nutritionist periodically to be evaluated, the first 8 weeks are extremely important so the consultations will be frequent. The Bariatric Nutritional monitoring is as follows:


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Nutritional follow up LABS

Week 1Week 2Week 4Week 8Month 3 XMonth 6 X

Month 12 XMonth 24 X

Documents

€¦ · Web viewGastric Sleeve and Gastric Bypass do not constitute a cure for morbid obesity; they are great tools that we need to teach you how to apply. The most important part