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Patient Information Guide

Pre-Operative Nutrition Program

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.

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.

What to expect?

Common symptoms post-surgery:

  • Nausea and Vomiting
You may experience nausea the first day after to your surgery. Pay attention to the precise timing of symptoms and identify the reason, thus avoiding the discomfort in the future. The most common cause of nausea and vomiting is accelerated food intake, including liquids, make sure when you start to chew the solid diet; lack of proper chewing is a common cause of these symptoms. If there is discomfort to progress from one stage to another, continue with the previous stage without progressing 3-5 days until you feel more confident to progress.
  • Gastro Esophageal Reflux
Reflux is the partial return of stomach contents into the esophagus, this symptom occurs commonly inpatients with gastric sleeve and appears when you eat food or drink rapidly. To prevent gastro esophageal reflux you must drink and eat straight, avoid lying down immediately after eating as this promotes reflux; if you want to rest you have to wait at least half an hour from your last intake to prevent symptoms. It is rare that this symptom presents itself in patients with Gastric Bypass, but it can also appear.
  • Dehydration
Reflux is the partial return of stomach contents into the esophagus, this symptom occurs commonly in patients with gastric sleeve and appears when you eat food or drink rapidly. To prevent gastro esophageal reflux you must drink and eat straight, avoid lying down immediately after eating as this promotes reflux; if you want to rest you have to wait at least half an hour from your last intake to prevent symptoms. It is rare that this symptom presents itself in patients with Gastric Bypass, but it can also appear.
  • Constipation
Drastic changes in your diet will affect your digestive habits, it is common the absence of need to defecate in the first weeks, remember that your diet is based on full liquids for this short period of time and no solid matter may form along the intestine. The normal digestive habits return after three weeks of nutritional stage, consult your doctor if symptoms persist.
  • Diarrhea
You received broad-spectrum antibiotics during hospitalization and in the first week post-surgery recovery. The optimal function in our gut bacterial flora is compromised by the presence of these antibiotics; this also affects the optimal intestinal function. 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 last from 1-2 months and must regain vitality in this period.
  • Lactose Intolerance
This phenomenon is commonly present in 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.

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.

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.

Foods Allowed:

  • 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 kcal
Type of exercising: walking
Time: 30 Minutes
Calorie expenditure with exercise: 50 –100 kcal

Foods Allowed:

  • Liquids included in Stage 1
  • Chicken Broth
  • Fish Broth
  • Greek Yoghurt
  • Protein cocktail
  • Low fat milk and/or lactose free milk Recommendations

Recommendations:

  1. 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 70–100g.
  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.

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
  3. 120 ml of prepared broth (liquid) and strained.
  4. 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.
  5. You can finish the meal later or have it as a snack.
  6. Do not forget to include your drinks 30 minutes before or after each meal.

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 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 kcal
Type of exercising: Walking
Time: 30 minutes
Calorie expenditure with exercise: 50–100 kcal

This graph shows that in this stage, out of the total amount of calories, 75% comes from protein, 20% from carbohydrates and only 5% of calories come from fat.

Foods Allowed:

  • 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 Food Allowed

Recommendations:

  1. During this stage the foods need 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.
  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 Bariatric app 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.

Stage 4: Solid Food days 30 to 60 post-op

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 food 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 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.

This graph shows that in this stage, out of the total amount of calories, 66% comes from protein, 9% from carbohydrates and 25% of calories come from fat.

Calorie daily intake: 500 –700 kcal
Type of exercising: Walking
Time: 30 minutes
Calorie expenditure with exercise: 50 –100 kcal

Foods Allowed:

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

Stage 5: Days 60 to 120 Post-op

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 –100g 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.

This graph shows that in this stage, out of the total amount of calories, 50% comes from protein, 210% from carbohydrates and 29% of calories come from fat.

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

Foods Allowed:

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

Stage 6: Month 4 to 12 Post-op

At this point you are entering in a new sage 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. And for this reason 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 in the days of increased physical activity. You still need to continue your daily protein intake of 70 –100g, 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 expense. If you have problems with your joints give preference to exercises that make less pressure on them, like swimmingor 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 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 kcal
Type of exercising: walking, swimming, jogging, Zumba, rope jumping, spinning, running, bicycle riding.
Time: 30 –60minutes in intervals of 30 minutes
Calorie expenditure with exercise: 200 –350 kcal

Foods Allowed:

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

Stage 7: Month 12 -24 month post-operative

You come to a relevant point in its long path after his surgery, can you notice that there is ease of eating food that seemed impossible 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 junk food. At this stage you have lost enough weight, the bariatric patient tends to lose between 50%- 70% of excess weight at this stage. 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 other experiences, every individual is different and will have different results, remember this is not a competition.

The key to continue with their weight loss (if you require it) is the continuation of a healthy, low simple carbohydrate diet, high in protein and moderate fat, you’ve already lost enough weight and have been doing exercise by a year, the new challenge of this stage is to increase caloric expenditure by increasing the time devoted to your work out, continuing the food featured in the previous stages, taking into account that if your calorie expenditure is greater, their intake will also has
to be.

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

Secrets to Success:

How you should eat the way you eat after your surgery is as important as what you’re going to eat after surgery. You need to reprogram your behavior from the moment you sit down at the table to focusing in every bite, even in the way you chew.

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)
  • Fill your plate of 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 your portions, you can use including child-sized.
  • Eat small portions and weigh them.
  • Enter each food you eat and record in Bariatric app; this will help to have an objective control over the nutritional goals and how to accomplish them.
  • Cook your own food, and measure the portions, this will help you to have a specific idea of what you eat, write it in your application.
  • Look for foods allowed on their nutritional information depending on STAGE, always seek the sources that contain significant amounts of protein.
  • Rest your body, he needs rest; sleeping from 7 to 8 hours daily helps to increase energy levels and promotes optimal recovery.
  • Set a time each week to weigh yourself, do not obsess over the scale. Weighting yourself weekly helps keep track of your surgical outcome, write it in your application.

Make plans:

  1. Organize food choice days in advance.
  2. Your diet plan starts while 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.
  3. Cook your own food so that you are aware of the portions and quality of food.

“The Plateau”:

The Plateau is a stage that occurs between the first and second postoperative month, ie 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 be disappointed to believe that the purpose of the procedure and nutrition education is lost. This stage is all part of the process and patient experience. Do not be disappointed, this stage is also characterized by the loss of sizes as you begin to notice differences in body image.

Nutritional Supplements:

The amount of food needed to meet the nutritional requirements will be insufficient, therefore it must be replaced with nutritional supplements depending on the surgical procedure. The supplementary food needs of the gastric sleeve and gastric bypass are different. It is recommended that patients with gastric sleeve is maintained with these supplements at least 2 years after, the supplementation with gastric bypass patient is for life. Recent studies have found that the pre–post intake of lactobacilli, decreases subsequent gastrointestinal symptoms, ask your doctor about the nutritional requirements and follow the rules according to these guidelines.

Red Meats:

Red meat is a food that will be avoid in the first 4-6 months, the patient usually tries to eat red meat is prior to this date. It is usual also that he starts with abdominal pain, nausea and vomiting. We recommend starting with ground beef, as is softer to chew and less aggressive to the newly healed stomach.

Alcohol

It is important that you avoid alcoholic beverages while your stomach heals completely the first 6 months. You should avoid all kinds of carbonated drinks like beer. Calorie levels in distilled liqueur like whiskey, vodka and tequila are high, this type of liqueur can cause stomach upset, nausea and vomiting. The gastric bypass patient is highly susceptible to the effects of alcohol after the surgery; because alcohol directly enters to your intestine, absorption is almost immediate, therefore increased toxicity in your body, not to mention that the side effects appear sooner and more intense. The patient should be aware that the best decision is to avoid alcohol beverages of any kinds to prevent symptoms that caused discomfort.

Drugs

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

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 nutritional deficiencies and insufficient weight loss. You will have to visit your Nutritionist periodically to be evaluated, the first 8 weeks are extremely important so the visit will be frequent.

Nutrition Counseling

If you need additional help for your postoperative food and nutrition, we also offer our 2 year signature after-care support through our resident nutritionist:

Carla Lavin: carla@weightlossgetaways.com

Our food and nutrition counseling and post-op programs are on:

  • Bariatric nutrition
  • Meal planning and nutrition tips
  • Physical exercise plans
  • Weight management strategies

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