Good Nutrition After Weight Loss Surgery



[pic]

Gastric Bypass

Life-long

Nutrition Manual

Dr David Provost

2501 Scripture St., Suite 303

Denton, TX 76201

940-323-3450, FAX 940-323-3451



Good Nutrition After Gastric Bypass Surgery

Gastric Bypass is a surgical procedure that decreases the size of your stomach, reducing hunger and limiting dietary intake to promote weight loss. The initial eating plan after this procedure is very limited in choices and amounts as we are trying to heal your stomach after surgery. Over time, your diet will be advanced as tolerated to include softer items and then eventually more solid items, which are eaten in a more “normal” pattern. Your surgery is a tool that is there to help you, but it can’t make choices for you—it can only make it more difficult for you to eat the way you did before surgery. Nutrition is extremely important for the long-term maintenance of weight loss resulting from this surgery.

A Tool to Make the Job Easier: Like any type of tool, the Gastric Bypass has instructions that tell you how to make it work the way it’s supposed to. Not following the instructions can mean that the tool won’t work the best that it could.

How to Use the Bypass: The Gastric Bypass works in two ways: 1) by allowing you to eat less and still feel full 2) by making your body digest and absorb food less effectively. However, to get the maximum benefit from this surgery, it is important to eat solid foods. If you choose foods that easily run through your stomach pouch, it will slow or inhibit your weight loss. Why? Liquids, salty crunchy foods and softer foods will not stay in your new stomach pouch and you will become hungry again shortly after eating. You will also be able to eat a lot of them because they slide through the pouch! These foods can also cause Dumping Syndrome. The longer this cycle continues, the less weight you will lose. In fact, this pattern of eating commonly can result in weight re- gain.

Where Nutrition Fits: Because you will not be able to eat as much as before, good nutrition is even more important! Making your food choices count is key. Choose foods rich in nutrients but low in calories. Choose solid foods like meats, vegetables, fruits, and whole grains that will stay in the pouch over liquid and soft foods that will easily slide through and not help you stay full. Establishing healthy eating habits is very important for lifelong success.

Why should you follow these instructions? The purpose of this food plan is to limit calories while providing you with adequate nutrition to preserve muscle mass and prevent nutritional deficiencies. The diet is intended to prevent complications from your surgery and to promote food tolerance, long-term weight maintenance, and optimal health. If you do not follow this food plan carefully, your new stomach pouch may stretch and you may experience: pain, discomfort, nausea, vomiting, or dumping syndrome.

Dumping syndrome occurs when food empties quickly from your stomach into your intestine. Drinking with meals, extreme temperatures, fried foods, all sugars, and refined carbohydrates (such as pasta and potatoes) can trigger dumping syndrome. Symptoms include: nausea, vomiting, diarrhea, abdominal cramping and bloating, feeling dizzy, sweating, or feeling like you might faint. If you follow your dietary guidelines, this won’t happen!

Exercise! Getting regular exercise is a vital part of sustained weight loss. A goal could be to work up to 30-35 minutes of activity each day. Exercise is very important during the first 3-6 months after surgery. It will help you lose weight faster. The added weight loss achieved with an hour of exercise during the first months following surgery may require 5 hours of exercise a year or two later. Remember this when you don't feel like exercising. You want to make the most of this special post-operative time.

Gastric Bypass Nutrition Flowchart for Clinic Visits

New Patient Visit: Evaluation and education day. We will review the material contained in this manual. Insurance may require 3-6 months of medically supervised weight loss before approving your surgery. In addition, we may require special lab work or testing prior to your surgery.

~2 weeks before surgery: At this time you will begin your pre-op very low-calorie, low-carbohydrate liquid or solid food diet. You will also learn about the diet you will follow after your gastric bypass.

~2 days to 1 week before surgery: Pre-Op testing day. Clinic and hospital visits for your pre-op physical, pre-admission to the hospital, and pre-surgical paperwork at the hospital.

Night before and morning of surgery: Nothing by mouth after midnight

After surgery: Once Dr Provost feels it is medically appropriate for you to begin consuming liquids by mouth, you will start with a clear liquid diet, which includes water, sugar –free juices, and broth.

Afternoon of post-op day 2: Phase 1: Full Liquid Diet that includes water, juice, milk, and liquid nutrition supplements. Stay on this plan from the day of hospital discharge until your 2 week Post-Op Visit

Post Op Visit: ~2 weeks after surgery: Post-op check. Begin Phase 2 Diet: Full Liquid/Soft Diet, start after your clinic appointment

Dietician visit via phone or office ~4.5--6 weeks after surgery: Begin Phase 3: Solid Foods.. This will be your lifelong eating pattern, thus it is a way of life, not a true ‘phase’

1st and 2nd Year Post-Op – Appointment every 3 months, blood tests every 6 months

3rd Year Post-Op – Appointment every six months, blood test every 12 months

Lifelong Follow-up – Appointment with blood tests once a year

Dietary Timetable

|Stage of Diet |What To Eat |Amount to Eat |

|Pre-Op Diet |Very low-calorie, low carbohydrate liquid or solid food |3 oz protein 3 x per day, 1-2 cups vegetable 3x per day or 3 |

|(2 weeks before Surgery) |diet |cups protein drink per day |

|Night Before/ Morning of Surgery |Nothing after midnight |Nothing after midnight |

|Surgery! |Surgery! Then small amount of clear liquids |Surgery! Then small amount of clear liquids |

|Phase I |Full Liquids (3 cups protein drink + 3 cups |1 oz (2 tablespoons) every 15 minutes all day long, while awake|

|1-2 Weeks After Surgery |water/non-calorie liquids). Drink more water as needed. | |

|Phase II |Full Liquids/Soft Foods (2 cups protein drink + 1 cup |Start with 4 meals |

|2-5 Weeks After Surgery |pureed soft foods) = 3 cups total per day |Meal; size ¼ cup |

| | |Continue protein drinks, zero calorie fluids, etc. |

|Phase III |Solid Foods. The beginning of the rest of your life! |Start with 4-5 smaller meals |

|5+ Weeks After Surgery and beyond| |Goal is 3 meals per day |

| | |Meal size: ½ cup |

|Life-Long |Multivitamin with iron, Calcium citrate with Vitamin D |2-3 children’s chewable multivitamin and 1000-1500 mg Calcium |

| |(1000-1200 mg daily) divide into ½ dose twice daily |citrate |

| | |Take vitamins and calcium separately. Only 500-600 milligrams |

| | |of calcium at a time. |

The Bariatric “Solid Food Pre-Op” Diet

Follow for 2 weeks prior to surgery to shrink your liver

A very low calorie, very low carbohydrate diet.

|Protein Foods |Vegetables |Extras |

|Three, 3-ounce portions per day | | |

|90% lean |1-2 cups, 3 portions per day |You may have up to three items off this list per day |

|or | | |

|less than 3 grams of fat per ounce | | |

| | | |

|Fish |Asparagus |Light mayonnaise (1 Tbsp) |

|Chicken (white meat, skinless) |Alfalfa Sprouts |Regular salad dressing (1 Tbsp) |

|Turkey (white meat, skinless) |Artichokes |Reduced-fat salad dressing (2 Tbsp) |

|Beef (sirloin, top round) |Beets | |

|Pork (tenderloin) |Bean Sprouts |Olive or canola oil (1 tsp) |

|2 Eggs or egg sub |Bell peppers |Regular margarine (1 tsp) |

|Veal (chop, leg, cutlet) |Broccoli |Reduced calorie margarine (1 Tbsp) |

|Shellfish: crab, shrimp, lobster |Brussels Sprouts | |

|Tofu (low-fat) |Cabbage |Non-fat milk (½ cup) |

| |Cauliflower |0-2% cottage cheese (½ cup) |

|Luncheon Meat [pic] |Carrots |Fat-free, sugar-free yogurt (½ cup) |

|Cheese, low-fat [pic] |Celery | |

|Ham, low-fat [pic] |Cucumbers | |

|Canadian Bacon [pic] |Eggplant | |

|Beef Jerky [pic] |Garlic |In addition: |

| |Green beans |Take a multi-vitamin with iron |

| |Greens: spinach, turnip |1000-1200 mg calcium citrate with vitamin D each day. |

| |Lettuce: |***Separate into (2) 500-600 mg doses. Allow at least 2 |

| |Mushrooms |hrs between calcium supplement and multivitamin. |

|Meats should be baked, broiled, grilled, boiled, or|Onions |Make sure you are getting 800 mg of vitamin D in each day|

|steamed. |Peppers: all types |(via vitamin, calcium supplement, etc). |

| |Parsley | |

| |Radishes |Tbsp: tablespoon |

|3 ounces is about the size of a deck of playing |Snow peas |tsp: teaspoon |

|cards. |Squash: summer, zucchini | |

| |Tomatoes | |

| |Turnips | |

| |Vegetable Juice [pic] | |

| |Water Chestnuts | |

|Free Foods: consume as desired: |

| |

|Non-caloric beverages: Condiments: Other: |

|Water Lemon or lime juice Sugar-free Popsicles |

|Coffee Vinegar Sugar-free gelatin |

|Tea Cooking oil spray (PAM) Light Soy Sauce [pic] |

|Crystal Light Herbs/Spices |

|Sugar-Free Kool-Aid or like beverages Mustard [pic] |

|Broth, fat-free [pic] (low salt varieties are available) |

[pic] If you have hypertension, avoid these sodium rich foods.

Phase 1 Gastric Bypass Diet: “FULL LIQUIDS””

Generally followed from post op day 2 until 2 weeks after surgery.

Stay on this diet until you come into the clinic for your 2 week post-op checkup.

Be sure to measure your liquids carefully and keep a log of your fluid intake to help ensure that you are drinking enough

Consume 1 ounce every 15 minutes (while you are awake!) Drink slowly. Do not force

| | |

|Nutrition Beverages: “Protein Drinks” |Calorie-free Beverages |

|1 ounce/ 2 tbsp at a time, 15 minutes apart |1 ounce at a time, 15 minutes apart |

| | |

|Try to consume 3 cups (24 oz) each day: |Consume at least 3 cups (24 oz) per day: |

| | |

| | |

| |Water |

| |Tea |

| |Coffee |

| |Crystal Lite |

| |Sugar-free Kool-Aid or like mixes |

| |Fruit2O |

| |AquaCal |

| |Sugar-free Popsicles |

| |Sugar-free Gelatin |

| |Broth, fat-free (chicken, beef, veg) |

| | |

| |No Carbonated Beverages |

| |Beverages must be non-caloric |

| |“Sugar-free” |

| | |

| | |

| |Juice: You may substitute up to 1 cup of no sugar added fruit juice each day |

| |for non-caloric beverage. This is allowed during this stage only. In later |

| |stages we suggest avoiding all juices. |

|Bariatric Advantage Meal Replacer |Lactose-free choices | |

|Carnation Instant Breakfast, |Boost Glucose Control* | |

|Sugar-free (skim milk) |Glucerna Shake* | |

|Slim Fast High Protein Low Carb |Isopure* | |

|EAS Myoplex Low Carb Lite |Nectar* | |

|Muscle Milk Lite |Choice DM* | |

|Carb Solutions |Glytrol* | |

|Atkins Shake |Resource | |

|Pure Protein |Diabetic* | |

|***If you choose to use Isopure Zero Carb talk to your dietitian. | |

Sample Full Liquid Menu

|7:00 a.m. 1 oz Carnation Instant Breakfast |5:00 p.m. 1 oz unsweetened juice |

|7:15 a.m. 1 oz unsweetened juice |5:30 p.m. 1 oz Carnation Instant Breakfast |

|7:30 a.m. 1 oz Carnation Instant Breakfast |5:45 p.m. 1 oz water |

|7:45 a.m. 1 oz water |6:15 p.m. 1 oz Carnation Instant Breakfast |

*Continue consuming allowed foods/beverages every 15 minutes.

Acceptable Protein Drinks:

Dr Provost’s Recommended Protein Drink: Bariatric Advantage is available for purchase in the clinic. Bariatric Advantage is a high quality supplement designed for the post-surgical nutritional needs of a bariatric patient.

If you are either unable or unwilling to purchase protein drink from the clinic, the above are acceptable alternatives.

Protein Drink Nutrient Specs: A good protein drink should have the following nutrients per serving:

~20 g protein per scoop/serving

• ~5 g or less of carbohydrate/sugars per scoop/serving

• ~5 g or less of fat per scoop/serving

Additional Instructions:

Lactose intolerant:

Choose lactose-free supplements or lactose-free/lactose-reduced milk. Chewable lactase enzymes are also available over the counter which can be consumed with dairy products to improve tolerance

Gum:

Avoid chewing gum (or be very careful with it). Swallowed gum can block the opening to your stomach.

Do not force liquids/ food:

Do not force yourself to consume liquids/ food if you are not hungry or are uncomfortable. Continuing to eat/ drink when you are full can cause nausea and vomiting and can possibly stretch your pouch.

Unable to eat/ drink:

Call Dr Provost if you are not able to eat due to nausea or vomiting, or if you have severe diarrhea. Call immediately if you cannot hold down liquids.

Take your supplements every day:

1. 1 dose of a good quality chewable or liquid multivitamin/mineral with iron each day

2. 1000-1200 mg of chewable or liquid calcium citrate with vitamin D each day each day in divided doses of 500-600 mg at a time. Separate calcium supplement from multivitamin by 2 hours before or after.

Fluids:

Caffeine is a diuretic (increases urine production.) If you are having a hard time getting enough fluids in, drink decaffeinated beverages. You do not need to avoid caffeine for life.

Beverages that are very hot or very cold may stimulate dumping. Avoid extreme temperatures if you suspect this is happening to you.

Avoid alcohol. It adds calories and may impair your judgment leading to poor food choices. It is also a diuretic.

Advancing your diet:

Do not advance your diet until you are seen in the clinic and either Dr Provost or his dietitian tells you to do so.

Phase 2 Gastric Bypass Diet: “SOFTS”

Begin after your 2 week post-operative visit and follow until you are advanced to solid foods by Dr Provost or the dietician.

You remain on full liquids and softs for a few more weeks in order to continue healing from the surgery. Your intestines are not ready yet for the consistency of solid food.

|Nutrition Beverage |Calorie-free Beverages |

|2 ounces at a time |2 ounces at a time |

| | |

|Consume 2 cups (16oz) each day: |Consume at least 3 cups (24 oz) per day: |

| | |

| |Water |

| |Tea |

| |Coffee |

| |Crystal Lite |

| |Sugar-free Kool-Aid or like mixes |

| |Fruit2O |

| |AquaCal |

| |Sugar-free Popsicles |

| |Sugar-free Gelatin |

| |Broth, fat-free (chicken, beef, veg) [pic] |

| | |

| |No Carbonated Beverages |

| |Beverages must be non-caloric |

| |“Sugar-free” |

| |Avoid alcohol. It adds calories and may impair your judgment |

| |leading to poor food choices. It is also a diuretic. |

| | | |

|Bariatric Advantage Meal |Lactose-free choices | |

|Replacer |Boost Glucose Control* | |

|Carnation Instant Breakfast, |Glucerna Shake* | |

|Sugar-free (skim milk) |Isopure* | |

|Pro Complex (mixed w/ a zero-cal|Nectar* | |

|beverage) |Choice DM* | |

|Slim Fast High Protein Low Carb |Glytrol* | |

|EAS Myoplex Low Carb Lite | | |

|Muscle Milk Lite | | |

|Carb Solutions | | |

|Atkins Shake | | |

|***If you choose to use Isopure Zero Carb talk to your dietitian.| |

|This is a Pureed food NOT |Additional Instructions |

|Limit 2 oz (1/4 cup) at a time a Goal | |

| | |

|Consume 4-5 “meals” each day: |Do not drink 15 minutes before and at least 60 minutes after |

| |eating pureed food |

|¼ cup Cooked cereal | |

|¼ cup Sugar-free, fat-free yogurt |Remember to take your multivitamin and calcium citrate supplement|

|¼ cup Scrambled Eggs |each day. |

|¼ cup Pureed MOIST Meats: turkey, fish, chicken, tofu, shellfish,| |

|etc | |

|¼ cup Pureed vegetables | |

|¼ cup Pureed fruit, unsweetened | |

|Meal 1 |Meal 2 |Meal 3 |Meal 4 |

|Pro 1/8 cup |¼ cup |Pro 1/8 cup |¼ cup |Pro 1/8 cup |¼ cup |Pro 1/8 cup |¼ cup |

|Veg 1/8 cup |total |Fruit 1/8 cup |total |Fruit 1/8 cup |total |Fruit 1/8 cup |total |

| | | | |

|Pro 1/8 cup |¼ cup |Pro 1/8 cup |¼ cup |Pro 1/8 cup |¼ cup |Pro 1/8 cup |¼ cup |

|Veg 1 Tbsp |total |Veg 1 Tbsp |total |Veg 1 Tbsp |total |Veg 1 Tbsp |total |

|Fruit 1 Tbsp | |Fruit 1 Tbsp | |Fruit 1 Tbsp | |Fruit 1 Tbsp | |

Phase 1 and 2 Shopping List

Use while you are on liquid and/or soft foods.

Acceptable Protein Drinks:

| |Lactose Free Beverages |

|Bariatric Advantage |Boost Glucose Control* |

|Carnation Instant Breakfast, Sugar-free |Glucerna Shake* |

|Pro Complex (mixed w/ a zero-cal bev) |Isopure* |

|Slim Fast High Protein Low Carb |Nectar* |

|Lean Body, Carb Watcher’s, powder | |

|EAS Myoplex Low Carb Lite | |

|Muscle Milk Lite | |

|Carb Solutions | |

|Atkins Shake | |

|Pure Protein | |

Fluids:

Crystal Light or Sugar-free Kool Aid

Fruit2O

Tea/coffee

Sugar-free gelatin

Sugar-free Popsicles

Broths, Bullion, or Base, fat-free (Chicken, Beef, Vegetable) [pic]

Phase 2 Soft Foods

Chunk Lite Tuna in water

Canned chicken breasts in water

White Fish Fillets: such as White sea bass, Halibut, Tilapia, Catfish, Cod

Eggs OR Egg Beaters (flavor of your choice)

Pureed fruits

Pureed vegetables

Pantry Necessities:

Zero-calorie sweeteners: Splenda, Equal, NutraSweet, or Sweet N Low, Stevia

Herbs and spices, your choice

Cooking Oil spray, example: PAM

Supplements:

1. Complete multivitamin-mineral with iron, chewable or liquid for the first 3 months:

EXAMPLE: Bariatric Advantage, Centrum Complete, Flintstones

2. Calcium Citrate with Vitamin D, chewable or liquid for the first 3 months:

EXAMPLE: Bariatric Advantage, Blue Bonnet Liquid Calcium, Citracal Creamy Bites, other chewable or liquid calcium citrate with vitamin D

After 3 months you may advance to solid forms, if you can tolerate them.

Phase 3 Gastric Bypass Diet: “SOLIDS”

This will be your way of eating for LIFE

Please do not advance to this stage until you are told to do so by Dr Provost or his dietitian at approximately

5-6 weeks after surgery

|This is a Solid food NOT a Goal | |

|Limit 3-5 small meals (1/2 cup) at a time |Calorie-free Beverages |

| |small sips away from meals |

| | |

|Any lean protein (at least 90% lean or less than 3 grams fat per ounce). |Consume at least 6 cups (48 oz) per day: |

|Eat first at every meal. | |

| |Water |

|Protein : |Tea |

|Fish |Coffee |

|Chicken |Crystal Lite |

|Turkey |Sugar-free Kool-Aid or like mixes |

|Beef (tenderloin, sirloin, top round) |Fruit2O |

|Pork (tenderloin) |AquaCal |

|Eggs, egg substitute |Sugar-free Popsicles |

|Veal (chop, leg, cutlet) |Sugar-free Gelatin |

|Shellfish: shrimp, crab, lobster |Broth, fat-free (chicken, beef, veg) |

|Tofu (low-fat) | |

| | |

|Luncheon Meat [pic] |No Carbonated Beverages |

|Cheese, low-fat [pic] |Beverages must be non-caloric |

|Ham, low-fat [pic] |“Sugar-free” |

|Canadian Bacon [pic] | |

|Beef Jerky [pic] | |

| |Avoid alcohol. It adds calories and may impair your judgment leading to |

|Fruits and Vegetables: |poor food choices. It is also a diuretic. |

|Eat several small portions of these each day: | |

| | |

|Raw or lightly cooked vegetables are best. Try to avoid potatoes and |No beverages |

|avocados. |15 minutes before or 60 minutes after a meal |

| | |

|Fresh crisp fruits. Try to avoid high-sugar fruits like raisins and dried | |

|fruits. | |

| | |

|Whole Grains: | |

|Brown rice | |

|Oatmeal or oat bran | |

|Whole grain breads | |

| | |

| | |

|[pic] Sodium rich choices: limit if you have a history of hypertension. | |

| | |

|Meal 1 |Meal 2 |Meal 3 |

|Pro ¼ cup |½ cup |Pro ¼ cup |½ cup |Pro ¼ cup |½ cup |

|Veg 2 Tbsp |total |Veg 2 Tbsp |total |Veg 2 Tbsp |total |

|Fruit 2 Tbsp | |Fruit 2 Tbsp | |Fruit 2 Tbsp | |

INSTRUCTIONS FOR PHASE 3:

1. At this point stop all liquid calories such as protein beverages, soup, juice, milk, and all soft foods. Consuming these items will not lead to weight loss and may cause weight gain. You will not go back to these unless Dr Provost specifies.

2. Begin solids slowly, starting with “easier” solid foods (cooked veggies, moist meats like chicken and fish, oatmeal) and gradually transitioning to more “advanced” solid forms (raw fruits and veggies, brisket, ribs, chicken breast, rice and breads.) Meats will always need to be moist and tender. Fruits and vegetables will eventually need to be firm/crisp for best results.

3. The long-term goal is for you to be eating 3 meals per day; however, at first you will likely need to eat 4-5 solid meals a day until your body gets used to your new anatomy.

4. Start with meals that are about ½ cup in size (4oz) and maintain that amount for 6 months. From 6 to 12 months limit meal size to ¾ cup and from 12 months on limit meal size to 1 to 1 ¼ cup.

5. Do not drink fluids 15 minutes before, during, or up to 60 minutes after a meal.

6. Finish your meals within 20 minutes.

7. Avoid snacking between meals.

8. Cut all foods into pea-sized bites and chew at least 15 times with each bite.

9. Between meals sip on non-caloric, non-carbonated beverages.

10. Eat your protein first each meal. It is most important. Protein foods can be poached or steamed in the oven in foil or parchment paper to soften the muscle fibers. Add broth or another non-caloric liquid for added moisture and tenderness.

11. Call Dr Provost if you are not able to eat or drink due to nausea, vomiting (especially with liquids only!), or severe diarrhea.

SUPPLEMENTS; TAKE THEM EVERY DAY FOR THE REST OF YOUR LIFE

1. 1 good quality chewable or liquid multivitamin with iron each day

2. 1000-1200 mg chewable or liquid calcium citrate with vitamin D each day in divided dose.

Separate your multivitamin from your calcium supplement and do not take more than 500-600 milligrams of calcium at a time. After three months, if you can tolerate them, you may move to solid tablets.

FLUIDS:

1. Caffeine is a diuretic (increases urine production). If you are having a hard time getting enough fluids in, then drink decaffeinated beverages.

2. Beverages that are very hot or very cold may stimulate dumping. Avoid extreme temperatures if you suspect this is happening to you.

3. Remember: no carbonation.

4. Avoid alcohol. It adds calories and may impair your judgment leading to poor food choices. It is also a diuretic.

TIPS:

New foods:

Try new foods one at a time. If you do not tolerate a particular food well, wait about 1 week before trying it again. If you still do not tolerate the particular food, avoid it. Please know that this may change over time.

Eat protein with every meal.

Getting enough protein is very important. One ounce of meat or one egg contains 7 grams of protein. Women should consume around 50 grams of protein per day. Men should aim for around 60 grams of protein per day. THIS IS A GENERAL GUIDELINE. You do NOT need to supplement protein in order to reach a “quota.” Follow protein rich foods with vegetables and fruits.

Good sources of protein include: beef, poultry, pork, fish and eggs, shell fish, and tofu. Limit high fat meats, such as sausage, bacon, hot dogs, luncheon meats, meats with a lot of fat or marbling and fried meats. Be careful with tough, stringy meats. Avoid fried fish or meat.

Milk and liquid/semi solid dairy products:

Milk products are good sources of protein as well as calcium and vitamin D; however, they will slide through your pouch easily. In general we want you to limit your consumption of milk and dairy products; you will take supplements for calcium and vitamin D. If you do eat dairy products occasionally, choose those that are fat-free without added sugar such as skim milk, fat-free, sugar-free yogurt, and fat-free- cottage cheese.

Fish versus chicken verses beef:

In general fish is the easiest to tolerate followed by tender chicken. Some people will find beef difficult to manage due to its tough muscle fibers; however if you choose lean tender cuts and prepare it well, you may be able to tolerate beef just fine. Everyone is different and you will just need to try it out and see. A lot has to do with the specific grade, cut, and preparation techniques used. Cooking meat with added liquid (steaming or braising) is tenderizing. If you do not tolerate it well, wait a week or two and try it again. You may do better next time. Some foods may never be tolerated well again. You will just have to wait and see how you do.

Tough or stringy food:

Tough or stringy foods (such as celery, pineapple, ribs, and brisket) that are not chewed well may get stuck in your pouch. Chewing well and cutting your food into pea size pieces before they ever enter your mouth can minimize problems. Do not eat tough peels, skins, seeds or cores of fruit. Avoid eating the membranes of oranges and grapefruits or tough pineapple.

High fat or starchy foods:

Avoid high fat starches, such as donuts, sweet rolls, croissants, French fries, pancakes, waffles, biscuits and chips. Avoid high fat foods such as nuts, cheese, seeds, peanut butter, olives, sour cream, avocado, and coconut.

Mushy foods and small salty crunchies:

Foods that are mushy or dissolve easily in the stomach will slide through your pouch quickly. As they will not keep you full for long and you will be able to eat a large amount of them, they should be avoided. You will gain weight if you consume these items. These include foods like: cereal, crackers, chips, soup, chili, stew, casseroles, pasta, macaroni and cheese, spaghetti, shakes, smoothies, milk, ice-cream, peanut butter and all potatoes. You will learn more about these foods during your nutrition counseling sessions.

Foods that swell:

Food such as rice, pasta, heavy or tough hard crusty breads, corn bread, and bran can all swell in the pouch causing discomfort. You should eat them carefully and only in small amounts with small bites.

Dumping Syndrome:

Can be avoided by: not consuming high sugar foods, greasy foods, and refined carbohydrates, not overeating, not drinking after meals, and avoiding beverages that are either very cold or very hot. Foods rich in sugar include: cookies, cake, pie, candy, ice cream, soda, syrup, honey, jam and jelly. “Sugar –free” candies sweetened with sugar alcohols like sorbitol or manitol can also cause abdominal distress. You may also want to avoid them.

Supplements:

You will need life-long multivitamin with iron and calcium citrate with vitamin D supplements. Dr Provost will check your iron and vitamin B12 level. Patients who have had weight loss surgery may develop vitamin and mineral deficiencies.

Support Groups:

Support groups are available for people who have had weight loss surgery. Encouragement from and interaction with others who are facing the same challenges can be invaluable. Our support group meets on the 2nd and 4th Thursdays of each month from 7-8pm at Dr Provost’s office. You may also come for a walk with his staff from 5:45-6:45pm.

Gastric Bypass Pouch Rules

A gastric bypass works by limiting food intake and minimizing physical feelings of hunger. Eating or drinking distends the pouch sending signals to the brain, which result in a "full" feeling, eliminating hunger. When initially created, the pouch is small, less than an ounce in size.

Over time all pouches increase in size. As the pouch size grows it becomes easier for food to empty, causing feelings of hunger to return more quickly. Scientific studies have shown that when the pouch remains between 2 to 8 ounces, the rate of weight loss or weight maintenance is not affected. Weight loss is more dependent on how the pouch is utilized.

Continued forced overeating can overstretch a pouch. An overstretched pouch can hold more food. Eating more food can slow or stop weight loss. You will eventually begin to regain weight if you continue to eat too much food.

Protect your pouch by:

• not eating more than ½-1 cup of food at a meal

• limiting meals to 20 minutes or less

• never drinking during a meal, and up to 1 hour after a meal.

The first 3-6 months: Most patients have very little hunger during the first 3 to 6 months after surgery. During this time period, frequent sips of liquids are enough to keep the pouch distended and to minimize hunger.

During these first months after gastric bypass, weight loss will be the most rapid. Weight loss is easiest during this period because food consumption is at its lowest. Take advantage of this and watch your intake carefully. Avoid eating soft foods, small salty crunchies, and liquid calories, which tend to allow hunger to return sooner.

It has been observed that some patients may experience a quicker return of hunger when using “artificial” sweeteners.

Exercise during the first 3-6 months: Exercise is very important during the first 3-6 months after surgery. It will help you lose weight faster. The added weight loss achieved with an hour of exercise during the first months following surgery may require 5 hours of exercise a year or two later. Remember this when you don't feel like exercising. You want to make the most of this special post-operative time.

After 6 months: Six months to a year after surgery, hunger will likely return. Additional alterations in eating habits will be needed to keep your calorie and food consumption low.

Remember:

1. Soft foods, small/ salty crunchies, and liquid calories empty the gastric pouch faster. This will cause hunger to return more quickly. Try to avoid these items.

2. Solid food stays in the pouch longer, resulting in a longer feeling of fullness. Focus on having a protein and vegetable or solid fruit at each meal.

3. Extending meals over 20 minutes to an hour is not advisable. This allows you to eat more resulting in greater calorie intake, which defeats the purpose of the pouch. Eat your meals over a 15-20 minutes time period. You will eat less food and feel fuller longer.

4. Drinking with meals or shortly after meals washes food out of the pouch, emptying it within 30 minutes. This results in a quicker return of feelings of hunger. By not drinking liquids with meals and for 1 hour after eating, a pouch may remain distended/full for up to 4 hours. This will lead to greater weight loss over time.

If your weight loss has slowed or you are gaining weight, don’t panic, just

get back to basics:

1. Limit yourself to 3 meals a day that are ½ - 1 cup each in size

2. AVOID liquid calories such as juice, milk, fancy coffee drinks, sweet tea. All beverages should be ZERO calories.

3. Eat small bites of more solid foods such as: lean protein without gravy or sauce; crisp/firm veggies like carrots, broccoli, or cauliflower; and crisp/hard fruits like apples and pears.

4. Eat at least 2 ounces of solid protein at each meal. You will stay fuller longer.

5. Minimize soft foods, crunchy/ salty foods, and caloric liquids. This does not mean these foods are banned. You just need to understand when exceptions are made, you will likely experience hunger sooner and you will consume more calories, and must deal with the weight regain consequences.

6. Try to finish your meal within 15 to 20 minutes. Longer meals lead to more food consumption and overstretched pouches.

7. Avoid drinking with meals and for 1 hour (maybe longer) after meals. This will keep your pouch fuller longer.

8. Avoid snacking. Small snacks are usually insufficient to eliminate hunger and you will end up eating too many calories over the day. If you must snack due to PHYSICAL hunger, then snack on more solid items like meat, fruit, and vegetables.

9. OR instead of snacking, start drinking when the feelings of hunger return. Drink 8 to 12 ounces of water rapidly over 20 seconds, then top off with sips until you feel comfortably full. Do this whenever you feel hungry. This will keep the pouch distended and minimize hunger. Drink a final glass of water 15 minutes prior to eating. By drinking a lot of water before the meal, you should be able to go longer without feeling thirsty after meals.

10. Keep a food log of everything you eat and drink; you may find some foods and habits have crept back into your life that are keeping you from your goal!

11. Get to a support group! Studies show that patients who attend regular support groups are more likely to maintain their weight loss. We have a support group that meets twice a month.

e in and see us! The best time to see us is when you are struggling. You are not alone in this journey. Please let us be of assistance to you.

FAQ’s

I thought cereal helps me lower my cholesterol, isn’t it good for my heart?

While wheat fiber helps remove cholesterol from the body by sweeping fat out from the intestine, this is only one way of addressing blood cholesterol. However, weight loss surgery is a much better way to lower cholesterol, and eating a diet with fruits and vegetables instead of cereals will improve cholesterol levels more effectively. Soft foods like cereal with milk or crunchy foods like dry cereal slide right through your gastric bypass, so you can eat plenty of them without getting full and you defeat the purpose of your surgery. Consistent eating of cereal can slow your weight loss.

I thought milk and dairy are good sources of calcium and vitamin D, why can’t I use them?

While dairy products are good sources of calcium and vitamin D, they are also soft and high in carbohydrate and fat. They also slide right through your gastric bypass, so you can eat plenty of them without getting full and thus you defeat the purpose of your surgery. Instead of eating dairy, a Gastric Bypass patient should take their calcium and vitamin D supplements and be aware that inclusion of these foods should be minimal.

I thought that juice was good for me? Why can’t I drink it?

While juice can be good source of vitamins, it is also loaded with calories and sugar. (Yes, even the “no sugar added 100% juice has a lot of calories.) Juice also slides right through your gastric bypass, so you can drink plenty of it without getting full and thus you defeat the purpose of your surgery. Instead of drinking juice (100-150 calories per glass—as much as a can of coke!!) EAT your vitamins by eating an orange, an apple, berries, etc.

How about Vitamin Water? Why can’t I drink it?

Vitamin water and other “sports” type drinks are loaded with sugar. Vitamin water is simply bottled water with a cup of sugar and a vitamin dropped in it. It has 150 calories per bottle—as much as a can of coke. Please, spare yourself the calories, the inevitable weight re-gain, and simply take your vitamins and drink plain water.

I thought that nuts and avocados have healthy oils that are good for my heart?

While nuts and avocados are a good source of heart-healthy oils, they are also very high in fat and calories and go through the pouch easily. It takes very few nuts to equal a lot of calories (one handful can have as many as 190 calories!). If you must eat nuts, they should not be eaten as a meal or snack, but rather as a garnish.

I thought that cheese and peanut butter are good sources of protein. Why can’t I eat them?

Cheese and peanut butter have some of protein in them, but they also have enormous amounts of fat and calories AND they go through the pouch easily. (2 oz of cheese or 2 Tbsp of peanut butter have 200 calories!) Due to the high fat/ calorie content and soft texture, they are not a good choice for a Gastric Bypass patient.

How about these “Sugar free chocolates/cookies/cakes/candy?” Aren’t they good?

SUGAR FREE DOES NOT MEAN CALORIE FREE. In order for the manufacturer to make a product that tastes good, they have to replace the sugar with something else. It is likely that it will be fat. These foods can have nearly as many calories as their regular-sugar counterparts.

At the end of the day, you will lose weight because you are consuming LESS calories. It’s your choice.

(We hope you make a good one! Please, READ FOOD LABELS!)

Reading Food Labels

The labels on canned, packaged, and frozen foods tell you what’s really in the foods you eat. Comparing labels will help you choose foods that are low in fat, sugar, and calories. Reading food labels is a big step toward eating for a healthier heart and body weight. Look for the “Nutrition Facts” label on packaged foods.

1. Serving Size. Look at this closely. This is the amount of food in 1 serving. If you eat more, you get more of everything on the label—including fat, sugar, and calories.

2. Servings per Container. This information is possibly the most important piece of information on the label. It tells you how many servings are in the container that the label is on and determines the amount of calories, fat, sodium, fiber, etc. you eat. Watch out for this one, your concept of a single serving may not be the same as the label. Small packages with multiple servings per container add up calories, fat, carbohydrates, and sodium quickly.

3. Total Fat. This number tells you how many grams (g) of fat are in 1 serving. Choose foods with a low number for total fat.

4. Saturated Fat. This number tells you how many grams (g) of saturated fat are in 1 serving. Saturated fat raises your cholesterol the most. Look for foods that have little or no saturated fat.

5. Trans Fat. This number tells you how much trans fat is in 1 serving. Like saturated fat, trans fat raises your cholesterol. Choose foods that have little or no trans fat.

6. Cholesterol. This number tells you how much cholesterol is in 1 serving. You should eat less than 300 milligrams (mg) of cholesterol a day.

7. Calories from Fat. This number tells you how many calories from fat are in 1 serving. Look for foods with few calories from fat.

8. % Daily Value. A large number means 1 serving contains a lot of that ingredient. A low number means 1 serving contains a small amount. Look for foods that have low numbers for total fat, saturated fat, trans fat, sugar, cholesterol, and sodium.

9. Sodium (salt). This number tells you how much sodium is in 1 serving. Choose foods with low numbers for sodium. Or look for foods that say Low-Sodium or Sodium-Free.

10. Sugars. This number tells you how much sugar is in 1 serving. Look for foods that are low in sugar (< 10 grams per serving.) Keep in mind that sugar also goes by other names such as: corn syrup, corn syrup solids, cane juice, organic cane juice, evaporated rice syrup, agave nectar, fruit paste/ puree, fructose, sucrose, maltose

11. Dietary Fiber. This number tells you how much fiber is in 1 serving. Look for foods that are high in fiber.

What To Look For On A Label For Healthy Choices:

Choose foods that are a good source of protein, high in fiber, low in sugar, low in sodium, low in fats with no trans fats and as few of calories as possible. Make sure the carbohydrates are a reasonable amount. A food choice high in carbs impacts your blood sugar and can create hunger and cravings that lead to excess eating. It can also lead to dumping syndrome.

Life After Carbonated Drinks

After your gastric bypass surgery, do not drink carbonated beverages…ever.

When a person drinks carbonated beverages, the gas in the beverage is released and expands in the stomach, much like a balloon. Pressure caused from carbonated beverages can be uncomfortable. Occasionally, a person may not be able to belch to release the gas pressure. When this occurs it can lead to extreme pain and on rare occasion a medical emergency. Additionally, some people think carbonated beverages will stretch a person’s stomach pouch; however, no one really knows.

Carbonated beverage intake correlates closely with obesity. The more carbonated beverages a person drinks, the more likely they are to be obese or overweight. There are lots of theories surrounding this observation; some feel carbonation increases hunger, others theorize that sugar or non-caloric sweeteners increase appetite. Whatever the cause, we do not want you to drink carbonated beverages at all, diet or regular.

Examples of carbonated beverages include:

• Regular and diet sodas

• Club soda

• Beer

• Champagne

• Sparkling wine

• Sparkling water

• Red Bull, Rockstar, Full Throttle, Monster, etc

• Any drink that says “carbonated water”

Try these beverages instead:

• Water

• Coffee, hot or iced, sweetened with splenda

• Tea, hot or iced (regular or Herbal)* and sweetened with splenda

• DaVinci Sugar-Free Syrups (add to coffee or tea)

• Fat-free, non caloric broths (meat or vegetable based)

• Fruit2O

• Aquacal

• Minute Maid Light: Orangeade, Lemonade, etc

• Non-caloric fruit flavored drinks like Sugar-Free Kool-Aid, Crystal Lite, or Wylers sugar-free drink mixes.

EXERCISE

Physical activity is extremely important to the success of bariatric surgery. Surgery is one small portion of the overall equation to successful weight control. Establishing a physically active lifestyle prior to surgery will benefit you in the recovery phase. Exercise, proper nutrition, and routine follow-up care are essential to your success. They are what allow you to best utilize the tool that we have given you to fight the battle of obesity and win that battle.

Start TODAY! We want you to walk as much as you can, as often as you can. Daily exercise for 30 minutes is your goal and will be ESSENTIAL in your weight loss journey. Dr Provost expects you to begin exercising immediately. Walking is the easiest exercise. We want you to start DAILY sustained aerobic exercise beginning at 5 minutes per day and working your way up to 30 minutes per day. You will know you are getting a good work out because you are sweating a little and feeling a little short of breath. Keep in mind that housework, walking or climbing stairs at work, parking far away in parking lot, and playing with children are all great starts, but we would like you to advance to more vigorous, sustained exercise as your health improves.

19 Reasons to Exercise

1. Achieve and maintain goal weight

2. Build muscle tissue

3. Increase strength and endurance

4. Increase metabolism, burn fat

5. Improve mobility and flexibility

6. Improve skin elasticity

7. Enhance mood and Improve self-esteem

8. Lower blood pressure

9. Lower blood sugar

10. Reduce stiffness in joints

11. Strengthen bones and reduce bone loss

12. Increase energy level

13. Improve lipids (increase HDL/lower LDL)

14. Improve posture

15. Promote sleep

16. Decrease stress, depression, and anxiety

17. Increase capacity for physical work

18. Increase life expectancy

19. Dr Provost said so

4 Steps to a Lifestyle of Physical Activity

Step 1: Set Personal Goals

Set goals based on the "reason to exercise" listed above. Example: "My goal is to achieve and maintain my goal weight."

Step 2: Determine How to achieve Goals

Choose activities that fit your lifestyle from each of the following categories:

1. Cardiovascular - Examples: walking, biking, treadmill, water exercise, aerobics/ fitness classes, dancing

2. Strength Training - Examples: weight machines, free weights, resistance bands

3. Flexibility - Example: stretching before and after exercise, Yoga, Pilates, Seated Chair Exercises

Schedule timing of physical activity

Choose location for exercise: Examples: home, mall, park, work, fitness center, church or school

Step 3: Implement Plan

Make a commitment and start today

Get started slowly and pace yourself

Stay consistent

Fit physical activity into your daily routine

Step 4: Regularly Evaluate Plan

Discuss with exercise physiologist/trainer/ Dr Provost

Monitor progress

Recognize achievement

Vitamin & Mineral Supplements for the

Gastric Bypass Patient

These should be taken EVERYDAY for the rest of your life:

|Supplement |Dosage |Suggestions |

|Multivitamin with Iron |2 chewable or liquid children’s multivitamins Begin after surgery.|Take separate from any Calcium supplements; usually at lunch |

| | | |

| | | |

| |You can switch to a solid daily multivitamin once on solid foods. | |

| |Examples: Bariatric advantage, Flintstones Complete, One A Day | |

| |Kids Complete, Centrum Junior | |

|Calcium Citrate with Vitamin D |1000-1200mg per day, divided into 2 doses. |Do not take at same time as Iron or within 1-2 hours of any other |

| | |meds. |

| |Check label to determine exact number of pills needed for your | |

| |particular supplement. |Take in 2 doses daily (usually breakfast and dinner). |

| | | |

| |Examples: Bariatric Advantage, Citracal Tropical Oasis, |Calcium supplement needs to contain Vitamin D, at least 400 IU. |

| |Bluebonnet (Liquid), Global Health (powder) | |

These should be taken only if directed by Dr Provost:

|Supplement |Dosage |Suggestions |

|Vitamin B12 |This can be taken as either a monthly injection (by |Sublingual tablets are available over the counter, take 1000mcg once daily |

| |primary care physician or yourself) or as a prescribed | |

| |weekly nasal gel or as over the counter | |

|Iron |Multivitamin should contain Iron, but you may need |Do not take at same time as calcium |

| |extra | |

| | |Increased absorption occurs when taken with 250mg of Vitamin C |

| |Especially important for menstruating women, people | |

| |with history of anemia or other chronic diseases | |

| | |Take with food, but not teas or coffee |

| |Ferrous fumarate and ferrous gluconate are most easily | |

| |absorbed (Vitron C, Ferro Sequels, or Fergon) |If causes upset stomach/ constipation, try ‘Slow Fe’ |

Multivitamin: A Multivitamin is important to make sure you are receiving all nutrients, especially right after surgery when your diet is very limited and your body is trying to heal. A chewable tablet is recommended to help avoid problems with swallowing. All supplements should be crushed or dissolved if they are not chewable. This should be taken daily for the rest of your life.

Calcium Citrate: A calcium supplement with vitamin D is necessary to maintain bone strength and avoid osteoporosis. Supplements should not be taken in doses over 500-600mg at one time. Recommendations are total 1000mg per day (or 1200mg per day if over age 50) along with at least a total of 800 IU of vitamin D.

B-12: Vitamin B-12 is essential for cell growth and reproduction. This vitamin requires gastric juice in order to be absorbed, so a deficiency may occur ~6 months after gastric bypass surgery.

Iron: Your body needs Iron to make red blood cells which transport oxygen to all parts of the body. A deficiency in Iron may result in anemia. Liquids such as coffee, tea, and cola prevent absorption while Vitamin-C rich foods help absorption.

It is advisable to begin regular vitamin supplementation at least 2 weeks prior to surgery. Your labs will be checked every 6 months for the first 2 years after surgery, and annually thereafter.

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