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Nutrition AfterBariatric SurgeryUnderstanding the behavior changes andlong-term care after bariatric surgery

Topic Outline Stages of the Diet after Surgery Vitamin and Mineral Supplementation Tips for Long-term Weight Loss and Health

Stages ofPostoperativeDiet

Stage 1: Days -1, 0 and1Pre-op (1 day before surgery)Day 0 Day of surgeryDay 1 Day after surgeryCLEAR LIQUIDS Wateror Ice chips Broth Diluted,clear 100% juice Sugar-free Jell-O Sugar-free popsicle*Limit sugar-free products(1/4 cup juice, ¾ water)

Stage II: Days 2 through 14FULL LIQUIDSFood that is blended to aTHIN liquid consistencysuch as milk.BLEND and STRAIN

What Can I Have? Protein shakes (!!!)Water (try alkaline if tap water not tolerated)Low-fat milkBroth with protein powderLow-fat, low-sodium blended and strained soupVegetable juiceDiluted fruit juice (1/4 cup juice, ¾ water)Plain cream of wheat (no sugar)Plain, low-fat yogurt (not Greek)Unflavored protein powder added to any full liquidsTo Prepare Full Liquid Foods . Use the blender until it is a thin liquid consistency Mix with liquid item to thin (broth, water, low-fat milk) STRAIN

Stage II Key points Begin liquid protein supplements Focus on rate of consumption Goal is 80-100 grams protein. Slowly work your wayup to this. Can take 2-3 weeks to reach this goal.Track volumeSlowly increase your rateGoal is 64 oz of fluid per dayLISTEN TO YOUR BODY STOP at first sign of fullness BEFORE you experience “stomach pain”

Protein Shake**Find a protein shake that you like before surgery** The protein drink should consist of the following:100-200 calories 10g sugar 15g carbohydrates 15g proteinper serving Avoid: “collagen” protein products – not a complete proteinDo not consume more than 30 grams of protein per meal/snackIf lactose intolerant: Look for vegan products or “100% whey Isolate”and avoid “whey concentrate”

Recommended Shakes Premier protein (Costco, Sam’s club)EAS Myoplex Lite (Walmart)Pure Protein (Trader Joe’s and www.pureprotein.com)Unjury shakes and unflavored powder (www.unjury.com)Isopure (Vitamin Shoppe)GenPro (unflavored 100% whey isolate)Bariatric Advantage shakes (www.bariatricadvantage.com)BiPro Unflavored Protein (www.biprousa.com) – discount code “UCLA”Orgain Organic Protein Powder (Costco and www.orgain.com)www.Insurenutrition.com supply protein drinks through your insurance

Stage II Sample Menu: Full LiquidMealLiquidsLiquid GoalProtein (g)BreakfastProtein ShakeSip water5 ounces5 ounces15SnackProtein ShakeSip water5 ounces5 ounces15LunchBlended/StrainedSoup with unflavoredprotein addedSip water5 ounces20SnackProtein ShakeSip water5 ounces5 ounces15DinnerProtein ShakeSip water5 ounces5 ounces15SnackProtein ShakeSip water5 ounces5 ounces15Total: 60 ozTotal: 955 ounces**Remember to work your way up to this. It may take 5-10 days to be able to drink this much!

Stage IIIWeek 3 through 5Day 15-35SOFT FOODSFoods that are soft or chewed easilyThink baby food

What Can I Have?Protein/dairy Scrambled egg, egg whites, poached eggs Low-fat cottage cheesePureed meats Do not overcook. Must be softSoups, patéSoft fish, Soft tofuEgg/chicken/tuna salad made with low fat plainGreek yogurtLow/nonfat vegetarian refried beans Or homemade, pureed beans

What Can I Have?Fruit/vegetablesUnsweetened applesauce Soft banana Pureed fruit/veggies Canned fruit in water or juice (rinsed) Well-cooked, low-fiber vegetables Squash, spinach, carrotsLow Fat, low sodium pureed soups

Stage III Key Points Introduce one new food item at a time. Eat slowly and sip your liquids. No liquids 15 minutes before meals and 30minutes afterwards. Discontinue the use of fruit juices. Avoid soft, high-calorie food and drinks such asice- cream, which go down easily, but can haltweight loss.

Stage III Key Points Continue to get 40-60g protein from proteinbeverages The rest you should get from food. Goal is 80-100grams proteinNO MORE THAN:3/4 cup (6 oz) of food per meal ½ cup (4 oz) of food per snack Avoid regular texture food until 6 weeks postsurgery!

Stage III Key PointsPortion Sizing Portion sizing plates Portiondiet.com Purchase plates and meal plans for bariatrics , designedby a bariatric dietitian Using smaller plates, bowls and utensils helpsyou feel fuller – like an optical illusionEbbinghas Illusion, Wikipedia source

Stage III Sample Menu: Soft FoodsMealFoodsAmountProtein (g)BreakfastScrambled egg (soft)Low fat cottage cheese11 Tablespoon10SnackProtein Shake5 fluid ounces(1/2 bottle)15LunchTuna salad with low-fatplain Greek yogurtPureed veggie soup2 ounces142 TablespoonSnackProtein Shake5 fluid ounces(1/2 bottle)15DinnerSoft fishMashed carrotsMashed unsweetenedyams2 ounces1 Tablespoon1 Tablespoon14SnackProtein Shake6 fluid ounces(1/2 bottle)15Total: 83** SIP SIP SIP water! (Stop 15 minutes before meal/Start 30 mins after)

Stage IVStart of Week 6, Day 36Solid Foods! Expand your food choices as tolerated Goal is 800-1200 calories, 80-100 grams protein/day Goal will vary from person to person One new food item at a time Maintain fluid intake Goal is 64 ounces. Sip! Sip! Sip! No liquids 15 minutes before meals and 30 minutes afterwards NO MORE THAN 3/4 cup of food per meal and ½ cup food per snack

Stage IV Tips Eat SLOWLY and CHEW your food Take 20-30 minutes to eat each meal! STOP at the first sign of fullness Avoid caffeine It is a diuretic and can dehydrate youContinue protein supplements Goal is 80-100 grams protein If this goal can not be met from food alone, continue toincorporate protein shakes

Food Choices At mealtime: Eat protein first, then vegetables, then carbohydrates Choose complex carbohydrates Avoid simple carbohydrates, which are low in nutritional value Chicken breast, low fat cottage cheese, whole vegetables, whole fruitsAvoid trigger food White bread, cookies, cakes, fruit juiceChoose nutritionally dense foods Whole grains, brown rice, quinoa, barley starchy vegetablesUsually high in sugar and fatsTough meats: Avoid steaks for 3 months after surgery; Some may continue to have difficulty toleratingmeat after this time

Stage IV Sample Menu: Solid FoodsMealFoodsAmountProtein (g)BreakfastScrambled egg whites100% Whole grain toast21 Slice74SnackPB2 powder½ peeled apple4 tbsp10LunchSteamed chicken breast,skinlessSpinach salad with oliveoil and lemon juice2 ounces14Snack2% plain Greek yogurtStrawberries½ cup¼ cup12DinnerBaked SalmonQuinoa, cookedSauteed Mushrooms2 ounces¼ cup¼ cup142SnackProtein Shake12 fluid ounces(over 1 hour)251 cupTotal: 88** SIP SIP SIP water! (Stop 15 minutes before meal/Start 30 mins after)

Post-Operative WARNINGS Avoid alcohol Avoid carbonated (bubbly) drinks The bubbles can give you gas, cause bloating and painAvoid chewing gum It is dehydrating and has no nutrientsIf you swallow it, gum can block the stomach openingDo not drink from a straw You can’t control your intake with a straw, which can be painfulThe straw makes you swallow air, which causes bloating and canbe painful

Post-Operative WARNINGS Do not drink with your meals Avoid items with greater than 10 grams sugar Avoid coffee and caffeinated tea for 3 months after surgery Only decaf from months 3-12Can start regular coffee and tea after 1 year if there no nutritionalissues The caffeine in coffee or tea is a diuretic and can dehydrate you Caffeine increases gastric acids, which causes heartburn andgastroesophageal reflux It limits the absorption of calcium and iron

Beware of Dumping Syndrome Early Dumping: Immediate reaction to sugar and fat Symptoms: Diarrhea or nausea Late Dumping: Occurs 2 hours after a meal that is usually high in carbohydrate and containslittle to no protein (avoid by always having a protein with meals) Symptoms: Fatigue, sleepiness, lightheadedness, near fainting, sweating, lowblood pressure, reactive hypoglycemia What can cause Dumping:Anything with more than 10-15 grams sugar Milkshakes, coffee drinks, fruit juice, sport drinks High fat liquids and foods: Creamy soups, alfredo sauce

Gout Flares It is possible to have gout flares after surgery due torapid weight loss and high protein intake Avoid foods high in purine Turkey Some seafood: anchovies, herring, sardines, mussels,scallops, trout, haddock, mackerel and tuna Increase consumption of Low-fat dairy (greek yogurt, milk, cottage cheese,etc) Whole grains (quinoa, whole wheat bread, brownrice, etc) Fluids (alkaline water, herbal tea)

StretchBreak!

VitaminsandMinerals

Vitamins Why do we need them? Bypass creates a degree of malabsorption andsleeve creates a degree of restriction You are at an increased risk of not receivingenough from your food Will require life long supplementation Will require regular monitoring of blood values inorder to measure body requirements 3 month, 6 month, 12 month and annual appointments

Vitamin AVitamin DB1ThiaminB6PyridoxineFood SourcesDeficiencies maylead toAnimal fats, milk, cheese, eggyolk or beta-carotene: carrots,dark leafy green vegetables,carrots, cantaloupe, sweetpotato, peachesEgg yolk, fortified juice/ milk,and sunlight, liver, salmon, tunafish, and sunlight.Nyctalopia (nightblindness), dry skin,xerophthalmis (cornealdamage)Fortified cereals, beans, pork,liver, grains, potatoesBeriberi, memory loss,tachycardiaRickets, osteomalaciaFortified cereal, banana,Microcytic anemia,legumes, sunflower seeds, beef, dermatitis, glossitis,pork, liver, egg yolk, oatmealperipheral neuropathy(nerve damage),convulsion

Best source: animal protein;Cyanocobalamin liver, milk, fish, eggs, cheese,and meat. Vegans arerequired to use supplements.B12CalciumIronZincSpinach, dairy products,legumes, , oysters, kale,clams, tofu, sardinesHeme iron: animal foods;meat, fish poultry. NonHeme: fortified cereals, &vegetables. Need Vitamin Cto help with absorption.Caffeine inhibits absorptionof iron.Pernicious anemia (dueto lack of intrinsicfactor), macrocyticanemia, megaloblasticanemiaTetany muscle spasmsIron deficiency anemia,pale tongue, fatigue,spoon-shaped nails,Best source; animal protein. Poor wound healing,Meat, fish, eggs, liver,hypogeusia (tasteoysters, beef, clams, herring sensitivity), alopecia

Vitamin and Mineral Intake SummaryBEGIN DAY 2 POST OP (FULL LIQUIDS)Everyone MultivitaminIf Doctor Recommends B-complex Calcium Citrate Folic AcidIronVitamin DVitamin AZincBEGIN DAY 2 POST OP (FULL LIQUIDS)

Multi-Vitamins Well balanced daily multi-vitamin containing 100% of dailyvalue (Multi-plus, Multi-Complete) Choose a complete adult formula such as www.bariatricadvantage.com – discount code UCLA www.wellesse.com www.PatchMD.com - Available at 100 UCLA Medical plaza www.bariatricfusion.com – Available at 100 UCLA medical plaza*Best to look for Bariatric targeted supplements Route/Form: Capsule, Patch Liquid: usually 30 cc once a day Chewable/Chew NO GUMMIES! NO children’s formulas!

B-Complex Well balanced daily B-complexthat includes: B1, B9, B12 and B6Route/Form: Capsule, Chewable, or Liquid Take as directed on the bottle unless otherwisespecified by your Doctor

Calcium Name: Calcium Citrate Route/Form: Capsule, patch, chewable or liquidOral Dose: 1000-1200 mg per day PLUS 400-800 IU Vitamin D 500 – 600 mg is absorbed at one time Space at least 3 hours apart If taking an iron supplement space iron and calcium apart by2-3 hours.

Make Your Supplement Life Easy!Find a vitamin that incorporatesEVERYTHING Read the label and check the %DV Some companies to try:Patch MDBariatric Fusion Chews or Stick Pack

Vitamin and Mineral Intake SummaryBEGIN DAY 2 POST OP (FULL LIQUIDS)Everyone MultivitaminIf Doctor Recommends B-complex Calcium Citrate Folic AcidIronVitamin DVitamin AZincBEGIN DAY 2 POST OP (FULL LIQUIDS)

Fiber Supplement Why do you need it? Regularity, prevent constipation Dose: Variable per person, as needed Forms: Powder: Metamucil, Benefiber, Psyllium Husks Liquid: Milk of Magnesia Don’t forget: 64 ounces of water and exercise helpsmove things along