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Center for Obesity and MetabolicHealth (COMET)2

Meet the DietitiansChristine Zouein, MS RDNczouein@mednet.ucla.eduAllison Barbera, MS RDNabarbera@mednet.ucla.edu3

Nutrition After Bariatric SurgeryThe providers will evaluate your nutritional status and labs:2 weeks: with surgeon and dietitian3 months: with nurse practitioner and dietitian6 months: with nurse practitioner and dietitian12 months: with surgeon and dietitianAnnual follow-up visits: with surgeon and dietitian4

Stages of Postoperative Diet5

Stage I: Clear LiquidsA clear liquid diet consists of clearliquids such as water, broth andsugar-free gelatin to help preparethe body before surgery and heal thebody after surgery.Day -1 Pre-op (1 day before surgery)Day 0 Day of surgeryDay 1 Day after surgery Water or Ice chips Broth Diluted, clear 100% juice (1/4 cup juice, ¾ water) Sugar-free Jell-O Sugar-free popsicle Herbal tea (caffeine free) Country Time Sugar FreePink Lemonade Mix Sugar Free Kool-Aid mix Crystal Light Propel6

Clear Liquid Diet Sample MenuPrior to SurgeryDay Of Surgery/Day After SurgeryMealIntakeMealIntakeBreakfast priorto 10 AMYour Choice (for example,2 eggs, 1 slice toast)Breakfast½ Premier Protein ClearSip waterSnackLow sodium vegetablebrothSip waterSnackSugar free Jell-oSip waterLunchPremier Protein ClearSip waterLunch½ Premier Protein ClearSip waterSnackLow sodium chicken brothSip waterSnackLow sodium chicken brothSip waterDinnerLow sodium vegetablebrothSip waterSnackSugar free popsicleSip waterDinnerPremier Protein ClearSip waterSnackSugar free popsicleSip water7

Stage II: Full LiquidsDays 2 through 14Full liquid diet (milk-like) consistencyAim for 3 protein shakes dailyAim for 80-100 g protein and 64 oz.daily as tolerated (fluid goal does notinclude protein shakes)8

Stage II: Full LiquidsProtein shakes / powdershould meet thefollowing:100-200 calories 10g sugar 15g carbohydrates 20g protein perserving9

Stage II: Full Liquids Choose ready to drink shakes OR blendprotein powder with water or low-fat milkand strain For a savory option, add unflavored proteinpowder to broth or use Unjury ChickenSoup Protein If lactose intolerant: look for veganproducts or “100% whey isolate” and avoid“whey concentrate” Avoid predominantly “collagen” proteinproducts – not a complete proteinBlend then strain protein shakes NO FRUIT SMOOTHIES- no adding fruit!10

Recommended SupplementsFind protein products that you like before surgery but remembertaste buds may change after afterwards Bariatric Advantage (www.bariatricadvantage.com) Ensure Max Protein (Walmart, Target, CVS) Fairlife Nutrition Plan (Amazon, Sam’s Club) Genepro- Dissolves well in soup and food (Amazon) Premier Protein (Costco, Sam’s club) Pure Protein (Trader Joe’s, Ralph’s, www.pureprotein.com) Isopure (Vitamin Shoppe) Muscle Milk (Target, Walmart, Vitamin Shoppe) Orgain Organic Protein Powder (Walmart and www.orgain.com) Unjury (www.unjury.com) try the chicken soup flavored proteinpowder as a savory option Vega (Target, Vitamin Shoppe)11

Stage II Full Liquids Sample MenuMealLiquidsProtein (g)Breakfast½ Protein Shake15Snack½ Protein Shake15LunchUnjury Chicken Soup21Snack5Dinner½ cup thinned plainyogurt (with cinnamonand stevia)½ Protein Shake15Snack½ Protein Shake15Calorie Goal: 450-550Total: 8612

Stage II Full Liquid Key PointsSpace meals every 2-3 hoursBegin liquid protein supplements – goal of80-100 grams protein Slowly work your way up to this, itcan take 2-3 weeks to reach thisgoalFocus on rate of consumption – goal of 64oz. fluid per day Track volume Slowly increase your rateDrink meals every2-3 hours80-100 g protein64 oz. waterSTOP at first sign of fullness,BEFORE you experience stomachpain13

Stage II Full Liquid Diet Warnings NO solid foods untildesignated time The greatest risk ofdeveloping leaks happenwithin the first 2 weeksafter surgery14

Stage III: Soft FoodsDays 15 through 35, Weeks 3-5 The soft food diet consists of foods that are soft,mashed or pureed This helps to transition to solid foods andminimize stomach discomfort These foods are nutritious and easy to digest Do not prematurely advance to solid foods, asthis can be dangerous15

Stage III: Soft Foods, ProteinLow fat dairy: cottage cheese (noadded fruit), Greek yogurt, ricottacheese, other soft cheesesEggs: Egg Beaters, egg whites,whole eggs, boiled, scrambled,baked, poachedPureed meats, moist ground meatssuch as turkey or chicken Prepared with broth or invegetable soup Slow cook chicken untiltenderSoft fish: tuna, tilapia, grouper,cod, haddock, sea bassLegumes: black beans, peas,kidney beans, garbanzo beans, whitebeans, lentils, vegetarian refriedbeans, mashedTofu: tofu, Boca BurgerShellfish: scallops, lobster, shrimp,crabHomemade egg/chicken/tunasalad made with low fat plainGreek yogurt, olive oil, lowfat mayo or pickle juice fortaste and moisture16

Stage III: Soft Foods, Fruits and Vegetables Pureed or mashed fruit, fresh or canned inwater: unsweetened applesauce, banana,blackberries, blueberries, cherries, honeydewmelon, kiwi, peaches, pears, raspberries, seedlessgrapes, seedless watermelon, strawberries No dried fruit Avoid seeds Pureed, steamed/mashed vegetables:artichokes, beets, cabbage, carrots, cauliflower,garlic, leeks, mushrooms, onion, pumpkin,spaghetti squash spinach, tomatoes, zucchini Pureed, strained vegetable soups are safe17

Turkey Chili Recipe Adapted from My Bariatric DietitianPost-operative serving: 1/4-1/2 cupServes: 16Nutrition facts:Ingredients:Fat: 2 grams1 lb. lean ground turkeyCarbs: 8 grams1-2 tbsp. olive oilFiber: 2 grams1 (14.5 oz.) can kidney beansProtein: 6 grams1 (28 oz.) can diced tomatoesTip:Calories: 751 (8 oz.) can tomato pureeFreeze someleftover chili foran easy, healthymeal1 large onion, finely chopped4 tsp minced garlic1 tsp c-turkey-chili2 tbsp. ground cuminDirections: Place a large skilled over medium-high heat and add ground turkey. Usinga wooden spoon, break it into smaller pieces and cook until browned, 7-9 minutes.While turkey browns, in a medium to large pot, heat olive oil over medium heat. Addthe onions, garlic and spices to the pot and sautee until soft. Add the turkey to the pot.Mix in the diced tomatoes, tomato puree, and tomato paste. Bring to a boil. Onceboiling, reduce to simmer and cook for 15-20 minutes. Serve immediately or cool andstore in fridge for up to 5 days.18

Stage III: Soft FoodsDays 15 through 35, Weeks 3-5Food Recommendations Food should be soft and eithermashed or pureed Eat slowly and chew well Add one new food at a time to testtolerance Use moist cooking methods such asboiled, baked, sautéed, poached,stewed or braised Use broth to moisten food Avoid grains (oatmeal, cream ofwheat, rice, bread, noodles,crackers, pasta, etc.) Don’t bread or fry foods Avoid spicy foods (jalapenos,chili powder, cayenne, etc.) Other seasonings are safe toflavor food (salt, pepper, garlic,cumin, cinnamon, etc.) Avoid red meat for 3-6 months Avoid sugar sweetened andcaffeinated drinks such asjuice, soda, energy drinks,coffee for at least 3 months Avoid carbonated drinks for 3months19

Stage III Soft Foods Sample MenuMealFoodsAmountProtein (g)BreakfastScrambled egg (soft)Low fat cottage cheese11 Tablespoon10SnackProtein Shake5 fluid ounces(1/2 bottle)15LunchTuna salad with low-fat plainGreek yogurtPureed chicken veggie soup2 ounces162 TablespoonSnackProtein Shake5 fluid ounces(1/2 bottle)15DinnerSteamed soft fishMashed carrotsMashed sweet potato2 ounces1 Tablespoon1 Tablespoon14SnackProtein Shake5 fluid ounces(1/2 bottle)15Calorie Goal: 600-800Total: 85 gSip water, stopping 15 minutes before meal and starting 30 minutes after20

Stage IV: Solid foods21

Stage IV: Solid foodsDay 36, Start of Week 6Goal of 800-1200 calories, 80-100 grams protein/dayGoal will vary from person to personMaintain goal of 64 ounces of fluid per day Noliquids 15 minutes before meals and 30 minutesafterwardsPortion control 1/2 cup food per snack and 3/4 cup offood per mealIntroduce one new food item at a time22

Stage IV: Solid foods Key Points Eat slowly and chew your food - Take 20-30minutes to eat each meal! Stop eating at the first sign of fullness Continue protein supplements to meet goal of80-100 grams protein If this goal cannot be met from food alone,continue to incorporate protein shakes andsupplements*Wait 3 months to try steak23

Stage IV Sample Menu: Solid FoodsMealFoodsAmountProtein (g)BreakfastScrambled egg whites100% Whole grain toast21 Slice74Snackpeanut butter½ peeled apple1 tbsp.4LunchSteamed chicken breast,skinlessSpinach salad with olive oiland lemon juice3 ounces21Snack2% plain Greek yogurtStrawberries½ cup¼ cup12DinnerBaked SalmonQuinoa, cookedSauteed Mushrooms3 ounces¼ cup¼ cup212SnackProtein Shake5 fluid ounces15Kcal Goal: 800 – 1200½ cupTotal: 8624

Things to Remember1.2.3.4.Eat protein first, then non-starchy vegetables, thencomplex carbohydratesChoose lean protein: turkey, chicken, fish, lean cuts ofbeef, soy, low-fat dairyChoose non-starchy vegetables (vegetables with a highwater content)Choose complex carbohydrates: whole grains, brown rice,quinoa, barley, buckwheat, fruit, yucca, plantains, lentilsstarchy vegetables (corn, peas, beans, potatoes)25

Limit:Sugarlimit to 10 g per serving, toomuch can cause Dumping SyndromemonthsTough Meats: Limit for 3-6 months Can introduce decaf after 6 weeksAlcohol: Limit 1 yearTrigger foods are easy to over-eat/hardpost-surgery High in caloriesRisk for transfer addictionSlows down metabolismDehydratingCarbonated (bubbly) drinks,drinking through a straw andchewing gum: Limit 3 months Can create gas, causing bloatingand pain If chewing gum is swallowed, cancause a blockageCoffee and caffeinated tea: Limit 3 Caffeine can cause heartburn and refluxto portion control (chips, chocolate, icecream, cake, crackers, cookies, etc.)Excess calories Coffee and tea drinks (latte, frappuccino,creamers, chai teas, etc.) are high inprocessed sugars, fats, and calories Use low fat milk, unsweetenedalmond/soy milk and avoid added sugarin your drinks26

Early & Late Dumping SyndromeEarly Dumping: Immediate reaction to sugar and fat Symptoms: diarrhea or nauseaLate Dumping: Occurs 2 hours after a high carbohydrate meal that contains little to no protein Symptoms: Fatigue, sleepiness, lightheadedness, near fainting, sweating, low bloodpressure, reactive hypoglycemia To prevent, pair carbohydrates with proteinWhat 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 sauce27

Gout FlaresGout flares may develop after surgery due to rapid weightloss and high protein intakeAvoid foods high in purine: Turkey Some seafood: anchovies, herring, sardines, mussels,scallops, trout, haddock, mackerel and tunaIncrease consumption of: Low-fat dairy (Greek yogurt, milk, cottage cheese,etc.) Whole grains (quinoa, whole wheat bread, brownrice, etc.) Fluids (alkaline water, herbal tea)28

SupplementationWhy do we need to take vitamins / minerals? Bypass creates a degree of malabsorption Sleeve creates a degree of restriction You are at an increased risk of malnutritionWe recommend life long supplementation, take vitaminsdaily!We will regularly monitoring your blood values in order tomeasure body requirements:3 month, 6 month, 12 month and annualappointments29

Vitamin and Mineral SupplementationEveryone Begin Day 2 Post-Op1. Multivitamin2. B complexOR1. Bariatric Multivitamin30

Multi-Vitamins- (Begin day 2 post-op)Look for a well balanced daily multi-vitamin containing 100% of daily value (Multiplus, Multi-Complete) Choose a complete adult formula such as www.bariatricadvantage.com For example, One a Day Ultra Solo (capsule), Chewy Bites, etc. The chewy bites are a good option if you are prone to nausea www.bariatricfusion.com www.barilife.com www.procarenow.com www.unjury.comRoute/Form: Capsule Chewable Liquid: usually 30 cc once a dayNo gummies!31