dietary advice following laparoscopic gastric banding · 2018-11-26 · dietary advice following...

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Dietary advice following laparoscopic gastric banding

Information for patientsSheffield Dietetics

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What is the purpose of laparoscopic gastric banding?

The laparoscopic gastric band is a tool to help you lose weight. The gastric band is placed around the top of your stomach to form a pouch. The pouch is approximately the size of an egg cup (15-30mls). The gastric band can be adjusted by adding or removing the fluid inside the gastric band through the port, to control your appetite and portion sizes.

Initially after the operation, the pouch will only be able to hold approximately 25g / 1oz or 2 tablespoons. Once the gastric band is adequately adjusted it will slow the rate at which food is emptied into your stomach, making you feel full sooner and for longer after meals.

You will need to work closely with the dietitian and nurse to achieve successful and safe weight loss.

You will need regular clinic appointments to assess whether your band is adequately adjusted and your diet is suitable.

Band adjustments will be arranged, if needed, following your clinic appointment. However, you will need to come back to the hospital for your band adjustment as it cannot be done on the same day.

Follow up

Particularly in the two years following your operation, you will need to work closely with the dietitian and specialist nurse to ensure that your new eating habits and lifestyle changes help you to achieve successful and safe long term weight loss. You will be required to attend regular reviews in order to check your weight, vitamin and mineral blood levels and dietary intake.

You should not require routine gastric band tightenings after 2 years following your surgery. However, if you feel that this is the case, you should speak to a member of the team in clinic to decide on an individual weight loss plan.

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The laparoscopic gastric banding diet

The diet is designed to result in significant weight loss. By developing new eating habits, reducing your intake and following the dietary advice, you will not only lose weight but also help maintain this weight loss in the longer term if you continue to follow the advice.

Protein

It is important to have protein in your diet after the operation, to ensure that your wounds heal properly. In the long term, protein will help preserve your muscle and encourage your fat stores to be used as energy.

Foods high in protein and low fat foods include:

• Fish and shellfish• Semi-skimmed or skimmed milk• Lean meat, such as chicken, turkey• Peas, beans and lentils• Eggs• Soya, tofu, seitan and Quorn• Light cream cheese / reduced fat soft cheese• Low fat cottage cheese• Diet / light yoghurts• Low fat fromage frais

High sugar foods and fluids to avoid

These foods and fluids will slow your weight loss:

• Full sugar fizzy drinks, such as cola, lemonade• Full sugar cordials / squashes• Mints / toffees / boiled sweets (unless sugar free)• Energy drinks, such as Lucozade, Powerade, Red Bull, Monster

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• Alcohol• Sugar and syrups added to tea and coffee• Full sugar jelly• Jam / marmalade / lemon curd• Honey• Syrup / treacle / glucose syrup• Chocolate• Biscuits / cake / pastries / donuts• Puddings• Ice cream / sorbet• Icing• Meringue

Fat

Fat is a concentrated source of calories and can be difficult to digest after surgery. Fat can delay stomach emptying and lead to heartburn and slow your weight loss.

High fat foods / drinks to avoid are:

• Fatty meats / products such as sausages, pate, corned beef, streaky bacon, burgers, sausage rolls, pasties, scotch eggs, kebabs, pork pie, meat pies and quiche

• All food covered in batter or breadcrumbs• Butter / margarine / lard / dripping / oil / ghee• All fried foods• Mayonnaise• Salad cream• Salad dressings• Whole milk• Condensed milk / evaporated milk• Cream / cream cakes

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• Cake• Pastries• Full fat cheese• Full fat yoghurts• Biscuits• Crisps• Chips• Nuts• Samosas / pakoras

Cooking methods

It is important to consider the cooking methods that you use to reduce your fat and calorie intake. Avoid frying and roasting. Grill, bake, microwave, stew, poach, boil, and steam instead.

Fluid

It is important that you drink at least two litres of fluid per day, to ensure that you do not become dehydrated and to help prevent constipation.

Fluids to choose are:

• Water• Low calorie / reduced sugar / no added sugar squash• Diet drinks• Non-fizzy diet drinks• Tea• Herbal tea• Coffee• Semi-skimmed / skimmed or 1% fat milk• Diluted fruit juice (half water and half fruit juice)• Thin liquid fruit smoothies• Diet or light malted / chocolate drinks

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You will need to take small, slow, frequent sips of fluid throughout the day.

Take fluids in between meals and at least 30 minutes before and after meals, as you may not be able to manage as much food because your stomach will be filled with fluid. Eating and drinking together may also cause you to vomit and may also stretch your stomach above the gastric band (pouch dilatation).

Fizzy drinks

Fizzy drinks should be avoided in the long term, as they can make you feel bloated and may cause the gastric pouch to stretch (dilate).

Alcohol

Alcohol is not recommended for 12 months after surgery. It is high in calories and provides little nutrition. Alcohol will slow your weight loss or even lead to weight gain.

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The laparoscopic gastric band diet

There are four stages to the gastric band diet:

The exact time of progressing to the next stage varies between individuals. It is important to ensure that you do not rush through each stage and move on before you are ready, as you are more likely to get pain and to vomit.

You are less likely to have problems if you slowly introduce textured foods and follow the dietary rules.

Each time your gastric band is adjusted you will need to make your way up through the dietary stages again.

Moving through the dietary stages

You will find that your portion sizes will gradually increase during the first 4-6 weeks.

By week 4-6 after the operation, you should be able to eat a normal textured diet (stage 4). At this stage you should include three regularly spaced (up to tea plate sized) meals. Avoid missing meals.

Stage 1 Stage 2 Stage 3 Stage 4

Fluids only

→ Pureed diet → Soft/mushy/crispy diet

→ Solid textured diet

Day 1 and 2

→ From day 3for 1-2 weeks

→ From week 2 to

week 4

→ From week 4 onwards

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It is important to remember that you still need to restrict the calories and portion sizes to help you to lose weight.

Remember your new stomach is approximately the size of an egg cup. It is important that you avoid vomiting as it can cause problems with your band and make it more likely to slip. Vomiting is not normal after a gastric band operation. If you are vomiting it is worth asking yourself whether you are following the dietary rules and eating the correct texture of food for the stage you are at after surgery.

Stage 1 - High protein nutritious fluids

For the first two days after your operation you should have liquids only.

After your surgery you will only be able to take small sips of fluid and will have intravenous fluids through a drip. You will start with sips of water and then gradually build up to small (25 - 50ml), slow, frequent drinks.

Use a straw or a water bottle with a sports cap to prevent you taking large amounts of fluids at any time. Include a nutritious liquid such as a meal replacement drink or smooth thin soup at meal times.

Fluids allowed include:

• Water• Semi-skimmed / skimmed or 1% fat milk• Diluted fruit juice (half water and half fruit juice)• Meal replacement drinks, such as Slim and Save / Tesco Ultra Slim

/ Slim Fast (one at lunch and one at dinner)• Smooth diet / light yoghurt drinks• Strained / liquidised thin soup• Low calorie / reduced sugar / no added sugar squash / cordials• Tea / coffee / herbal teas• Thin, smooth fruit smoothies

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Stage 2 - Low calorie liquids / smooth protein pureed foods

Once you have been able to tolerate 2 days of liquids you can move onto pureed foods. It is important that you follow this liquid / puree diet for the first 2 weeks after your operation to allow your band to settle in the correct position. Choosing high protein options will help your wounds heal.

Pureed food should not be of a thick and dry consistency, but be the consistency of custard with no lumps or bits.

It is much easier to use a blender to prepare your pureed meals. If the puree is too thick once blended, just add more sauce or gravy.

You should eat small, frequent meals to ensure that you get enough nutrition. Begin with 2-3 tbsps of food at each meal and aim for 4-6 meals a day. Over time your portion sizes will naturally increase. You should be aiming for no more than a tea plate sized portion three times a day.

You may find it more convenient to freeze meals in ice cube / small containers, so that meals can be prepared quickly and food is not wasted.

Aim for at least two litres of fluid each day. Wherever you go, take a bottle of water with you. Meal replacement drinks or smooth soup would count as both a meal and liquid if you are struggling to eat enough.

Eat slowly, as soon as you feel full, stop eating, as you may vomit. In time, you will be able to recognise your tolerance level to food and fluid and feeling of fullness. Remember that your new stomach is only the size of an egg cup.

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Meal plan for stage 2 - Liquid / smooth pureed diet

Breakfast (choose 1)

• 2-3 tbsp (half) Weetabix / porridge / Ready Brek with plenty of semi-skimmed / skimmed or 1% fat milk made to a very runny / liquid consistency

• 2-3 tbsp soft pureed scrambled egg• 1 meal replacement drink (Slimfast, Tesco Ultra Slim or Slim and

Save)

Mid morning (choose 1)

• 200ml semi-skimmed / skimmed or 1% fat milk• 150ml fruit smoothie• 2-3 tbsp diet / light smooth yoghurt• 2-3 tbsp low fat fromage frais• 2-3 tbsp smooth low fat custard• 2-3 tbsp light smooth mousse made with semi-skimmed /

skimmed or 1% fat milk• 2-3 tbsp milky pudding, such as tapioca, sago or rice pudding

pureed

Lunch (choose 1 protein item, add a carbohydrate food and some vegetables) meals should be no more than 2-3 tbsp initially

Protein

• Finely minced, pureed meat, such as chicken / turkey / beef / pork• Pureed tender fish, such as haddock, cod or plaice• Pureed tinned fish in water, tomato sauce or brine, such as

salmon, tuna, mackerel, pilchards• Pureed lentils / beans / pulses• Pureed meat free mince / chicken / fillets or tofu• Smooth soft meat / fish / vegetable pate / paste

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• Very soft cooked scrambled egg• Light cream cheese or grated reduced fat cheese mixed into hot

food, such as pureed potato• Plain low fat cottage cheese• 1 x 200ml smooth soup (with meat, fish, chicken, peas, beans,

lentils, tofu or other meat-free alternatives), add in some pureed vegetables

• 1 meal replacement such as Slimfast, Tesco Ultra Slim, Slim & Save (do not need to have with carbohydrate or vegetable foods)

Carbohydrate

• Pureed mashed potato / sweet potato

Vegetables

• Pureed vegetables, such as broccoli, cauliflower or carrots mixed with white / cheese sauce or gravy

Mid-afternoon (choose 1)

• 200ml semi-skimmed / skimmed or 1% fat milk• 150ml fruit smoothie• 2-3 tbsp diet / light smooth yoghurt• 2-3 tbsp low fat fromage frais• 2-3 tbsp smooth low fat custard• 2-3 tbsp light smooth mousse made with semi-skimmed /

skimmed or 1% fat milk• 2-3 tbsp milky pudding, such as tapioca, sago or rice pudding

pureed

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Evening meal (choose 1 protein item, add a carbohydrate food and some vegetables) meals should be no more than 2-3 tbsp initially

• See 'Lunch'• Remember you can add herbs and spices for extra flavour

Supper

• 2-3 tbsp smooth puree fruit• 200ml semi-skimmed milk (sipped slowly)

Only move onto stage three soft / mushy & crispy, when you can eat more than half a tea plate sized portion of pureed food and

you do not feel much (if any) restriction.

Move onto stage 3 no earlier than week 3.

Stage 3 - Soft / mushy & crispy foods (week 3 onwards)

You should continue to choose the foods from stage two but slowly introduce new foods and replace them with more texture and variety. Crispy foods are foods which will fall to bits in water, such as melba toast, crisp breads and bread sticks. They are not the same as crunchy foods such as raw vegetables and salad. Crunchy foods are likely to cause problems if eaten at this stage.

Start with 2-3 tbsps of food and gradually increase your portion size. It is better to underestimate your portion sizes to avoid feeling uncomfortable and causing pain. It will also prevent vomiting.

You may find when you move onto stage 3 that you can eat less than you could on stage 2. This is because the food is more textured and will make you feel fuller more quickly.

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If you are able to manage up to a tea plate size portion then have 3 meals per day. Cut out any snacks or calorie containing liquids in between meals, these fluids / snacks will slow your weight loss.

Soft, mushy, crispy foods should be:

• Soft, tender, well cooked and moist but need some chewing• Able to be mashed with a fork• It usually requires a thick, smooth low fat sauce or gravy to help

get the right texture• Vegetables should be cooked until soft; remove any skins

Caution: Foods to be avoided

These foods should be avoided at this stage of the diet. They are only to be included once you are well established at the final stage of the diet, stage 4 (normal, solid foods), and are tolerating a wide variety of foods. Trying these foods too early can cause vomiting or damage to your new pouch.

• Non-toasted bread, particularly soft, white, doughy bread• Pasta, unless small shapes with plenty of sauce, cooked until very

soft• Rice, unless risotto rice or rice pudding• Skins and husks from potatoes, vegetables and fruits, such as

sweetcorn, peppers and jacket potatoes• Stringy vegetables and fruits, such as green beans, celery, lettuce

and pineapple• Pips, seeds and pith from fruits and vegetables, such as oranges• Mushrooms• Nuts• Dried fruit

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Soft, mushy, crispy diet plan

Most people can still only manage between 2-5 tablespoons (tbsp) of food at meal times. It is better to under-estimate your portion size to avoid feeling uncomfortable and causing pain. It will also prevent vomiting. This menu plan is intended as a guide only. Remember if foods are chosen that aren’t on this plan, you must ensure that they are soft, mushy or crispy!

Foods to try and introduce are:

• Soup with bits in, such as vegetables, meat, chicken, lentils, tofu, beans

• Casserole / stew / hot pot• Fish pie / shepherds pie / cottage pie• Minced meat, such as beef, lamb, pork, turkey, with a sauce or

gravy• Tinned meat particularly in sauce / gravy, such as minced beef /

lamb, chicken, ham, stewed steak• Soft, boneless fish, such as cod / haddock in white sauce / parsley

sauce (mashed) • Fish fingers / fish cake• Tuna / salmon tinned in brine / spring water• Soft plain omelette• Soft-boiled/poached egg• Well mashed and mushy beans, lentils and peas, baked beans• Tinned vegetables or softly cooked vegetables such as carrots,

cauliflower or broccoli• Tinned dishes, for example ravioli, macaroni cheese, beans,

spaghetti, tomatoes• 1-2 bread sticks / melba toast / crackers / crisp bread or half slice

of wholemeal toast (without crust) with low fat spread / light cream cheese / pate / paste

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• Jacket potato with no skin or mashed potato with fillings• Macaroni cheese / cauliflower cheese (mashed) with soft

vegetables• Soft fruit such as ripe melon, ripe mango, banana, raspberries,

strawberries, kiwi and blackcurrants• Beetroot, radish, tomatoes (without skin), cucumber without skin

Breakfast (choose 1)

• ½ -1 slice wholemeal toast (no crust) and scraping of margarine with 1 very soft scrambled egg or baked beans

• Soft fruit such as a ripe banana or melon with low fat yoghurt or fromage frais

• 3 tbsp breakfast cereals such as Rice Krispies, Weetabix, Corn Flakes (fully softened with skimmed, 1% fat or semi-skimmed milk)

• Porridge with skimmed, 1% fat or semi-skimmed milk (could add soft fruit for sweetness)

Mid-morning (choose 1)

• Small glass of fruit juice diluted with water (200ml)• ½ -1 small low fat / diet yoghurt with soft fruits (such as

raspberries, strawberries, melon, mango)

Lunch (choose 1)

• Jacket potato (no skin) with fillings, such as tuna or salmon with low fat mayonnaise / low fat cream cheese / low fat cottage cheese / baked beans

• Mince / chicken pieces stewed or in casseroles, or meat-free alternatives / tofu, or wafer thin chicken / ham with mashed potato and softly cooked vegetables

• Small matchbox size of low fat / reduced fat cheese with 2 cream crackers

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• ½ tin soup, such as meat / chicken / bean / lentil varieties with 2 crackers

• ½ -1 slice wholemeal toast with beans or cheese or scrambled egg or hummus

• Tinned macaroni cheese or beans with sausages• 2 crackers or 2 crisp breads or 2 cream crackers with suitable

topping, such as egg with low fat mayonnaise / hummus / grated low fat cheese / low fat cream cheese / low fat cottage cheese / pate

Mid-afternoon (choose 1)

• Small glass of fruit juice diluted with water (200ml)• ½-1 small low fat/diet yoghurt with soft fruits (such as raspberries,

strawberries, melon, mango)• 2 crackers or 2 crisp breads or 2 cream crackers with suitable

topping, such as egg with low fat mayonnaise / hummus / grated low fat cheese / low fat cream cheese / low fat cottage cheese / pate

Evening meal (choose 1)

• ½ slice toast or 1-2 crackers / crisp breads / rice cakes with light cream cheese or hummus or 1-2 tbsp cottage cheese or refried beans

• 1 soft boiled egg with 2 cream crackers / crisp breads• 1 small jacket potato (no skin) with beans or cottage cheese or low

fat cheese or chilli con carne• 1 fishcake or 2 fish fingers with chopped tinned tomatoes or

mushy peas or baked beans• Egg omelette with grated cheese and chopped tinned tomatoes• Stewing beef / chicken pieces / mince with gravy, mashed potato

and softly cooked vegetables with cous cous or mashed potato and mushy peas

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• Mince / mixed bean / Quorn based shepherds pie / cottage pie with mushy peas or softly cooked vegetables

• Mince / mixed bean / Quorn based lasagne with softly cooked vegetables

• Fish pie or softly cooked fish in a sauce with mashed potatoes, mushy peas or softly cooked vegetables

• Cauliflower cheese

Supper (choose 1)

• 2-3 tbsp stewed fruit such as apples• Soft raw fruit (for example banana, strawberries, melon, tinned

peaches, ripe pears without skins, pips or seeds)

Only when you are able to tolerate a variety of foods from stage three and you can manage half a tea plate sized portion at meal times, should you then move onto stage four.

What should I do if I have had problems trying new foods at stage 3 of the diet?

If you have problems with pain, discomfort or vomiting it is important that you try to identify the reasons why, as this can help you make changes to avoid the same thing happening in the future.

Ask yourself:

• Did I eat too quickly or not chew my food well enough?• Did I over-eat?• Did I take fluids with a meal, or too close to a meal time?• Did I try a food that was too textured at this stage? Remember,

foods at this stage must be soft, mushy or crispy in texture.

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Stage 4 - Longer term laparoscopic gastric band diet (solid textured diet)

Approximately 4 weeks after your operation you should be able to begin to eat a variety of solid textured foods, up to a tea plate sized portion. These foods will make you feel fuller quicker and for longer, which will help reduce your appetite. It is important to start meals with high protein foods, such as meat, chicken, fish, eggs, peas, beans, lentils, tofu, meat-free mince to ensure that you have an adequate daily protein intake. Aim to have a good variety of high protein, low fat and low sugar foods in your diet. Fruit and vegetables should be included with each meal as they contain fibre, vitamins and minerals.

Aim for no more than three tea plate sized meals per day (breakfast, lunch and dinner) and have low calorie liquids in between meals. Avoid going back to meals once you feel full and avoid snacking in between your meals, as this will slow your weight loss and could lead to weight regain.

Your diet will need to be healthy and nutritious to make sure that you prevent any nutritional deficiencies and have successful longer term weight loss.

If you choose to snack on high calorie foods such as crisps, ice cream, biscuits, cake and chocolate, your weight loss will slow and you may even gain weight.

Once you can manage a tea-plate sized portion at meal times, you should consider the proportions of the food groups on your plate. The current recommendation is that half of your tea plate should be salad or vegetables, a quarter carbohydrate (potato, rice, pasta, cereals) and a quarter protein.

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Solid foods to include are:

• Tender, soft meat such as chicken, turkey, pork, and beef cut up into very small pieces (1cm squares) and chewed thoroughly

• Half a slice of wafer thin ham / turkey / chicken• Tender, soft flaky fish• Reduced fat hard cheese• Pasta / rice / noodles• 1 slice toasted bread (no crust)• Seeded crackers• Vegetables and salad• Small soft non-fibrous fruit such as a peeled apple, pear or banana• Tomato• Cucumber

Meal and snack ideas

It is easy to lose variety in your diet and stick with the same meals; here are some example meal plans.

Menu plan 1:

• Breakfast: 2 boiled eggs• Lunch: sandwich thin or 2 small slices of wholemeal or granary

bread, with low fat margarine, salad and ham / chicken / turkey / hummus + 1 piece of fruit

• Dinner: homemade healthy pizza - use a tortilla wrap or pitta bread as a base, a thin layer of tomato puree and reduced fat cheese, then meat and/or vegetable toppings

• Snack: ⅓ small tub of low fat cottage cheese on 1 large rice cake

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Menu plan 2:

• Breakfast: porridge x 1 sachet or 30g porridge oats made up with 200ml of skimmed milk (add 1 tbsp dried fruit / 1 handful of fresh fruit)

• Lunch: ½ tin of baked beans on 1 slice of toast• Dinner: spaghetti Bolognese• Snack: banana

Menu plan 3:

• Breakfast: 1 piece of fruit of choice chopped up, mix with 1 diet yoghurt and 1 tbsp mixed seeds

• Lunch: bean / chickpea salad with crumbled feta and spinach / lettuce

• Dinner: chicken or fish with potato wedges and salad• Snack: one individual bag low kcal popcorn

Portable snacks for on the go

• Boiled eggs• Fruit• Low fat / fat-free / diet yoghurt• Sugar-free jelly• Vegetable crudities and mini pots of hummus (carrot, celery,

cucumber)• 1 x individual bag of low calorie popcorn (for example ‘Metcalfe's’

Skinny Popcorn, ‘Propercorn’)• Rice cakes / oatcakes / Ryvita with cottage cheese

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Main reasons for vomiting

You should not vomit if you follow the dietary advice and rules. However, there may be a few occasions when this may occur. If you vomit, one or more of the following is likely to have happened:

1. You ate too much. The portion size was too much.

2. The texture of the food was unsuitable

3. You ate too quickly

4. You had fluid and food too close together

5. You did not chew the food well enough.

If you are vomiting and it seems unexplained or your diet is more restricted than it should be, contact the dietitian or nurse for advice.

Vitamin and mineral supplements

Vitamin and mineral deficiencies can occur following a gastric band. Iron, folic acid, vitamin B12, calcium and vitamin D are the most common deficiencies. This is more common in people who do not take a daily complete A-Z vitamin and mineral supplement and do not eat a healthy, good quality, varied diet.

All patients following a gastric band operation should take daily multivitamins and minerals to help to prevent any deficiencies. Initially the supplement should be chewable, until you are on the soft/mushy crispy stage (stage 3) of the diet. This is to make sure that the tablet can get through the gastric band. These supplements can be bought at the chemist, supermarket or on the internet. You should take one A-Z complete multivitamin and mineral every day lifelong.

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Brands include:

• Superdrug A-Z Multivitamins and Minerals Chewable• Centrum Fruity Chewables• Nature's Plus Source of Life Adult's Chewable Multi-vitamin and

Minerals• Asda / Tesco Children's Chewable Multivitamins and Minerals

Once you are able to manage stage 3 (soft, mushy crispy) you should be able to manage vitamin and mineral tablets. You should choose a 'complete' A-Z vitamin and mineral supplement.

These tablets contain more vitamins and minerals than chewable supplements and should be taken, once per day, lifelong, to prevent any nutritional deficiencies and complications.

Brands include:

• Asda A-Z Multivitamin and Mineral• Lloyd's Pharmacy A-Z Multivitamin and Mineral• Morrison's A-Z Multivitamin and Mineral• Sainsbury's A-Z Multivitamin and Mineral• Sanatogen A - Z Multivitamin and Mineral• Tesco A-Z Multivitamin and Mineral• Wilkinson's A-Z Multivitamin and Mineral• Holland and Barrett ABC Plus

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What diet do I follow after my band is adjusted?

Every time you have your gastric band adjusted you will need to go back to the fluid stage of the diet.

You should follow a fluid-only diet for the first 24 hours after your adjustment to allow the band to settle.

After 24 hours on fluids only then move onto the pureed stage 2 -3 tablespoons (as per menu plan).

Gradually increase your portion size. Once you can manage half of a tea plate sized portion of pureed food or more then move onto stage 3 of the diet (soft / mushy / crispy).

Once on stage 3 start with 2-3 tablespoons and gradually increase the portion size.

At week 4-6 after your band adjustment you should be able to follow a varied, solid textured diet up to a tea plate sized portion.

PD5236-PIL1712 v5 Issue Date: November 2018. Review Date: November 2021

Name: ...................................................................

Specialist Dietitian for Weight Loss Surgery

0114 226 9083

Clinical Nurse Specialist for Weight Loss Surgery

0114 226 9083

Produced with support from Sheffield Hospitals Charity

Working together we can help local patients feel even better

To donate visitwww.sheffieldhospitalscharity.org.uk Registered Charity No 1169762

Alternative formats can be available on request.Please email: [email protected]© Sheffield Teaching Hospitals NHS Foundation Trust 2018Re-use of all or any part of this document is governed by copyright and the “Re-use of Public Sector Information Regulations 2005” SI 2005 No.1515. Information on re-use can be obtained from the Information Governance Department, Sheffield Teaching Hospitals. Email [email protected]

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