Nutrition After

Bariatric Surgery Understanding the behavior changes and

long-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 of

Postoperative

Diet

Stage 1: Days -1, 0 and1 Pre-op (1 day before surgery)

Day 0 = Day of surgery

Day 1 = Day after surgery

CLEAR LIQUIDS Water or Ice chips

Broth

Diluted, clear 100% juice (1/4 cup juice, ¾ water)

Sugar-free Jell-O

Sugar-free popsicle

*Limit sugar-free products

Stage II: Days 2 through 14

FULL LIQUIDS

Food that is blended to a

THIN liquid consistency

such as milk.

BLEND and STRAIN

What Can I Have?

Protein shakes (!!!)

Water (try alkaline if tap water not tolerated)

Low-fat milk

Broth with protein powder

Low-fat, low-sodium blended and strained soup

Vegetable juice

Diluted 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 liquids

To 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

Goal is 80-100 grams protein. Slowly work your way up to this. Can take 2-3 weeks to reach this goal.

Focus on rate of consumption Track volume

Slowly increase your rate

Goal is 64 oz of fluid per day

LISTEN TO YOUR BODY STOP at first sign of fullness

• BEFORE you experience “stomach pain”

**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 protein

per serving

Avoid: “collagen” protein products – not a complete protein

Do not consume more than 30 grams of protein per meal/snack

If lactose intolerant: Look for vegan products or “100% whey Isolate” and avoid “whey concentrate”

Protein Shake

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 Liquid

Meal Liquids Liquid Goal Protein (g)

Breakfast Protein Shake Sip water

5 ounces 5 ounces

15

Snack Protein Shake Sip water

5 ounces 5 ounces

15

Lunch Blended/Strained Soup with unflavored

protein added Sip water

5 ounces

5 ounces

20

Snack Protein Shake Sip water

5 ounces 5 ounces

15

Dinner Protein Shake Sip water

5 ounces 5 ounces

15

Snack Protein Shake Sip water

5 ounces 5 ounces

15

Total: 60 oz Total: 95

**Remember to work your way up to this. It may take 5-10 days to be able to drink this much!

Stage III

Week 3 through 5

Day 15-35

SOFT FOODS

Foods that are soft or chewed easily

Think baby food

What Can I Have?

Protein/dairy

Scrambled egg, egg whites, poached eggs Do not overcook. Must be soft

Low-fat cottage cheese

Pureed meats Soups, paté

Soft fish, Soft tofu

Egg/chicken/tuna salad made with low fat plain Greek yogurt

Low/nonfat vegetarian refried beans Or homemade, pureed beans

What Can I Have?

Fruit/vegetables

Unsweetened applesauce

Soft banana

Pureed fruit/veggies

Canned fruit in water or juice (rinsed)

Well-cooked, low-fiber vegetables

Squash, spinach, carrots

Low 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 30 minutes afterwards.

Discontinue the use of fruit juices.

Avoid soft, high-calorie food and drinks such as ice- cream, which go down easily, but can halt weight loss.

Stage III Key Points

Continue to get 40-60g protein from protein beverages The rest you should get from food. Goal is 80-100

grams protein

NO 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 post surgery!

Stage III Key Points

Portion Sizing

Portion sizing plates Portiondiet.com

• Purchase plates and meal plans for bariatrics , designed by a bariatric dietitian

Using smaller plates, bowls and utensils helps you feel fuller – like an optical illusion

Ebbinghas Illusion, Wikipedia source

Meal Foods Amount Protein (g)

Breakfast Scrambled egg (soft) Low fat cottage cheese

1 1 Tablespoon

10

Snack Protein Shake 5 fluid ounces (1/2 bottle)

15

Lunch Tuna salad with low-fat plain Greek yogurt Pureed veggie soup

2 ounces

2 Tablespoon

14

Snack Protein Shake 5 fluid ounces (1/2 bottle)

15

Dinner Soft fish Mashed carrots

Mashed unsweetened yams

2 ounces 1 Tablespoon 1 Tablespoon

14

Snack Protein Shake 6 fluid ounces (1/2 bottle)

15

Total: 83

Stage III Sample Menu: Soft Foods

** SIP SIP SIP water! (Stop 15 minutes before meal/Start 30 mins after)

Stage IV

Start of Week 6, Day 36

Solid 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 you

Continue protein supplements

Goal is 80-100 grams protein

If this goal can not be met from food alone, continue to incorporate protein shakes

Food Choices At mealtime: Eat protein first, then vegetables, then carbohydrates

Choose complex carbohydrates Whole grains, brown rice, quinoa, barley starchy vegetables

Avoid simple carbohydrates, which are low in nutritional value White bread, cookies, cakes, fruit juice

Choose nutritionally dense foods Chicken breast, low fat cottage cheese, whole vegetables, whole fruits

Avoid trigger food Usually high in sugar and fats

Tough meats: Avoid steaks for 3 months after surgery; Some may continue to have difficulty tolerating

meat after this time

Meal Foods Amount Protein (g)

Breakfast Scrambled egg whites 100% Whole grain toast

2 1 Slice

7 4

Snack PB2 powder ½ peeled apple

4 tbsp 10

Lunch Steamed chicken breast, skinless

Spinach salad with olive oil and lemon juice

2 ounces

1 cup

14

Snack 2% plain Greek yogurt Strawberries

½ cup ¼ cup

12

Dinner Baked Salmon Quinoa, cooked

Sauteed Mushrooms

2 ounces ¼ cup ¼ cup

14 2

Snack Protein Shake 12 fluid ounces (over 1 hour)

25

Total: 88

Stage IV Sample Menu: Solid Foods

** SIP SIP SIP water! (Stop 15 minutes before meal/Start 30 mins after)

Avoid alcohol

It is dehydrating and has no nutrients

Avoid carbonated (bubbly) drinks

The bubbles can give you gas, cause bloating and pain

Avoid chewing gum

If you swallow it, gum can block the stomach opening

Do not drink from a straw

You can’t control your intake with a straw, which can be painful

The straw makes you swallow air, which causes bloating and can be 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 3-12

Can start regular coffee and tea after 1 year if there no nutritional issues

• The caffeine in coffee or tea is a diuretic and can dehydrate you

• Caffeine increases gastric acids, which causes heartburn and gastroesophageal reflux

• It limits the absorption of calcium and iron

Post-Operative WARNINGS

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 contains little to no protein (avoid by always having a protein with meals)

Symptoms: Fatigue, sleepiness, lightheadedness, near fainting, sweating, low blood 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 to rapid 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, brown rice, etc) Fluids (alkaline water, herbal tea)

Stretch Break!

Vitamins

and

Minerals

Vitamins Why do we need them?

Bypass creates a degree of malabsorption and sleeve creates a degree of restriction

You are at an increased risk of not receiving enough from your food

Will require life long supplementation

Will require regular monitoring of blood values in order to measure body requirements 3 month, 6 month, 12 month and annual appointments

Food Sources Deficiencies may

lead to

Vitamin A Animal fats, milk, cheese, egg

yolk or beta-carotene: carrots,

dark leafy green vegetables,

carrots, cantaloupe, sweet

potato, peaches

Nyctalopia (night

blindness), dry skin,

xerophthalmis (corneal

damage)

Vitamin D Egg yolk, fortified juice/ milk,

and sunlight, liver, salmon, tuna

fish, and sunlight.

Rickets, osteomalacia

B1

Thiamin

Fortified cereals, beans, pork,

liver, grains, potatoes

Beriberi, memory loss,

tachycardia

B6

Pyridoxine

Fortified cereal, banana,

legumes, sunflower seeds, beef,

pork, liver, egg yolk, oatmeal

Microcytic anemia,

dermatitis, glossitis,

peripheral neuropathy

(nerve damage),

convulsion

B12 Cyanocobalamin

Best source: animal protein;

liver, milk, fish, eggs, cheese,

and meat. Vegans are

required to use supplements.

Pernicious anemia (due

to lack of intrinsic

factor), macrocytic

anemia, megaloblastic

anemia

Calcium Spinach, dairy products,

legumes, , oysters, kale,

clams, tofu, sardines

Tetany muscle spasms

Iron Heme iron: animal foods;

meat, fish poultry. Non

Heme: fortified cereals, &

vegetables. Need Vitamin C

to help with absorption.

Caffeine inhibits absorption

of iron.

Iron deficiency anemia,

pale tongue, fatigue,

spoon-shaped nails,

Zinc Best source; animal protein.

Meat, fish, eggs, liver,

oysters, beef, clams, herring

Poor wound healing,

hypogeusia (taste

sensitivity), alopecia

Everyone

Multivitamin

B-complex

Calcium Citrate

If Doctor Recommends

Folic Acid

Iron

Vitamin D

Vitamin A

Zinc

Vitamin and Mineral Intake Summary

BEGIN DAY 2 POST OP (FULL LIQUIDS)

BEGIN DAY 2 POST OP (FULL LIQUIDS)

Multi-Vitamins

Well balanced daily multi-vitamin containing 100% of daily value (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-complex that includes:

• B1, B9, B12 and B6

Route/Form:

Capsule, Chewable, or Liquid

Take as directed on the bottle unless otherwise specified by your Doctor

Calcium

Name: Calcium Citrate

Route/Form:

Capsule, patch, chewable or liquid

Oral 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 by 2-3 hours.

Make Your Supplement Life Easy!

Find a vitamin that incorporates EVERYTHING

Read the label and check the %DV

Some companies to try:

Patch MD

Bariatric Fusion Chews or Stick Pack

Everyone

Multivitamin

B-complex

Calcium Citrate

If Doctor Recommends

Folic Acid

Iron

Vitamin D

Vitamin A

Zinc

Vitamin and Mineral Intake Summary

BEGIN DAY 2 POST OP (FULL LIQUIDS)

BEGIN 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 helps move things along

Probiotic Supplement BEGIN DAY 2 POST OP

Helps promote gut health

Promotes maintaining a healthy weight

May help with bowel movements

May help defend against post-operative infection

Suggested route:

Liquid yogurt

• 3-4 teaspoons, maximum ½ bottle per day

Tips for

Long-Term

Success

Tips

Set realistic goals for weight reduction

60 – 80 % of excess body weight

Make sure goals are within your control

Focus on behavior changes

What could you put on a star chart?

Keep a diary – record those significant events of success and achievement!

Tips Regular attendance at Support Group meetings. View

schedule on our website: surgery.ucla.edu/bariatrics

Keep your post-op appointments!

2 weeks, 3 months, 6 months, 12 months and annually

Our team will help provide you the support you need for long-term success

Consider consistent therapy

DON’T READ THE BLOGS!!!

Exercise

Benefits of Exercise include:

Improves your mood

Combats chronic diseases

Helps you manage your weight

Strengthens your heart and lungs

Helps promote better sleep

Reduces stress

May reduce extra skin

Improves your body shape

Improve self-esteem

Exercise Guidelines

Week 1 – 4: walk, stationary bike

NO swimming/hot tub

Week 6+: As you progress you will need to change:

Duration of time you exercise

Distance of each type of exercise

Type of exercise:

• Biking, swimming, tennis

Intensity:

• Weight lifting

• Level, speed, or resistance of machine

Dietary Habits • DO NOT advance to

next stage until designated time

• Eat slower – use a timer! Spend 20-30 minutes on meals

• Listen to what your bodily cues, learn to stop just before the first sign of fullness

• Use smaller plates and utensils

Dietary Habits

Cut food into small bite size pieces

Chew to liquid consistency

Set utensils down between bite

Fluids between meals not with meals

Limit/avoid alcoholic beverages

Mindful Eating

Avoid distractions during eating (TV, iPad, Radio)

Do not eat in the car

Eat sitting down at a table

Set your table, make it pretty!

Activate all 5 senses

Take a long, cleansing breath before you begin your meal or snack

Try to detach emotions from food

Be present – enjoy your food!

Review

What supplements will everyone need to take after surgery?

How many weeks after surgery can you begin a regular texture diet?

How many months after surgery should you avoid tough meat?

Don’t forget!

Homework link will be sent via email

EMMI Video

Will be scheduled by your dietitian and please watch it by the last viewing date