21: Eating Post-Surgery

Describe the fundamental eating principles that you will be following for the rest of your life. Explain the various post-surgery eating stages. List the recommended vitamin and minerals supplements that you will be using for the rest of your life.

Fundamentals
Above all, protein comes first Limit starches (bagels, cereal, crackers, noodles, pretzels) No snacking or grazing Dont eat and drink at the same time Avoid liquid calories (e.g.- any and all juices) Take your vitamins and minerals every day

Post Surgery Food Distribution Protein = 75% Vegetable = 10% Fruit = 10% Starch = 5%

Protein Vegetable Fruit Starch

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Protein
A high protein intake is important following surgery to allow wounds to heal properly and to help prevent protein deficiency. In order to meet your protein needs try to consume 100 grams of protein per day following your surgery. Preparing protein foods in a moist way (e.g.- crock pot, roasted with marinade or low-fat gravy) will help improve tolerance of these foods. Well tolerated protein foods include: fish, cottage cheese, yogurt, eggs, and tofu.

Carbohydrate
Sugar Too much sugar (full strength fruit juice, candy, cake, pie, cookies, etc.) can cause dumping syndrome. Read labels for sugar and avoid foods with more than 5 grams of sugar per serving. Do not eat foods containing any of the following types of sugars if listed as one of the first 3 ingredients: Sugar Brown sugar Corn sweeteners Modified food starch Honey Powdered sugar Fructose Glucose Sucrose Dextrose Maltose Molasses

Watch out for sugar-free products that contain sugar alcohols. These products are absorbed more slowly and can cause dumping like symptoms, especially when eaten in excess. Avoid foods with ingredients ending in ol, such as; Sorbitol, Mannitol, Xylitol, Maltitol. Starch Starches (bread, pasta, rice, etc.) can be a problem after your surgery because these foods can become doughy and expand in the stomach, and block the outlet from the stomach to the small intestine. Additionally, starches can fill up the stomach pouch and take space away from protein foods. Small amounts of starches can be eaten after surgery, but only after the protein of the meal has been consumed.

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Yogurt Yogurt is a complete food in that it contains carbohydrate, and is a good source of both calcium and protein. Yogurts soft texture is usually well-tolerated after surgery. To prevent dumping syndrome from yogurt, chose a type that offers about 15-18 grams of Total Carbohydrate per 6-8 ounce serving.

Fluid
It is very important to drink at least 64 ounces of fluid each to prevent dehydration. Immediately after surgery, it will be difficult to drink 64 ounces because of the size of your stomach. To meet your fluid needs you will have to sip fluids throughout the day. Try to drink 4-6 ounces every hour between meals. Recommended Beverages: Water Crystal Light Diet Snapple Aquafina Flavored Water Fruit20 Decaffeinated tea Decaffeinated coffee Sugar free beverages Propel water Dasani flavored water SOBE Lean

Beverages to Avoid: All soda and carbonated beverages Fruit Juice Coffee SOBE Whole milk Milkshakes Alcohol Vitamin Water Energy drinks (Red Bull, Monster, etc.) Fluid replacement drinks (Gatorade, Powerade)

Post-Surgery Eating Guidelines

Eat 3-4 small meals a day without skipping meals or snacking. Try to space meals about 4-5 hours apart. It should take you about 30-45 minutes to complete a meal. Eating slowly and chewing each bite 30 times will help to prevent vomiting and prevent obstructions. Do not drink liquids of any kind with meals. Wait at least 30 minutes before and after meals before drinking a beverage.
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Stage 1- Clear Liquid Days (0-3)

This will be your first stage after surgery. Hydration is the main concern. This stage consists of clear, sugar-free, and caffeine-free fluids. Stage 1 begins after being discharged from the hospital. You will follow Stage 1 for 3 days once you have returned home. If you experience difficulties as you advance to the next stages, you can always return to the clear liquid stage. During this stage you need to drink two and one-half 20 ounce bottles of a clear liquid protein supplement called Isopure. This product is available through the Bariatric Advantage company. Avoid drinking too much fluid at one time, it may overwhelm the pouch and cause pain Dont drink through a straw, it can cause gas and discomfort During this stage your goal is consume approximately 4-6 ounces each hour If you choose to drink juice, to reduce the risk for dumping, dilute your juice with 1 part juice and 3 parts water.

Suggested Clear Liquids: Water Crystal Light Diet Snapple Juice (diluted) Gatorade (diluted) Broth Bullion Decaffeinated tea Decaffeinated coffee Propel Water Diet Tang Diet Kool-Aid Sugar-free Popsicles Sugar-free jell-O Ice Chips

Sample Clear Liquid Menu

Breakfast Snack cup sugarfree gelatin cup low sodium broth Lunch Snack cup sugarfree gelatin cup low sodium broth Dinner Snack

10 oz Isopure (1/2 bottle)

10 oz Isopure (1/2 bottle)

20 oz Isopure (whole bottle)

10 oz Isopure (1/2 bottle)

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Stage 2- Full Liquid Days (4-14)

During the full liquid phase you will be transitioning to a more calorically dense, higher protein meal plan. During this stage you will move from the Isopure protein supplement to the EAS protein supplement. Suggested Full Liquids: In addition to all of the clear liquid offerings, the following full liquids are good choices: Strained, cooked cereals Light soy or fat-free Lactaid Milk Strained cream soups Light, fat-free, sugar-free yogurt without fruit (100 calories per serving) Sugar free pudding (prepared with Fat-free Lactaid or light soy milk)

Sample Full Liquid Menu

Breakfast Snack Lunch Snack Dinner Snack

cup strained Cream of Wheat cup light soy or Fatfree Lactaid milk

8 oz protein supplement

cup strained cream soup cup sugar free pudding (prepared with light soy or Fat-free Lactaid milk)

8 oz protein supplement

cup strained cream soup cup light, fatfree, sugar-free yogurt

8 oz protein supplement

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Stage 3- Pureed/ Soft Foods (Days 15-42)

Stage 3 begins during on day 15 post-surgery and lasts until day 42 post-surgery. All of the foods found in Stages 1 and 2 are allowed plus soft, low-sugar foods that are liquid or semiliquid such as strained cream soups and artificially flavored or plain yogurt. The purpose of this stage is to improve your nutrition status post-surgery while gradually advancing to more solid foods. Try to add one new food at a time to assess tolerance. Liquids that are extremes in temperature (hot or cold) may not be well tolerated during the first few weeks or months. Room temperature fluids may be better tolerated.

Protein
Stage 3 foods alone will not supply you with the protein you need for wound healing after surgery. During the Stage 3 meal plan you will continue to use a protein supplement to meet your protein needs. Acceptable supplements include EAS available at local Costco warehouse stores. Meal plans are based on supplements prepared with water only,

Suggested Stage 3 Foods

Food Group Protein Beverages Desserts Fruit Juice (Diluted) Dairy Soup Sugar Substitute Miscellaneous Suggested Foods EAS protein drink (to supplement your protein needs), cottage cheese, cheese, pureed meats Water, decaffeinated coffee or tea, other sugar free beverages, crystal light, diet Snapple No added sugar applesauce, sugar-free popsicle, sugar-free custard Apple juice, grape juice, low-calorie cranberry juice (diluted) Lower-carbohydrate yogurt (15-18 grams Total Carbohydrate/80-100 calories), Lactaid milk, calcium enriched plain or light soy milk Strained cream soup, broth, bullion, consomm Splenda, Equal, Sweet-N-Low Mild seasonings or herbs

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Sample Pureed/Soft Menus*

Breakfast Snack Lunch Snack Snack Dinner Snack

cup cooked Cream of Wheat (prepared with light soy or nonfat Lactaid milk)

8 oz protein supplement

cup tomato soup (prepared with light soy or nonfat Lactaid milk) cup pureed pears

8 oz protein supplement

cup sugarfree fat-free pudding cup unsweetened apple sauce

3 oz pureed chicken cup pureed green beans

8 oz protein supplement

Breakfast

Snack

Lunch

Snack

Snack cup fatfree cottage cheese cup pureed peaches

Dinner

Snack

cup cooked oatmeal (prepared with light soy or nonfat Lactaid milk)

8 oz protein supplement

cup cream of potato soup (prepared with light soy or nonfat Lactaid milk) cup unsweetened apple sauce

8 oz protein supplement

3 oz pureed turkey cup pureed carrots

8 oz protein supplement

*To ensure adequate fluid intake, remember to sip 4-6 ounces of fluid every hour between meals to help reach the goal of 64oz each day.

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Stage 4- Regular Diet (Day 43 and Beyond)

Stage 4 begins on day 43 and lasts the rest of your life. Stage 4 includes all of the foods in Stage 1, 2 and 3, plus a wider variety of food options. Additional foods include eggs, deli meat slices, fish, and cheese to name a few. During this stage you will eat only 3 meals a day plus one protein drink (made with just water) in order to meet your daily protein needs. Eat three-four meals a day and with no snacking. You are encouraged to include two protein drinks as part of your fluid intake between meals. Begin each meal with protein-rich foods to ensure your nutritional needs are met. Add one new food at a time to assess tolerance. The suggested meal plan is composed of low-fat animal protein foods, fruits, and vegetables. It is advised that you avoid steak for the first 6 months. If you become sick or feel badly after trying a new food, you can always return to Stage 1 to rest your stomach.

Suggested Stage 4 Foods

Food Group Protein Suggested Foods EAS protein drink (prepared with water), cottage cheese, steamed or poached fish, soft low-fat cheeses, tofu, thinly sliced turkey or chicken lunch meat, finely ground or pureed poultry, lamb or veal Scrambled, soft cooked, poached, hard boiled or egg substitute Water, decaffeinated coffee or tea, other sugar free beverages No added sugar applesauce, sugar-free popsicle, sugar-free custard, sugarfree Jell-O No sugar added applesauce, banana, all fruits without peals, canned fruit in juice (poor out juice), Apple juice, grape juice, low-calorie cranberry juice (diluted) All cooked and pureed vegetables Cooking spray, olive oil, canola oil, soft or liquid margarine, low-fat mayonnaise Lower-carbohydrate yogurt (15-18 grams Total Carbohydrate/80-100 calories), Lactaid milk, calcium enriched plain soy milk Mashed potato without skin, instant mashed potato prepared without milk, saltine crackers, well-toasted bread Cream soup made with pureed vegetables, broth, bullion, consomm Splenda, Equal, Sweet-N-Low Mild seasonings, herbs, lemon or lime juice

Eggs Beverages Desserts Fruits and Juices (Diluted) Vegetables Fats (use sparingly as these are high in calories) Dairy Starch Soup Sugar Substitute Miscellaneous

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Sample Stage 4 Menus*

Breakfast Snack
8 oz. protein supplement

Lunch

Snack

Snack

Dinner
3 oz lean pork chop cup seasoned peas cup cherries

1 boiled egg 1 slice wholewheat toast

3 oz grilled chicken with salad greens cup peaches

8 oz. protein supplement

1 oz low-fat mozzarella cheese 6 whole grain crackers

Breakfast

Snack
8 oz. protein supplement

Lunch

Snack

Snack

Dinner
cup whole wheat pasta 3 oz meat sauce cup cooked spinach cup cantaloupe

1 cup whole grain cereal 8 oz light soy or nonfat Lactaid milk

egg salad sandwich cup unsweetened apple sauce

8 oz. protein supplement

cup carrot sticks cup cucumber sticks 2 Tbsp hummus

*To ensure adequate fluid intake, remember to sip 4-6 ounces of fluid every hour between meals to help reach the goal of 64oz each day.

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Post-Surgery Supplements
After surgery you will not be able to get an adequate amount of vitamins and minerals from the foods you eat because you will be eating a much smaller amount of food. Additionally, the bypass surgery creates a chronic malabsorption of all nutrients including vitamins and minerals. To help prevent vitamin/mineral deficiencies the following Bariatric Advantage supplements are recommended in the following amounts: Sublingual B-12 (1000 - 3000 micrograms)- 1- 3 tablet per week o Begins during clear liquid stage (stage 1) o Over time your vitamin B-12 stores may diminish. When your B-12 levels begin to dip, begin using a 1000 microgram sublingual tablet 4-5 times per week. After your surgery, your MD should be drawing B-12 levels periodically, and will tell you when you need to increase your B-12 intake. Orange Citrus Chewable Multi Formula- 2 tablets every day (serving size = 2 tablets) o Begins during clear liquid stage (stage 1) Calcium Citrate Lozenge (400 mg)- 3 lozenges per day (contains vitamin K. If you take medication to thin your blood, you may need to purchase a standard commercial calcium citrate supplement*). o Begins one month after your surgery with the soft food stage (stage 3) Chewable Iron** (18 or 29 mg) o You will have iron stored in you body following your surgery. However, similar to vitamin B-12, iron stores may begin to diminish over time. o Begin an iron supplement as advised by your physician when iron levels begin to dip.

*The commercial calcium supplement that we recommend is Citracal Chews. To obtain the equivalent calcium in the Bariatric Advantage calcium supplement, you will need to take 2 of these chews each day, as each one contains 500 mg of calcium. Since calcium is best absorbed in doses less than or equal to 500 milligrams, it is recommended that you take no more that 2 chews at one sitting. **Take iron and calcium supplements 1-2 hours apart, as calcium inhibits iron absorption.

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Acceptable Foods to Eat After Surgery

The following list of foods may be used to help you shop before and after surgery Protein Beans (navy, pinto, black, etc.)*** Beef (very lean, ground) Chicken (moist, no skin) Cheese (reduced fat Swiss, cheddar, mozzarella, etc.) Cottage Cheese (reduced fat) Crab/imitation crab ***caution- may cause gas Egg/egg whites Egg substitute Game meats Ham Lamb Lobster Pork (lean) Fish (cod, tuna, trout, salmon, bass, etc.) Scallops/Shrimp Tofu/soy beans/edamame Soy milk/Lactaid milk Turkey (no skin) Veal Veggie burger (soy based) Yogurt (15-18 grams total carbohydrate)

Vegetables (make sure vegetables are well cooked for the first 6-8 weeks post-surgery) Alfalpha sprouts Artichoke Asparagus (well-cooked) Beets Broccoli*** Brussels sprouts*** Cabbage Carrots Cauliflower*** Chard ***caution- may cause gas Collard greens Cucumber Egg plant Green snap peas Jicama Kale Leeks Mushrooms Onions Radish Red, green, yellow peppers Salad/spinach/mustard greens Seaweed Tomato Water chestnuts Yellow squash Zucchini

Fruit Apple (without peal) Applesauce (unsweetened) Apricots (remove skin) Banana Blueberries Cantaloupe Cherries Grapefruit Grapes Guava Kiwi Lemon
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Mandarin oranges Nectarines Oranges (remove skin) Papaya Peach (remove skin) Pears (remove skin) Pineapple Plums Raspberries Strawberries Tangerine Watermelon
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Acceptable Foods to Eat After Surgery

Fat Avocado Olive oil Canola oil Cream cheese (reduced fat) Margarine (soft or liquid) Vegetable spray (e.g.- Pam) Sour cream

Miscellaneous Cinnamon Garlic/garlic powder Herb/seasonings Mrs. Dash Mustard Pepper Pickles/pickle relish Vinegar

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Foods to Avoid After Surgery

Avoid excessive amounts of the following list of foods following your surgery. These foods may cause unwanted weight gain, dumping syndrome, or block the anastomosis between the stomach and small intestine. Starches Bagels Biscuits Bread sticks Bread (untoasted) Cereals (hot or cold) Croissants Doughnuts English muffins French toast Grits Muffins Pancakes Pasta Pastry Pita bread Rice Rice cakes Rolls Stuffing Tortillas Waffles

Avoid the following list of foods entirely following your surgery. May Block the Anastomosis Coconut Dried fruit Nuts/seeds Potato skins Corn Gum Popcorn Celery, raw (cooked in soup is OK) Oranges (watch pulp) Skins/seed of fruits and vegetables Hot dog skins

May Cause Dumping Syndrome Ice cream Cookies Cake Fruit juice Juice smoothies Candy/candy bars Coffee drinks Soda pop Frozen yogurt Milkshake

High Fat Foods (may cause weight gain) Bacon Fast food French fries Fried egg rolls Fried food Hamburger Hash browns Mayonnaise Onion rings Pizza Potato chips Sausage

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Miscellaneous Foods Alcohol Caffeinated beverages Carbonated beverages Spicy foods

Special Cautions Milk may cause gas and discomfort after surgery. Try soy milk or Lactaid milk instead. Steak can be very difficult to tolerate after surgery. Wait 6 months to a year before trying steak.

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