Nutrition After

Bariatric Surgery Understanding the behavior changes and

long-term care after bariatric surgery

Created by: Yasmin Firouzman, RD

Edited by: Lauren Maddahi, MS RD (2016)

Christine Goukasian, MS, RD

Topic Outline

Stages of the Diet after Surgery

Vitamin and Mineral Supplementation

Tips for Long-term Weight Loss and Health

Learning Objectives

By the end of this session participants will be able to:

Identify the 4 main stages of the post-operative diet plan

Identify what vitamins and minerals to supplement with after surgery including amount and timeline

Communicate tips for long-term health and weight loss

Stages of

Postoperative

Diet

Stage I- Days 0 to 1 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 to 14

FULL LIQUIDS

Food that is blended to a

THIN liquid consistency

such as milk.

BLEND and STRAIN

What Can I Have?

Water

Protein shakes (!!!)

Low-fat milk

Broth OR low-fat, low-sodium strained soup

Vegetable juice, Diluted fruit juice (1/4 cup juice, ¾ water)

Runny, hot cereal (cream of wheat, no sugar added)

Plain, low-fat yogurt

Unflavored protein powder added to broth

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”

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 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 “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)

Body Fortress Whey isolate (www.amazon.com)

Bariatric Advantage shakes (www.bariatricadvantage.com)

BiPro Unflavored Protein (www.biprousa.com) – discount code “UCLA”

www.Insurenutrition.com - supply protein drinks through your insurance

Orgain Organic Protein Powder- plant based protein (Costco and

www.orgain.com)

Stage II Sample Menu: Full Liquid

Meal Liquids Liquid Goal Protein (g)

Breakfast Protein Shake Sip water

4-6 ounces 15

Snack Protein Shake 4-6 ounces 15

Lunch Protein Shake Blended/Strained

Soup

4-6 ounces 20

Snack Protein Shake Sip water

4-6 ounces

15

Dinner Protein Shake Sip water

4-6 ounces

15

Snack Protein Shake Sip water

4-6 ounces

15

Total: 64 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 or egg substitutes Do not overcook. Must be soft

Low-fat cottage cheese

Pureed meats

Soft fish, Soft tofu

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

Low/nonfat refried beans (mashed beans)

What Can I Have?

Fruit/vegetables

Unsweetened applesauce

Canned fruit in water or juice (rinsed)

Soft banana

Pureed fruit/veggies

Well-cooked, low-fiber vegetables (Squash, spinach)

Low Fat, low sodium puree/soft 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 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 and 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 6 fluid ounces (1/2 bottle)

15

Lunch Tuna salad with low-fat mayo

Pureed Vegetable

2 ounces

2 Tablespoon

14

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

15

Dinner Soft fish Well cooked carrots Skinless baked yam

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 Protein first, then vegetables and carbohydrates

Choose complex carbohydrates (whole grain, 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, cottage cheese, vegetables, fruits)

Avoid trigger foods

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

14

Snack Unsalted almonds Apple

10 1 small

6

Lunch Grilled chicken Green salad with olive oil

and lemon juice

2 ounces

1 cup

14

Snack 2% Greek yogurt Strawberries

½ cup ¼ cup

12

Dinner Baked Salmon Quinoa

Sauteed Mushrooms

2 ounces ¼ cup ¼ cup

14

Snack Protein Shake 12 fluid ounces (over 1 hour)

25

Total: 85

Stage IV Sample Menu: Solid Foods

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

Post-Operative WARNINGS Do not drink alcohol. It is dehydrating and has no

nutrients.

Do not drink carbonated (bubbly) drinks. The bubbles can give you gas, cause bloating and pain.

Do not chew gum. If you swallow it, gum can block the stomach opening.

Do not drink from a straw. Can’t control intake via straw, which can be painful. Straw makes you swallow air, which causes bloating and can be painful.

Do not drink with your meals.

No items with greater than 10 grams sugar.

Avoid Coffee for 3 months after surgery Only decaf from months 3-12

Can start regular coffee after 1 year if no nutritional issues

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

• It limits the absorption of calcium and iron.

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

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

What can cause Dumping:

Anything with more than 10-15 grams sugar: Milkshakes, coffee, 100% fruit juice

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

Increase potential of not receiving daily requirements in foods.

Food sources don’t have enough

Will require life long supplementation

Will require regular monitoring of blood values in order to measure body requirements

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 (with B Complex)

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.

Supplementation Schedule Complete Multi with B Complex (start day 2)

Complete Multi with B Complex

Calcium Citrate

Wait minimum 2 hours

Wait minimum 2 hours

Wait minimum 2 hours

Calcium Citrate

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

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! 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:

Length 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

Chew to liquid consistency

Listen to what your body is telling you. Learn to stop just before the first sign of fullness

Use smaller plates and utensils

Dietary Habits

Set utensils down between bite.

Cut food into small bite size pieces

Fluids between meals not with meals

Dining out: Follow the Balanced Plate

Alcoholic beverages: Limit/avoid

Mindful Eating Take a long, cleansing breath before you begin to

eat

Activate all 5 senses

Do not eat with distractions (TV, iPad, Radio)

Do not eat in the car

Eat sitting down at a table

Make your table pretty!

Try to detach emotions from food

Be present

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