A guide to surgery and lasting weight-loss success.
Bariatric Surgery Patient Manual A Guide to Surgery and Lasting Weight-Loss Success
Welcome Thank you for choosing Englewood Health for your bariatric surgery. We are excited to be a part of your weight-loss journey and commitment to improving your health and quality of life. Throughout this experience, you will work with our expert and compassionate surgical team who will provide information, address any concerns, and support you every step of the way. This manual will introduce you to the team including your care coordinator, who will personally guide you through every step of your individualized plan. It includes a description of the two kinds of surgical procedures, instructions for preparing for surgery, and information about what to expect after your procedure. You will also find information and resources to help you make your weight loss journey a lasting success. It is important that you be fully informed about your procedure and understand both the pre- and post-operative instructions you must follow to ensure optimal results. During your visits, your surgeon will describe the procedure you are about to undergo, provide pre- and post-op instructions, review your medications, go over the diet you will follow before your surgery, and review what and how to eat after the procedure. You will learn about the importance of nutrition, including vitamin and protein supplementation, and how exercise and emotional well-being can be powerful tools to keep you healthy. Your doctor will also review long- term goals and strategies to help you keep the weight off. Please bring this manual to your care coordinator and consent-sign meetings. It includes forms to be completed and useful information you will refer to during those visits.
We are excited to accompany you on this life-improving journey and ready to support you all along the way. Congratulations on taking the first step!
With our very best wishes,
Your Englewood Health Bariatric Surgery Team
Updated October 2022
Table of Contents YourHealthcareTeam . . . . . . . . . . . . . . . . 2 WeightLoss101...................4 Types of Bariatric Surgery . . . . . . . . . . . . . . . 5 FirstSteps.....................7 PreparingforSurgery . . . . . . . . . . . . . . . . 11 After Your Surgery: Post-Operative Instructions . . . . . . . . . . . . . . 15 Post-Operative Diet Phases . . . . . . . . . . . . . . 18 Supplements: Vitamins, Minerals, and Protein . . . . . . 23 Healthy Eating for Life: Nutrition 101 . . . . . . . . . . 31 Model Plate: Picturing a Healthy Meal . . . . . . . . . . 38 NutritionLabels..................40 Getting to Know Your New Stomach . . . . . . . . . . 43 Some Common Side Effects of Bariatric Surgery . . . . . 45 Maintenance: Making Change Last a Lifetime . . . . . . 51 Social Gatherings & Dining Out . . . . . . . . . . . . 54 Exercise......................55 The Mind-Body Connection . . . . . . . . . . . . . 57 AdditionalResources . . . . . . . . . . . . . . . . 59
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Your Healthcare Team Your life-long success with weight loss depends on your willingness to change your relationship with food and the foods that you eat. Throughout your experience, you will work closely with a team of weight loss experts who are dedicated to helping you make that change. Your bariatric surgical care team includes experienced professionals who specialize in every aspect of weight loss. These include board-certified surgeons, nurse practitioners, integrative medicine specialists, dietitians, social workers, and many other caring professionals from a wide variety of disciplines. Our team approach provides the kind of comprehensive support that can lead to lasting weight loss, improved health, and a better quality of life. Additional specialists are enlisted as needed. Depending on your particular medical conditions, these may include cardiologists, gastroenterologist, endocrinologists, pulmonologists, physical therapists, and others who will address any issues related to your condition to ensure your health and safety.
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Your Care Coordinator All patients are assigned a care coordinator, a dedicated professional who provides support and guidance from the period before surgery to post-surgery and beyond. Your care coordinator will: • Answer questions you or your family members have and address any concerns. • Act as a liaison between you and the rest of the care team. • Facilitate appointment scheduling. • Submit documentation to your insurance company for coverage approval. • Help you find a specialist or service when needed. • Offer additional resources to help you lose weight and improve your health.
Your patient care coordinator is:
.
Phone number:
EXT:
Please stay in regular touch with your coordinator by phone or through MyChart to keep them informed of your progress.
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Weight Loss 101
What is obesity? Obesity is a complex, progressive disease requiring lifelong treatment and monitoring. According to the Mayo Clinic, it is a result of “inherited factors combined with the environment and personal diet and exercise choices.” It is not evidence of a lack of will power or a moral failing. Obesity is diagnosed as having a body mass index (BMI) of 30 or more. (You can calculate your BMI through many online tools.) If left untreated, obesity can increase the risk for other serious medical issues, including diabetes, heart disease, high blood pressure, and some cancers, and can increase the risk for COVID-related deaths. Obesity can also significantly reduce one’s quality of life. How can bariatric surgery help? One of the most effective treatments for substantial weight loss and maintenance is bariatric surgery. It was developed over 30 years ago and has become increasingly safe and effective as improvements in technology, experience, and surgical techniques have been made over the years. Bariatric surgery works in many different ways. It changes your appetite, metabolism, satiety and even hormones. Studies have shown that successful bariatric surgery can help resolve complex medical issues, increase life expectancy, and improve quality of life.
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Types of Bariatric Surgery
The two most common bariatric surgeries are laparoscopic sleeve gastrectomy and laparoscopic Roux en-Y gastric bypass. (“Laparoscopic” refers to the minimally invasive technique used in these procedures.)
The procedures are described below. For additional information and to learn about the advantages and
disadvantages of each, please visit: englewoodhealth.org/bariatrics
Laparoscopic Sleeve Gastrectomy • In a sleeve gastrectomy, the stomach is reduced to about one quarter its original size. • The stomach is stapled and cut, giving it the shape of a tube or sleeve. • With a smaller stomach, you will feel full sooner and eat less. • Sleeve gastrectomy also removes cells that produce ghrelin, the hormone that is associated with increased appetite and cravings. • Length of hospital stay: 2 days, 1 night
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Laparoscopic Roux- en-Y Gastric Bypass • The Roux-en-Y gastric bypass changes how the stomach and small intestine handle food. • First, a small pouch, is
made from a part of the stomach. This pouch, which functions as the new stomach, is smaller than the original so you feel full with less food. • The pouch is connected to the small intestine, which results in the bypass of food from most of the stomach and part of the small intestine. Like the sleeve gastrectomy procedure, Roux-en-Y results in a change in the production of different hormones, which can help patients lose weight by lessening appetite and cravings. But because the stomach is the first portion of the intestines, it no longer sees food and changes the hormonal environment and greatly helps weight loss. • Length of hospital stay: 2 days, 1 night.
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First Steps Your weight loss journey begins with the steps outlined below. You will need to complete each one to proceed to surgery. Your care coordinator will answer any questions you may have and will work with you to stay on track. (Please remember to bring this manual to your appointments.) MyChart First, you will want to sign up for the MyChart patient portal. This will allow you to keep track of your medical record, communicate with your health team, and keep a record of your progress. In MyChart you can:
• Send messages directly to your doctor. • Request prescription refills. • Make and cancel appointments. • Review your medical history.
Bariatric Educational Video We want you to be fully informed about your surgery. If you have not already done so, please watch the bariatric patient education video at englewoodhealth.org/bariatrics and take the quiz at the end. Letter of Support/Medical Necessity Insurance companies require a letter of support/medical necessity from the patient’s primary care physician (PCP). Please ask your PCP to complete the form and fax it back to us. Our fax number is 201-894-0093.
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Blood Tests After your initial evaluation you will be required to get blood tests. Please contact your doctor’s office or Englewood Hospital’s lab (201-608-2245) to make an appointment. Once your blood draw is complete, please ask to have your results faxed to us. Our fax number is 201-894-0093. Sleep Evaluation If you are at risk for sleep apnea, the Sleep Center at Englewood Hospital will contact you to arrange for a sleep study. Please note: If you are diagnosed with sleep apnea, you will need to bring your CPAP machine with you to your surgery. Specialty Evaluations Some patients may need to see medical specialists for additional testing, evaluation, clearance, or recommendations before they can be cleared for surgery. If you are asked to see a specialist, please set this appointment up at least 1-3 months before your scheduled procedure. Depending on your health, you may be asked to see a/an:
• Cardiologist • Endocrinologist • Hematologist/Oncologist • Gastroenterologist • Pulmonologist
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Supervised Medical Weight Loss You will need ____ months of medically supervised weight- loss sessions. These visits may be with: • A physician who specializes in weight-loss management • A dietitian Please see the referral list. It is important that you continue appointments with the dietitian after surgery and for the long term. Visits must be consecutive to prevent insurance denials. Psychological Evaluation A psychological evaluation is required for approval for bariatric surgery. See the mental health referral list to find a provider. Mandatory Pre-Op Class One month before your surgery, you will be required to attend the pre-surgery educational class. The class is held the first Tuesday of every month.
Date: ________________
Medical Clearance Work-Up Pre-admission blood tests, medical evaluations, and medical clearance must be completed 2–4 weeks before your surgery. If you have diabetes, your HbA1c must be <7. Please note: Medical clearance and labs are good for only 30 days.
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Insurance Approval Some insurance companies will not approve bariatric surgery if you gain weight after the request for coverage has been made. To increase the likelihood of receiving approval and to decrease your risk of surgical complications, we encourage you to start an exercise regimen and make healthy food choices to aid in weight loss prior to requesting the approval. Please call your care coordinator as you complete each of the above steps. Your coordinator will answer any questions and help you stay on track. Once your file is complete, the required documents can be submitted to your insurance company for approval. We will call you as soon as we receive a response. This may take 4–6 weeks.
Consent-Sign Visit Once you have completed the requirements, your
coordinator will schedule you for a consent signing visit with your surgeon. During this visit the doctor will describe your procedure, review its risks and benefits, discuss your new diet and nutrition needs post-surgery, answer questions and address any concerns. At this visit you will also be asked to sign a consent form if you decide to move forward with the procedure. (Please remember to bring this manual to your appointment.)
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Preparing for Surgery: 6 Months Before Surgery Through Day of Procedure 3–6 Months Before Surgery Three to six months before surgery, you will work with one of our registered dietitians to learn how to make diet and lifestyle changes to help ensure long-term weight loss success. You will get practical information and helpful tips about nutrition, exercise, and a healthy lifestyle. Understanding and adopting these new habits can make you healthier, improve your quality of life, and help you keep excess weight off for life. 6–8 Weeks Before Surgery Research shows that smoking can lead to poor wound healing and increase the risk for blood clots. If you smoke, you must stop at least 6–8 weeks prior to surgery. This includes e-cigarettes, hookah, marijuana, and vaping. Englewood Health’s Smoking Cessation Program can help you to quit. For more information, go to englewoodhealth.org/calendar. 4 Weeks Before Surgery To reduce the risk of post-surgical blood clots, women taking estrogen-based birth control (oral or NuvaRing) should stop taking it four weeks before their scheduled surgery. They must also wait four weeks after having their surgery to resume it.
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2 Weeks Before Surgery • Attend your appointment for consent signing, where you will go over risks and benefits of surgery. • Also you will be prescribed medications which may include a scopolamine patch and omeprazole. • This is the time when you will need to eliminate most starches and added sugars. This diet is designed to reduce the size of your liver and make surgery easier and safer for you and your surgeon. • Aim for 60+ ounces of water a day • Practice taking 20-30 minutes to eat each meal
Liver-Shrinking Meals
MEAL WHAT TO EAT Breakfast • Protein shake (20–30 g protein <2 g sugar) • Example: 1 scoop of protein powder in 8 ounces unsweetened almond milk Lunch • 20-30 g protein with 1-2 cups of non-starchy vegetables
• Example: 1 cup tofu or 1/2 cup beans or 3 ounces chicken breast, plus 2 cups salad • 20-30 g protein with 1-2 cups non-starchy vegetables and 1/2 cup or 1 small piece of fruit • Example: 3-4 ounces fish, 2 cups broccoli, and 1/2 cup blueberries
Dinner
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10 Days Before Surgery • Stop all nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, aspirin, and naproxen sodium 7 to 10 days before your procedure. Also stop taking the following supplements: St. John’s Wort, vitamin E, omega fatty acids, and any herbal supplements. • Stop blood thinners, as instructed by your PCP. • Continue to take all other medications, such as blood pressure medication, as prescribed by your PCP. • If you have diabetes, follow your PCP or endocrinologist’s instructions regarding your medications. 2 Days Before Surgery You will be on a liquid protein diet consisting of one shake for each meal. Examples of high protein shakes include Ensure Protein Max and Premier Protein. These can be purchased at your local grocery store or pharmacy.
• 1 protein shake for breakfast • 1 protein shake for lunch • 1 protein shake for dinner
A fourth protein shake is acceptable if you are really hungry.
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It is important to stay hydrated. Please drink at least 60 ounces of fluid a day. You can have 1 sugar-free item daily. It is important to stay away from sugary drinks and artificially sweetened drinks unless otherwise indicated by your surgeon.
Here are some items to help you stay hydrated:
• Crystal Light • Sugar-free Kool-Aid • Decaffeinated tea • Herbal tea • Broth/consommé • Propel Water • Diet gelatin • Ocean Spray Light juice • Sugar-free ice pops
• Water • Miso soup • Diet Snapple • Smartwater • Vitaminwater • Zero Water (Fruit20) Country Time Zero-Sugar Lemonade • Luigi’s No Sugar Added Italian Ice
Please note: No caffeinated drinks are allowed.
Morning of Surgery • You may drink CLEAR LIQUIDS ONLY, up to the time you leave for the hospital. – Clear liquids include water, tea, and Gatorade (regular). – NO milk, coffee, or juice are allowed. Arrive at the hospital three hours before your scheduled surgery. You will receive an IV, antibiotics, and an injection of blood thinners when you arrive.
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After Your Surgery: Post-Operative Instructions Immediately following your surgery, you will be taken to the recovery room where you will be monitored and cared as you recover from the anesthesia. If you have any pain or nausea that is not well controlled, your nurse can provide medications to reduce these symptoms. Once you have recovered from the anesthesia, you will be encouraged to walk around your room and use the bathroom. Discharge Criteria Most patients can go home after one night in the hospital. Before discharging you, your surgeon will first make sure any pain or nausea are well controlled and that you can tolerate 3-4 ounces of liquid per hour consistently. Discharge Medications • Diabetics will be asked to stop all medications unless otherwise directed by their physician. Diabetic patients should continue to monitor their blood sugar levels. If these numbers go below 80 or rise above 200, call your PCP or endocrinologist for instructions. Once you are back home, you should continue to monitor your blood sugar 3 times a day. Always contact your physician if your results are too low or too high. • If you need pain relief, take Tylenol first. If it does not reduce it sufficiently, you may then take the prescription pain reliever your surgeon ordered. You may need to ask your surgeon for pain medication if needed.
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• If your surgeon has prescribed it, take omeprazole daily to prevent heartburn. • For all other medications, follow your physicians’ instructions. Please note: It is normal not to have a bowel movement for several days after your surgery, however, you may take MiraLAX or milk of magnesia to encourage a return to normal. Remember to drink plenty of fluids. Activity and Restrictions • No heavy lifting. Do not try to lift anything over 20 pounds for four weeks. • You may shower 2 days after your surgery. Do not take a bath or swim for 2 weeks. Be sure to be gentle when you dry yourself. Pat dry using a clean cloth or towel. • We want you to try to be as active as possible, gradually increasing your movements as you recover. Try to increase your activity each day. IMPORTANT. Once you are back home, call our office (201-608-2848) immediately if you experience any of the following symptoms: • Fever/chills; temperature over 100.4° F • Worsening chest or abdominal pain, with or without shortness of breath • Palpitations (rapid heart rate: over 100 beats per minute at rest)
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• Persistent or worsening nausea, vomiting, or inability to keep liquid and food down • Abdominal swelling or distension • Redness, foul odor, or drainage at incision sites • New leg pain, leg swelling, or redness Return to Work Most patients can resume work within 2 weeks of their surgery. If your job requires heavy lifting or other physical exertion, you may be required to postpone your return a bit longer. Please consult your surgeon. Follow-Up Appointments Your surgeon and the bariatric team will monitor your recovery, your overall health, and your weight loss progress for the first two years after your surgery. Here is the schedule for those appointments: • One week after surgery (may be a phone call) • 4 weeks after surgery • 6 months after your surgery (blood tests required)
• 1 year after surgery (blood tests required) • 2 years after surgery (blood tests required)
In addition to these routine visits, please call for an appoint- ment if any issues arise between these scheduled times.
FOR YOUR SAFETY Do NOT advance to the next diet phase until instructed to do so by your surgeon. Doing so will increase your risk of severe complications. Always call our office or your registered dietitian if you have any questions about foods.
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Phase 1: Unsweetened Liquids and Protein Shakes Start When discharged home from the hospital Duration Until first post-op visit (one week after surgery) Instructions Liquids should be sipped slowly, stopping when full. Fluid goal Post-Operative Diet Phases It will take time to adjust to your smaller stomach and adopt healthier eating habits. The diet outlined below is designed to help you heal and embrace a new way of eating. Your surgeon will tell you when to move on to the next phase.
You may not be able to reach your fluid and protein goals right away. Just do your best. • Consume 64 oz (at least 8 cups per day) of sugar-free, noncaffeinated, nonalcoholic, noncarbonated liquids. • Aiming for 4 oz per hour will help you to pace yourself.
Protein goal Suggested fluids
60–80 g per day
• Protein shakes • Water • One sugar-free item per day (such as Jello or popsicle) • Herbal tea • Sugar-free beverages (Crystal Light, Fruit2o, Protein 2o) • Electrolyte beverages (Gatorade, PowerAde Zero, Propel) • Broth or clear soups; no creamy soups
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Phase 2: Soft Textures
Start
After completing your first phase of unsweetened liquids and protein drink supplements Until next diet advancement, as determined by your surgeon or dietician
Duration
Instructions
3 meals a day: • Breakfast
• Lunch
• Dinner No snacking
Continue drinking the liquids and slowly begin to introduce soft-textured foods. As you increase your food intake, you may gradually decrease the protein shakes. Begin introducing new varieties of soft foods. Pay attention to the texture, making sure it is soft. Aim for more than 48–60 oz (at least 8 cups per day) of sugar-free, noncarbonated noncaffeinated, nonalcoholic liquids. At least 12 oz of beverages should contain electrolytes.
Fluid goal
Protein goal
60–80 g a day
(continued on next page)
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Phase 2: Suggested Foods
PROTEIN FOODS
COOKED
PEELED AND COOKED
Beans
Green beans Mushrooms
Pears
Tofu
Apples
Chickpeas
Zucchini
Peaches
Lentils
Summer squash Tomatoes
Ground meat (beef, chicken, turkey)
Tomatoes
Shrimp
Broccoli
Tuna
Cauliflower
Salmon Whitefish
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Phase 3: Regular Textures
Start
After completing Phase 2: Soft Textures
Duration
Ongoing • Use an 8-inch plate rather than a larger dinner plate. (See pages 38–39 for plate size, meal components, and food proportions.) • Eat each meal slowly and stop as soon as you are full. • Eat foods high in protein. (See plate model for correct proportions of each type of food.) • Eat protein first and then nonstarchy vegetables. • Consume 64 oz (at least 8 cups per day) of sugar-free, noncaffeinated, nonalcoholic, noncarbonated liquids. Tips: • Avoid frying your foods. Always bake, boil, stew, poach, grill, or microwave instead. 48–60 oz (at least 8 cups) clear liquids. (See clear liquid guidelines above.)
Fluid goal
Protein goal
60–80 g per day
(continued on next page)
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Please note:
• Even if you do not feel hungry, you should eat regularly, following the schedule outlined by your surgeon. • Drink 1–2 protein shakes per day if meal portions do not contain enough protein, and ween shakes. • Stop eating or drinking when you feel full. Please note: Sometimes this will feel like chest pressure or nausea. • Do not eat and drink at the same time. To prevent dumping syndrome and nausea/vomiting; wait 30 minutes after meals to drink any liquids. • Introduce one new food at a time. Remember to always take small bites and chew food thoroughly. • Avoid alcohol, which can cause dehydration, stomach ulcers, and stomach irritation. Moistening Your Food • Sometimes after surgery, food may feel dry or as if it is getting stuck in your throat. Moistening your food will prevent this uncomfortable condition. You can moisten your food by adding the following: – Unsweetened applesauce – Water – Soup or broth
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Supplements: Vitamins, Minerals, and Protein After your surgery, you will be taking in fewer calories and nutrients than before. This is especially true right after your procedure as you adjust to the size of your new stomach. To ensure you are getting adequate nutrition, you will need to take certain supplements. Your doctor will tell you what supplements to take and when to start taking them. (Please note: No gummies are allowed.) To make sure you are staying healthy, blood work will be drawn every 6 months for the first year and annually thereafter. More frequent testing may be required if you experience significant deficiencies.
The tables on the following pages includes a list of vitamin and mineral supplements you will be asked to take.
(continued on next page)
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Multivitamin Chewables (First 4 weeks after surgery)
NAME
WHERE TO BUY
Opurity Bypass and Sleeve Multivitamin Equate Children’s Complete Multivitamin
Unjury.com
Amazon, Walmart
Flintstones Complete Multivitamin
CVS, Walgreens
Centrum Chewable
CVS, Walgreens, Walmart
Target Brand Kids’ Multivitamin Complete
Target
Bariatric Fusion Chewable
bariatricfusion.com
Multivitamin Tablets (Can be added after 2-week post-op appointment)
Nature Made Multivitamin
CVS, Walgreens
Alive! Daily Energy or Women’s Energy Bariatric Advantage Ultra Multivitamin with Iron
Amazon, CVS, Vitamin Shoppe
Amazon, bariatricadvantage.com
Centrum Adult Complete
CVS, Rite Aid, Walgreens
ProCare Health
CVS, Target, Walgreens, Walmart
Vitamin Shoppe One Daily Multivitamin
Vitamin Shoppe
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Calcium (Can be added after 2-week post-op appointment). Preferred: Calcium Citrate NAME WHERE TO BUY
Citracal Petites
Walgreens, Walmart
Caltrate tablets
Costco, CVS, Walgreens
Celebrate Calcium Citrate Soft Chew
Amazon, Walmart
Viactiv Calcium Chews
Walgreens, CVS
Vitamin B12 (500 mcg can be added after 2-week post-op appointment) Nature Made Sublingual B12 CVS, Walgreens, Walmart Nature’s Bounty B12 Sublingual Costco, CVS, Walgreens CVS Instant Dissolving Vitamin B12 CVS Vitamin D (2000 IU can be added after 2-week post-op appointment) Many brands are available at stores Amazon, CVS, Walgreens, Walmart, the Vitamin Shoppe, and more.
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Food Sources of Vitamins and Minerals Whole foods are the best source of vitamins and minerals. The table below provides examples of nutritious foods to incorporate into your diet and the vitamins and minerals they provide.
Vitamins
Minerals
WATER-SOLUBLE
MAJOR
Vitamin B-1 : ham, soy milk, watermelon, acorn squash Vitamin B-2 : milk, yogurt, cheese, whole and enriched grains and cereals. Vitamin B-3 : meat, poultry, fish, fortified and whole grains, mushrooms, potatoes Vitamin B-5 : chicken, whole grains, broccoli, avocados, mushrooms Vitamin B-6 : meat, fish, poultry, legumes, tofu and other soy products, bananas Vitamin B-7 : whole grains, eggs, soybeans, fish Vitamin B-9 : fortified grains and cereals, asparagus, spinach, broccoli, legumes (black-eyed peas and chickpeas), orange juice Vitamin B-12 : meat, poultry, fish, milk, cheese, fortified soymilk, and cereals Vitamin C : citrus fruit, potatoes, broccoli, bell peppers, spinach, strawberries, tomatoes, Brussels sprouts
Calcium : yogurt, cheese, milk, salmon, leafy green vegetables
Chloride : salt
Magnesium : spinach, broccoli, legumes, seeds, whole wheat bread Potassium : meat, milk, fruits, vegetables, grains, legumes
Sodium : salt, soy sauce, vegetables
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Vitamins
Minerals
FAT-SOLUBLE
TRACE
Vitamin A : beef, liver, eggs, shrimp, fish, fortified milk, sweet potatoes, carrots, pumpkins, spinach, mangoes Vitamin D : fortified milk and cereals, fatty fish Vitamin E : vegetables oils, leafy green vegetables, whole grains, nuts Vitamin K : cabbage, eggs, milk, spinach, broccoli, kale
Chromium : meat, poultry, fish, nuts, cheese
Copper : shellfish, nuts, seeds, whole grain products, beans, prunes
Fluoride : fish, tea
Iodine : iodized salt, seafood
Iron : red meat, poultry, eggs, fruits, green vegetables, fortified bread Manganese : nuts, legumes, whole grains, tea Selenium : all meats, seafood, and Brazil nuts
Zinc : meat, shellfish, legumes, whole grains
Protein Supplements After surgery, as you adjust to your new, smaller stomach, it will take some time before you are able to eat a complete diet with adequate protein. Because of this, you will need to add protein supplements to your diet. These supplements come in the form of premade shakes, protein water, and powders. If you are vegetarian or vegan, your dietitian can tell you which products are best for you.
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Make sure the product you choose has 20–30 grams of protein per serving and less than 10 grams of carbohydrates. Here are some examples of protein supplements we suggest:
Protein Powders: Mix with 8 oz of skim or low-fat milk, unsweetened almond or coconut milk, or water.
Ready-to-Drink Shakes: Great options for on the go!
Protein Water: Combines water with protein powder.
Bariatric Fusion High Protein Meal Replacement Powder
Unjury Medical Quality Protein Shake
Protein 2 0 Protein Infused Water
Where to Find Protein Supplements:
• Amazon • Bariatric Choice (dietdirect.com)
• CVS • GNC • ShopRite • Target • Unjury.com • Vitamin Shoppe • Walgreens • Walmart
• bariatriceating.com • bariatricfusion.com • BJ’s Wholesale Club • chain grocery stores • Costco
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Protein Sources
WEIGHT AFTER COOKED
FOOD
GRAMS OF PROTEIN
½ cup
Beans, black, pinto, or lentil
7–11g
1 oz.
Beef, ground
7 g
1 oz.
Tuna, canned
6 g
1 oz. or ¼ cup shredded
Cheese
6–7 g
1 oz.
Chicken breast
6-8 g
1 oz.
Chicken deli meat
3.5–5 g
1 oz.
Chicken drumstick
11 g
1 oz.
Chicken thigh meat 7 g
¼ cup
Cottage cheese
7 g
½ cup
Edamame
9 g
¼ cup (2 fluid oz.)
Greek style yogurt
6 g
1 oz.
Ham
6 g
1 oz.
Hamburger patty
7 g
1 oz.
Lamb or pork loin/ chop
8 g
1 oz.
Large egg
6 g
1 oz.
Large egg white
3.5 g
1 oz.
Lobster
5 g
1 cup 8 oz.
Milk
8 g
1 oz. or 2 Tbsp
Nuts (almonds, pistachio, peanuts, cashews, walnuts, etc.)
2–8 g
1 oz. or 2 Tbsp
Peanut butter
4–7 g
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Protein Sources
WEIGHT AFTER COOKED
FOOD
GRAMS OF PROTEIN
1 oz.
Roast beef
9 g
1 oz.
Salmon/other fish 7 g
1 oz.
Sardines, canned in oil
6 g
1 oz.
Scallops
6 g
1 oz. or 2 tbsp
Seeds (flax, pumpkin, sunflower)
2–8 g
1 oz.
Shrimp
7 g
½ cup
Split peas
8 g
1 oz.
Steak
8 g
½ cup
Tofu
10 g
1 oz.
Turkey, ground/ roasted turkey breast
7–9 g
1 oz.
Turkey, deli meat
5 g
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Healthy Eating for Life: Nutrition 101 Losing weight and keeping it off means changing your relationship with food and embracing healthier habits. For optimum health and well-being, your daily diet should consist of the correct amounts of three essential nutrients: protein, carbohydrates, and fat. Protein Protein is in every cell in your body. To stay healthy and lose weight, your diet needs to include the right amount of this nutrient. Protein helps your body:
• Heal • Preserve lean muscle mass, which also helps you burn fat
• Build and maintain healthy bones • Maintain healthy hair, nails, and skin
Protein also makes you feel full longer than other types of foods, which can help you eat less. After surgery, it is especially important to eat enough protein to help your body heal. Please note: Too much protein can be converted into fat, so do not overeat protein.
See the table below for high quality sources of protein.
Carbohydrates Carbohydrates are your body’s principal source of energy. They include starches and sugars that the body breaks down into glucose to fuel the multiple activities that take place in your cells that keep you alive and healthy. Starches that are good for you include high-fiber vegetables and
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unprocessed foods, such as cauliflower and sweet potato, beans, and quinoa. Refined carbohydrates include foods like white flour, processed snacks, and sodas. They are much less nutritious and should be avoided. (More about refined carbohydrates below.) Healthy Carbohydrates Starch is the most common type of carbohydrate. Healthy starches are unprocessed and eaten in their whole, natural form. Here are some examples:
Whole grains such as: • Quinoa • Brown rice • Oatmeal (not quick or instant)
Starchy vegetables such as: • Root vegetables • Sweet potato • Squash • Chickpeas • Yams • Beans and lentils
Non-Starchy Vegetables Examples of these vegetables are listed below. Non-starchy vegetables are nutrition powerhouses and are an important part of your new way of eating. Benefits include: • Hunger control • Good source of fiber • Contain plenty of water • High in vitamins and other nutrients • Antioxidant properties
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Non-starchy vegetables • Asparagus • Kale • Leeks • Lettuce • Artichokes
• Parsnips • Brussels sprouts • Peppers • Radish • Cabbage • Rutabaga/turnips • Carrots • Spaghetti squash • Cauliflower • Spinach • Sugar snap peas
• Celery • Summer squash • Collard greens
• Tomatoes • Cucumber • Eggplant • Wax beans • Green beans • Zucchini
• Bean sprouts • Mushrooms • Okra • Beets
• Onions • Broccoli
Serving Size: Depending on your diet phase, 2 cups raw or 1 cup cooked
Refined Carbohydrates Refined carbohydrates (also called simple or processed carbohydrates) are sugars, or grains that have been stripped of their fiber, bran, and much of their nutritional value. They include such items as white bread, pastas, cakes, and white rice. Consuming too many refined carbohydrates can cause spikes in blood sugar and insulin levels. The insulin spike that accompanies consumption of processed carbohydrates can increase hunger and lead to overeating and weight gain. Unlike protein, which makes you feel full, refined carbohydrates and sugary foods do not satisfy for long, so you may feel hungry sooner and eat more than you should. Diets high in added sugars have been linked to overweight and obesity.
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To keep your blood sugar level steady and avoid gaining weight, aim to reduce your intake of the following foods:
• Bread, tortillas, and other products containing white flour • Bagels • Waffles, pastries, and cake • Many breakfast cereals (Check the label.) • White rice • Pizza dough • Pasta • Processed foods • Candies • Soda, regular or diet • Juices, even “all natural” or no-sugar-added • Flavored yogurt • Granola Excess sugar should be avoided. Please note it is not always listed as “sugar” on the product’s list of ingredients. Other names include: • Fructose • Agave syrup • Sucrose • Maple syrup • High-fructose corn syrup • Honey • Molasses • Maltose
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Check the ingredients list of packaged foods for sugar and any of the names listed above. Please note: Diet drinks should also be avoided. Though they may be labeled as sugar-free and have zero or few calories, the artificial sweeteners they contain can increase blood sugar and contribute to weight gain. Fiber Fiber passes through the body undigested, which supports good gastrointestinal health, facilitating bowel movements and flushing cholesterol from the body. Diets high in fiber are also associated with a lower risk of heart disease and stroke, a decreased incidence of Type 2 diabetes, healthier skin, improvements in weight loss, and a decreased risk for some cancers. Fiber stays in the stomach a long time, making you feel full longer and helping you eat less. To identify high fiber foods, keep in mind that, typically, the more natural and unprocessed a food, the higher it is in fiber.
Fiber can be found in: • Grains • Fruits • Nuts
• Beans • Vegetables
Fats There are many different kinds of fat. Some are good for your health while others can be harmful. Look for monounsaturated and polyunsaturated fats and omega 3 fats.
(continued on next page)
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Benefits of Healthy Fats: • Supports cell growth • Improves cholesterol levels: healthy fats increase HDL (good cholesterol) • Lowers triglycerides • Provides energy • Supports the immune system • Good for hair and skin • Supports brain health • Decreases inflammation • Helps prevent blood clotting • Lowers blood pressure • Reduces the risk of heart disease • Helps the body to absorb fat-soluble vitamins Sources of Healthy Fats Omega 3 fats can be found in fish and seafood, including salmon, trout, mackerel, tuna, anchovies, sardines, and oysters. They are also abundant in flax seeds, walnuts, and chia seeds. Sources of other healthy fats include: • Olive oil, sunflower oil, sesame oil, peanut oil, avocado oil • Peanut butter • Avocado • Nuts • Seeds
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Serving Size Examples of Healthy Fats FOOD ITEM
SERVING SIZE (2–4 PER DAY)
Avocado
1 ⁄
4 whole
Nuts and Seeds
1 ⁄ 4 cup or 1 oz
Peanut and Nut-Butters
1 tbsp
Olive, avocado, coconut oil
1 ⁄
2 tbsp
Olives
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Bad Fats: Hydrogenated and Trans Fats These unhealthy fats increase the levels of bad cholesterol (LDL) and decrease the levels of good cholesterol (HDL), increasing your risk for heart disease. If the ingredient list includes the words “hydrogenated,” “partially hydrogenated,” or “transfat,” it is not healthy for any diet.
Trans fat is found in foods such as:
• Crackers/cookies and other pre-made packaged goods • Margarine • Powdered coffee cream, flavored liquid coffee creamer
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Model Plate: Picturing a Healthy Meal To help you visualize what your meal should look like, please study the graphic on the following page. We suggest using an 8-inch salad plate rather than a larger dinner plate. This gives the illusion of larger portions and helps you feel satisfied with less food. To ensure good nutrition, your plate should include the percentages of foods pictured below.
We have created a plate to help guide you through your meal process.
• Eat protein first, then vegetables, and if still hungry, then starches. • Avoid sodas (even diet), juices, sweetened coffee and teas, sugar (candy or added in foods), flour, white rice, breads, fried food, processed foods, “junk” food • You need healthy fats to help stay full. Plant-based oils (olive oil, avocado oil) and small amounts of butter and animal fats are OK. • Eat 2 or 3 meals a day only. No snacking in between. No snacking after dinner! • Don’t eat when not hungry. Stop eating when no longer hungry. • If hungry, drink water first in case confusing hunger and thirst.
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50%
Non-Starchy Vegetables: Broccoli, cauliflower, spinach, lettuces, celery, zucchini, spinach
Protein: Prioritize plant-based: beans, lentils, tofu, chickpeas (1 cup) 4 ounces chicken, beef, pork, shrimp, fish, eggs, dairy
Healthy Starches (1/2 cup): Fruit, beans, whole grains
(oatmeal, quinoa), starchy vegetable (root vegetables)
25% 25%
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Nutrition Labels You will find nutrition labels on the side or back of prepared food boxes. They provide useful information that will help you eat healthy and stay on track.
Nutrition Facts 4 servings per container Serving size 1 cup (227g)
Serving information
280 % Daily Value*
Amount per serving Calories
Quick guide to percent Daily Value (%DV) • 20% or more is high
Total Fat 9g
12% 23%
Saturated Fat 4.5g
Trans Fat 0g Cholesterol 35mg
12% 37% 12% 14%
Sodium 850mg
Total Carbohydrate 34g
Carbohydrates
Dietary Fiber 4g Total Sugars 6g
0%
Includes 0g Added Sugars
Protein
Protein 2g Vitamin D 0mcg Calcium 320mg
0%
25%
Iron 1.6mg
8%
Potassium 510mg 10% * The % Daily Value (DV) tells you how much a nutrient in a serving of food contributes to a daily diet. 2,000 calories a day is used for general nutrition advice.
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1. Serving information: Serving size refers to the size of an individual portion. The nutritional facts listed on the package refer to a single serving size, not to the entire package. Example from previous page: 1 cup of the item contains 280 calories. If the entire container were consumed, the total number of calories would be 1120, not 280.
Nutrition Facts 3 servings per container Serving size 3 pieces
Serving size for this product is 3 pieces.
200 % Daily Value*
Amount per serving Calories
Total Fat 8g
9% 3%
Saturated Fat 0.5g
Trans Fat 0g Cholesterol 5mg
2%
One serving size, which is 3 pieces of this item, is 45g of carbohydrates.
Sodium 5mg
18% 20% 20%
Total Carbohydrate 45g
Dietary Fiber 5g Total Sugars 10g
0%
Includes 0g Added Sugars
Protein 8g
Serving size is not a recommendation of how much to eat. The nutrition information on the label is usually based on a single serving of the food; however, some containers may also give nutrition information for the entire package.
2. Carbohydrates: Includes fibers, starches, and sugars
• Dietary fiber is beneficial. It helps to maintain healthy and regular bowel movements and is a good source of healthy gut bacteria.
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• The total sugar amount includes natural and added sugar. For example, an orange has x amount of sugar, but zero added sugar. Milk has lactose, which is a naturally occurring sugar. • Avoid all foods with added sugar. These include table sugar, sugars from syrups and honey, and sugars from concentrated fruit or vegetable juices.
Nutrition Facts 5 servings per container Serving size 1.1 oz (32g)
160 % Daily Value*
Amount per serving Calories
Total Fat 10g
15% 15%
Saturated Fat 3g
Trans Fat 0g Cholesterol <5mg
1% 5% 6%
Sodium 125mg
Total Carbohydrate 19g
14%
Dietary Fiber 2g Total Sugars 0g
0%
Sugar Alcohol 5g
Protein 2g Vitamin A 0mcg Vitamin C 0mcg
0% 0% 0% 4%
Calcium 0mg
Iron 1mg
The above nutrition label for a sugar-free cookie shows how a sugar-free product can still be unhealthy. Though sugars are 0, the cookies are high in carbohydrates.
3. Percent Daily Value: The % Daily Value (DV) is the percentage of the recommended daily intake of a nutrient in a single serving. If you want to consume less of a nutrient such as sugar, fat, or sodium, select foods with a lower % DV (5 percent or less). If you want to consume more of a nutrient, such as fiber or protein, choose foods with a higher % DV (20 percent or more).
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4. Protein: Protein is used by the body as an energy source (providing 4 calories of energy per gram). Getting to Know Your New Stomach Making better food choices and adopting healthier habits are just part of your new approach to eating. After surgery, you will also be adjusting to your new, smaller stomach. Here are some tips to help you adjust. Listen to Your Body Your stomach will tell you when it is full. You may notice that you no longer feel hungry. Sometimes you may feel uncomfortable or slightly nauseated or you may feel some pressure in your chest. These are all indications that you have had enough and should stop eating or slow down. Remember to always eat slowly and chew your food well. And do not drink while you eat. These new habits will increase your awareness of your body. Trust your stomach. It will tell you when you should stop eating. Is it possible to stretch your stomach/pouch? Yes. Everyone’s stomach stretches over time. This is normal and even beneficial because it will help you get the nutrition your body needs. However, it is important to not overstretch your stomach, which can make you regain the weight you’ve lost.
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The most common causes of stomach stretching and weight gain after surgery include eating when you are not yet hungry; snacking between meals; or drinking alcohol, sugary juices, and carbonated drinks. How To Handle Cravings Everyone has cravings. They don’t come from an empty stomach, but from the part of your brain related to memory and pleasure. They are not a sign you are hungry. The good news is cravings don’t last. Driven by emotions or stress-related factors, they pass with time and we can use that fact to resist them. Here are some tips to help you overcome your cravings: • Pay attention to your triggers. If they are emotional or stress related, allow the emotion or anxiety to pass. • If you see the craved food on TV or in a movie, change the channel or fast forward. • Distract yourself. Engage in an activity such as calling a friend, playing a game, cleaning, or doing some stretches. The new activity will help take your mind off food. • Exercise regularly. Exercise changes your brain’s response to food. It reduces stress and improves sleep, which also helps reduce cravings • If you crave something sweet, pick something healthy. Fruits and vegetables make great snacks. • Remember to always check nutrition labels to avoid unhealthy substances and empty, non-nutritious calories.
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Some Common Side Effects of Bariatric Surgery
After surgery, you may experience the following symptoms. Some are merely annoying while others can be more worrisome. Please call us if you have any questions or concerns. Bad Breath • Not drinking enough fluids can increase the amount of bacteria in your mouth and cause bad breath. To avoid this, try to drink 48–60 oz of non-carbonated, non- caffeinated, sugar-free drinks every day. • Mints may help improve the smell of your breath, but remember to read the nutritional labels first as many contain sugar alcohols/fake sugar that may not be well tolerated.
Bloating To avoid this uncomfortable condition:
• Avoid overeating. Listen to your stomach and when you feel full, stop eating. • Avoid foods high in carbohydrates/sugar and fat.
• Avoid sugar alcohols/ fake sugar • Avoid carbonated beverages.
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• Remember to eat slowly. • Keep a food diary to review with your dietitian. This will help you identify any food or behaviors that may be contributing to bloating. Constipation Constipation is most common during the first few months after surgery. It is the result of a reduced intake of food and fiber, as well as insufficient fluids. The following tips can help: • Drink at least 64 oz. of water and non-carbonated, non- caffeinated, sugar-free beverages every day • Increase physical activity • Try over the counter stool softeners • Eat high fiber foods if your diet phase allows them. (Please refer to the list on page 35.) Diarrhea Some patients experience diarrhea during the first few weeks after surgery. This is normal and should resolve within 1–3 weeks. Diarrhea is not a normal long-term side effect of weight-loss surgery. If you continue to experience it, contact your surgeon. • Here are some tips to help you avoid or reduce the incidence of diarrhea: • Do not eat and drink at the same time. • Eat slowly and chew each bite at least 50 times.
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• Avoid foods high in carbohydrates/sugar and fat. • Avoid foods that contain lactose. • Avoid spicy foods until you are able to tolerate them.
• Avoid foods that contain sugar alcohols. • Avoid caffeinated and carbonated drinks.
Dizziness, Headaches, Lightheadedness To reduce your chance of getting these symptoms:
• Drink at least 48–64 oz. of non-carbonated, non- caffeinated, sugar-free beverages daily. Look for beverages containing electrolytes. • Do not skip meals. • Be sure to consume at least 70 g of protein every day. Dumping Syndrome Dumping syndrome is usually caused by eating too many high-fat or high-sugar foods. It occurs when food passes too quickly from the stomach into the small intestine. Symptoms include flu-like symptoms, nausea, vomiting, sweating, weakness, bloating, increased heart rate, lightheadedness, and diarrhea. To prevent this condition: • Avoid foods that are too high in carbohydrates/sugars. (25 g of sugar is considered too high.) • Eat more protein and avoid drinking with meals. • Avoid foods that are too hot or too cold.
Food Intolerances After surgery, you may find you are no longer able to
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tolerate certain foods. This can change frequently and is different for each individual. Here are some tips for coping with this symptom: • If you cannot tolerate a food, find an alternative or avoid it for a short period of time. • After avoiding the food for a few weeks, try gradually reintroducing it. • Keep a record of the foods you eat and note which ones are poorly tolerated. • Record your symptoms in case you need to discuss them with your PCP. • Contact your PCP or dietitian with any questions or issues. Frothing/Foamies Frothing, or “foamies,” occurs when too much mucous is produced to break down food that backs up into the esophagus, causing a thick discharge or frothy clear vomit/ foam. If this occurs, try drinking hot tea or hot water before or after a meal. Hair Loss Some patients experience hair loss during periods of rapid weight loss. This is caused by a protein or vitamin deficiency that can occur at first, while you’re getting used to your smaller stomach and eating less. Do not seek hair treatments, as the situation will improve over time as you become better nourished. (See below for more information about protein and vitamin deficiencies.)
To Reduce/Avoid Hair Loss: • Be sure to meet the protein goals set by your dietitian.
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