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Home , Bariatric surgery, Gastric bypass surgery

Bariatric Program Hawai‘i’s first program with a director who has walked the path you’re on

www.palimomi.org/bariatrics Your role You play a critical role in the long-term success of your surgery. You will need to:

• Commit to improving your health. • Discuss your health history with your surgeon. • Discuss any questions or concerns you have and learn all you can about the surgery before making a decision. • Follow all instructions on preparing for your surgery. • Commit to following all instructions described in the Your bariatric surgerY Handbook guide on nutrition, activity and other care after surgery (given to you by Your Role 3 your surgeon before surgery). Morbid and its Medical Impact 3 Both the bariatric team and you must Chart 4 commit to honesty, responsibility and “I talk to them about what Why Consider Major Surgery? 7 cooperation in order to increase your they will be going through so succes ate. Setting Realistic Expectations 8 they don’t feel alone. They call Promotion of With Bariatric Surgery 8 Morbid obesitY me at any time just to talk.” and its Medical iMpact Explore the Benefits and Risks of 9 —Christi Keliipio, R.N., M.S.N., FACHE A clear understanding of morbid obesity Bariatric Surgery Program Director; The Normal Digestive Process 10 is very important, because this is what is former bariatric surgery patient Malabsorptive Procedures 10 used to guide physicians in selection of Restrictive Procedures 11 therapy for people who are . A person is considered clinically severely Combination Procedures 12 The BMI is calculated as follows: obese (morbidly obese) when he or BMI=weight (kg)/height (m2) Roux-en-Y Gastric Bypass 12 she is so heavy that the fat tissue load Morbidly obese people have higher rates creates (or will create) other medical Bariatric Surgery – An Overview of Procedures 14 of medical problems, translating into problems. Expected Weight Loss After Gastric Bypass 15 greater need for weight loss and the Morbid obesity is a chronic condition rationale for more extreme measures 16 that is very difficult to treat. Roughly, (such as bariatric surgery) to control Nutritional Expectations 16 individuals are considered morbidly the weight. The medical complications General Recommendations 18 obese if their weight is more than 100 of obesity may occur in moderately pounds in excess of the ideal body obese people but the frequency of these Foods That May Be Difficult To Tolerate 18 weight. A more exact (and more widely associated problems (such as heart Our Bariatric Surgery Program Team 19 accepted) way to define morbid obesity disease, high blood pressure, , is to use the body mass index (BMI). premature death, etc.), increases

2 3 bMi as a Function oF HeigHt and WeigHt bMi as a Function oF HeigHt and WeigHt in Feet, incHes and pounds in Feet, incHes and pounds

NormaL oVerWeigHt oBeSe eXtreme oBeSity

Bmi 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Bmi 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

HeigHt HeigHt BoDy WeigHt (PouNDS) BoDy WeigHt (PouNDS) iNcHeS iNcHeS

58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181 186 58 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258 261 266 271 276 281 286

59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 59 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267 271 276 281 286 291 296

60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194 199 60 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276 281 286 291 296 301 306

61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201 206 61 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285 291 296 301 306 311 316

62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 62 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295 301 306 311 316 321 331

63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214 220 63 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304 311 316 321 326 336 341

64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 64 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314 321 326 331 341 346 351

65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 65 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324 331 336 341 351 356 361

66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235 241 66 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334 341 346 356 361 366 371

67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249 67 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344 351 356 366 371 376 381

68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256 68 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354 361 371 376 381 386 396

69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263 69 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365 371 381 386 391 401 411

70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 70 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376 381 391 396 401 411 421

71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 71 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386 391 401 406 411 421 431

72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 72 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397 401 411 416 421 431 441

73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295 73 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408 411 421 426 431 441 451

74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 74 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420 421 431 436 441 451 461

75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 75 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431 431 441 446 451 461 471

76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320 76 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443 441 451 456 461 471 481

Source: Adapted from Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report.

4 5 • Abdominal conditions – Gastric bypass surgery is a time-tested the only effective means of inducing disease, GERD (recurrent heartburn), operation. It has been endorsed by a significant long-term weight loss for recurrent ventral , fatty 1991 consensus panel convened by the the vast majority of patients with • Endocrine conditions – diabetes, National Institute of Health (NIH), as morbid obesity. hirsutism, , hyper- WHY consider Major surgerY? cholesterolemia • Urinary and reproductive conditions– Nearly 80% of obese patients have one Bariatric surgery has proven effective in frequent urinary tract or more of the following conditions: treating these conditions. In one study (uTI’s), stress urinary incontinence, • Diabetes of 104 patients at 1 year post-operation, menstrual irregularity or infertility • Dyslipidemia 90.8% of patient conditions were • Gallbladder disease improved or completely eliminated. • Musculoskeletal conditions – • Coronary Artery Disease/ See graph below. degeneration of knees and hips, disc herniation, chronic non-surgical low • back pain • Skin conditions – multiple disorders, ELIMINATE IMPROvE NO CHANGE WORSE most related to diabetes and yeast infections between skin folds

“It will change your life. It is • Cancer risk – breast, uterine, prostate, Osteoarthritis (64) renal, colon, pancreatic, gastric, one of the hardest, and the gallbladder and endometrium Hypercholesterimia (62) best thing you will ever do.” A BMI 40 and above indicates that a —Clesson Werner person is morbidly obese and there- GERD (58) Pali Momi bariatric surgery patient fore a candidate for bariatric surgery. Bariatric surgery may also be an option Hypertension (57) for people with a BMI between 35 and dramatically as weight increases. For 40 who suffer from life-threatening (44) example, very obese men between the cardiopulmonary problems or diabetes. ages of 25 and 35 are 12 times more likely However, as in other treatments for to die prematurely compared to normal obesity, successful results depend Hypertriglyceridemia (43) weight men of the same age. mainly on motivation and behavior. Medical conditions that are commonly Peripheral Edema (31) For nearly all people with morbid caused or made worse by obesity: obesity, bariatric surgery is the • Respiratory conditions – obstructive standard of care. When other medically Stress Incontinence (18) sleep apnea, obesity hypoventilation supervised treatments have failed, syndrome, asthma/reactive airway bariatric surgery offers the best option Asthma (18) disease of long-term weight control. One of the • Heart conditions – high blood most popular and successful surgical Diabetes (18) pressure, heart failure caused by approaches is the Roux-en-Y gastric 0% 20% 40% 60% 80% 100% pulmonary hypertension, higher bypass.

risk of coronary artery disease Schauer, et al, AnnSurg 2000 Oct:232(4):515-29 ()

6 7 Kenneth Jones, Surgery 5/13/11, proMotion oF WeigHt loss explore tHe beneFits and risks oF gastric bYpass surgerY lost over 100 pounds WitH bariatric surgerY beneFits risks Surgeons use techniques that pro- • Most patients lose weight rapidly and • 10-20% of patient who have open duce weight loss primarily by limiting continue to do so until 18-24 months bariatric surgery require follow-up how much the can hold. These after the procedure. operations to correct complications restrictive procedures are often com- • Significant sustained weight loss. (abdominal hernias are the most bined with modified gastric bypass • Although many patients regain some common). procedures that somewhat limit calorie of their weight after 24 months, few • Other possible post-surgical and nutrient absorption. regain it all. complications include , before after tWo WaYs surgical procedures • Bariatric surgery improves or bleeding and death. proMote WeigHt loss eliminates most obesity related • During rapid or substantial weight setting realistic • By decreasing food intake (restric- conditions such as high blood loss, a person’s risk of developing expectations tion), gastric banding, gastric bypass pressure, high cholesterol, sleep is increased. Gallstones The goal of surgery is to help lose over and vertical-banded gastroplasty are apnea and diabetes. can be prevented with supplemental half of your excess weight. This can that limit the amount of food • Blood sugar levels for most patients bile salts taken for the first six months reduce or prevent health problems. the stomach can hold by closing off or with adult onset diabetes (type II) after surgery. Keep in mind that: removing parts of the stomach. These improve almost immediately and • More than 1/3 of gastric bypass become completely normal within patients develop gallstones, which • It’s not cosmetic surgery. operations also delay emptying of the a year of surgery. could lead to a laparoscopic proce- • Other medically managed weight stomach (gastric pouch). • Less osteoarthritis pain and improved dure known as to loss methods must be tried first and Note: The majority of patients report mobility. remove the gallbladder. documented. Surgery is only an feeling full and satisfied after a small • Improved mood and self-esteem. • Nearly 30% of patients who have option if other methods have not been amount of food, and not feeling exces- bariatric surgery develop nutritional successful. sively hungry most of the time. If Brett Bulseco, surgery 2/9/10, deficiencies such as , osteo- • Surgery is meant to be permanent. much more than a quarter cup of food lost 200 pounds porosis and metabolic bone disease. You will need to make lifestyle changes is eaten at once, the patient will feel These deficiencies can be avoided if for the rest of your life. uncomfortable and may vomit. before lifelong and intake are • You must commit to making good • In the gastric bypass procedure, a maintained. food choices and being more active surgeon makes a direct connection • – caused by after surgery. Otherwise, you will not from the stomach to a lower segment stomach contents moving too rapidly maximize your weight loss. of the , thus bypassing through the small intestine, resulting • You will not reach a healthy weight the and some of the typically from a high intake of simple right away. Most of the weight is lost . This procedure causes food sugars and carbs. steadily over the first year and a half to be poorly digested and absorbed after surgery. (). • The surgery is a tool, which will help Note: vitamin and mineral supple- ments and a high protein intake will you lose weight and by being diligent after with and attending support be a lifetime commitment to prevent groups and workshops, your chances the problem of nutritional deficiencies. of losing more weight will dramatically Although results of the operations using increase. these procedures are more predictable Note: It is important to know that this surgery cannot be completely reversed. The and manageable, side effects persist for decision to have this procedure must be made in consultation with your surgeon, some patients. and a very careful consideration of the potential benefits and risks, and the lifelong consequences.

8 9 tHe norMal digestive Malabsorptive procedures restrictive procedures process Biliopancreatic diversion and Restrictive gastric procedures restrict The Vertical Sleeve is Normally, as food moves along the (dS) the size of the stomach. There are sev- regarded as a restrictive procedure digestive tract, appropriate digestive The DS is more effective in achieving eral types of restrictive procedures. where approximately 80% of the stom- juices and enzymes arrive at the right excellent weight loss in the extremely Vertical Banded and Silastic Ring Gas- ach is removed. The new, smaller place at the right time to digest and obese, but brings with it a higher rate troplasties use a staple line to restrict stomach is the shape of a banana. The absorb calories and nutrients. After of true malnutrition (malnutrition is very the size of the stomach. The LAP- limits the amount chewing and swallowing the food, it rare for those who undergo gastric BAND® system utilizes an adjustable of food intake, making you feel full after moves down the to the bypass). In the DS, a sleeve resection of band that restricts the opening to the eating small amounts of food. After the stomach, where a strong acid continues the stomach is performed by removing remainder of the stomach. The LAP- surgeon removes most of your stomach, the digestive process. The stomach can about 2/3 of the stomach, maintaining BAND® is a promising new technology the remaining portions of the stomach hold about three pints of food at one continuity of the gastric lesser curve. that is new to the uSA (approved by the are surgically stapled together creating a time. When the stomach contents move The small intestines are arranged so that FDA in june 2001). This procedure recalls “sleeve” shaped stomach. This procedure through the to the duodenum the section where the food mixes with the principle of doing the smallest (least does not bypass the intestines; therefore, (the first segment of the intestine), bile the digestive juices is fairly short. No invasive) procedure possible to achieve there is no gastrointestinal malabsorp- and pancreatic juice speed up digestion. small intestine is defunctionalized and the desired result. In this method, a band tion. The hormone is removed Most of the calcium and iron in the foods consistently liver problems are much is placed at the top of the stomach, cre- which significantly reduces the feeling we eat is absorbed in the duodenum. The less frequent. The procedure essentially ating a pouch. The opening to the rest of of hunger. This procedure is not recom- remaining two segments (the jejunum eliminates stomal ulcers and dumping the digestive tract is adjustable through mended for those with GERD as it may and ) of the nearly 20 feet of small syndrome. an epidermal port. The concept here is cause symptoms to worsen. intestine, complete the absorption of to create anatomy that provides a sen- almost all calories and nutrients. The sation of satiety after a very small meal. food particles that cannot be digested in Weight loss for restrictive procedures is the small intestine are stored in the large much less than that of the malabsorptive intestine until eliminated. procedures and the Roux-en-Y gastric bypass. It can also be accompanied by a considerable amount of .

10 11 Gastric–bypass may cause dumping will attach to the stomach pouch • Closing of trochar sites and skin – syndrome, whereby stomach contents later in the operation. The “standard” whether a larger incision for open move too rapidly through the small length of the roux limb is 75 cm. gastric bypass or several small intestine. Symptoms include , Sometimes, a longer roux limb is incisions for the laparoscopic gastric weakness, sweating, faintness, and, measured in heavier patients. bypass have been made, the muscle defects are often closed by suture occasionally, diarrhea after eating, • division of the stomach – the as well as the inability to eat sweets stomach is cut, using a device that that is absorbable (stitches do not without becoming so weak and sweaty simultaneously divides the tissue and need to be cut out later). The skin that the patient must lie down until the places staples to seal the tissue on incisions are then closed with suture, ® symptoms pass. each side of the cut. The purpose is steri-strips or staples, depending on to create a tiny stomach pouch that the surgeon’s preference. roux-en-Y gastric bYpass is 15 to 20 ml in size. In other words, Description of the procedure (surgical this creates a cuff of stomach on the Pamela Duprau, surgery 6/28/11, technique may vary): bottom end of the esophagus. lost 90 pounds

Ilustration Copyright © 2010 Nucleus Medical • Exploration of the abdomen – after • Formation of the gastro-jejunal Art, All rights reserved. www.nucleusinc.com. the abdomen is entered (with an open (attachment of stomach incision or laparoscopically using a “gastro” to the small intestinal roux coMbination procedures viewing telescope and small 5 to 15 limb”jejunal”) – this maneuver is the mm trocars, or tubes, through which key part of the entire operation. This The Roux-en-Y gastric bypass can be surgical instruments are passed into “hookup” must have excellent blood regarded as a restrictive procedure; the abdomen), the surgeon makes a supply and must not have any tension however, there is some quick check to be sure that no obvious remaining on it at the completion of due to bypassing food around the anatomic abnormalities are present. the operation. A stapling device is duodenum and the initial part of the Particular attention is given to the used to create this connection. jejunum. The risk for pouch stretching, gallbladder and the uterus/ovaries. • Other procedures, or drains – breakdown of the staple lines and In open cases, the gallbladder is felt cholecystectomy, tubal ligation, and leakage of stomach contents into to determine if it contains gallstones, placement of (stomach the abdomen are about the same for and if so, the gallbladder is removed tube) or are done at the gastric bypass as for vertical banded later in operation. In laparoscopic end of the operation as necessary gastroplasty. However, because cases, an ultrasound is done before and discussed with the patient. The gastric bypass causes food to skip the surgery to tell if gallstones are present. surgeon usually places a plastic duodenum, where most iron and calcium A cholecystectomy may be planned if drainage tube near the gastro-jejunal are absorbed, risks for nutritional the ultrasound shows gallstones. anastomosis, to serve as a “sentinel” deficiencies are higher. Anemia may • Creation of the roux limb –this part for a leak in this area and potentially result from malabsorption of vitamin B12 of the procedure is done by dividing to aid in therapy if a leak occurs. and iron in menstruating women, and the small intestine 15 to 40 cm decreased absorption of calcium may downstream from the ligament of after bring on and metabolic treitz (where the jejunum begins). bone disease. Patients are required to b e f o r e The length of the roux limb is take life-long nutritional supplements measured, which is the segment that that usually prevent these deficiencies.

12 13 bariatric surgerY – an overvieW oF procedures expected WeigHt loss aFter gastric bYpass

The gastric bypass procedure can A program of regular exercise is very procedure pros cons successfully start patients on the road important for promoting and maintain- to recovery from morbid obesity, but ing weight loss. Studies have shown that surgery alone will not ensure long-term patients who exercise 45 minutes at least • Jejuno-ileal Greater sustained • Increased risk of success. Surgery is a tool, something to three times per week lose an average of bypass weight loss with less malnutrition and help patients do the work. In order to get 18% more excess weight than patients dietary compliance vitamin deficiency • Biliopancreatic down to a healthy weight, patients must who do not exercise regularly. Diversion and • Constant follow-up to adjust their eating habits and exercise Duodenal Switch monitor increased risk patterns. Over 50% of patients achieve good to excellent weight loss results following • Intermittent diarrhea Most patients lose almost half of their alabsorptive gastric bypass surgery. Expected weight and/or foul smelling M excess weight in the first year and loss is 55-75% of the excess weight. More stool continue to lose weight after this point. weight has been shown to be lost by There is no amount of weight loss that patients who participated in an extensive is guaranteed. Weight control is the after-care program. However, this suc- • v ertical Banded • Relatively easy • Less weight loss personal responsibility of the gastric cess depends entirely on following a very Gastroplasty operation maintenance bypass patient. restricted diet for the rest of their lives, (vBG) • No protein-calorie • More late failures due and making major lifestyle changes. Successful habits include: • Silastic Ring malabsorption to dilation • Eating three small, well-balanced The first post-operative year is a critical Gastroplasty • No vitamin • Less effective with meals, and a maximum of one snack time that must be dedicated to changing • Adjustable Band or mineral sweet eaters a day. old behavior and forming new, lifelong Gastroplasty deficiencies due • Significant dietary • Avoiding carbonated, caffeinated or habits. The success of weight loss surgery (LAP-BAND®) to malabsorption compliance required sugary beverages and alcohol. is most commonly defined by the total estrictive

r • vertical Sleeve • Risk of decreased • Patients tend to gain weight back weight loss during the initial weight loss Gastrectomy esophageal function if they start eating larger portions, phase. However, in the minds of patients graze, consume high fat or “junk” undergoing surgery for morbid obesity • Risk of band erosion, foods or drink high-calorie beverages. the questions are: band slippage and silastic reaction • “Will this be a long-term permanent Tom & Edwina Oliveira, surgery performed solution?” in 2010, together lost over 200 pounds • “What can I do to insure my lifelong • Roux-en-Y Gastric • Sustained weight • Limited B-vitamin success?” Bypass loss with limited absorption after In other words, how can I maintain at least dietary compliance • Gradual

bination 74% of my initial excess weight loss after a

M • Can be performed over 15 years successful gastric bypass? o via laparoscope c Patients should take personal responsi- bility for staying in control. Patients who have a general feeling that maintaining before their weight is indeed their own respon- sibility and that surgery was a tool they used to reach and maintain a healthy weight, succeed and do better in the long term.

14 15 Lack of exercise, poorly balanced meals, sistency of applesauce or a pudding diet and then a modified regular diet. constant grazing and snacking and texture. It is very important to ensure The diet progression is designed to drinking carbonated beverages are the that the food you consume during this allow your body to heal. Initially, it will basic causes of not maintaining weight time is pureed well to prevent certain help you meet your protein and liquid loss. Additionally, regular attendance of types of blockage. requirements, and later, assist you in support groups and workshops greatly • Step 4: In step four, the texture and meeting your nutritional needs. It is increases patients’ compliance with the the thickness of your foods should imperative that you follow the diet’s recommendations for optimal weight resemble a mashed or ground tex- progression and adhere to this regimen loss and maintenance. ture. During this step, you will add new to maximize healing and minimize the foods to see if you are able to tolerate risk for unnecessary complications. The diet them. If you experience the inability to size of your stomach pouch is about After gastric bypass, the patients must tolerate new foods, do not give it up one ounce or one to two tablespoons. carefully follow the recommendations entirely. Try it again in a few days. Each At first your capacity will be somewhat outlined in the bariatric surgery guide person’s tolerance to different types of limited, so be patient. You may find that for the rest of their life in order to max- food varies from person to person. The two to three teaspoons of food fill you imize their weight loss success. You will only way to discover your tolerance up. This is expected. You may also find need to take a protein supplement to is by trial and error. Just remember to that you are able to eat more of one type ensure proper post-operative nutrition. chew your food completely and take of food than another. That is okay, too. In order to achieve optimal post-oper- small bites. Over time, your food pouch will stretch. ative nutrition, it is essential that you • Step 5: Congratulations, you have By six months after surgery, it may “You’ll go through stages take daily and mineral progressed onto solid foods! At the stretch to eight ounces or one cup. Long supplementations for the rest of your beginning of this step, you should still term, the size of your pouch is likely to of adjustment—physically life. Post-operative diets are separated gradually increase your intake of tex- be eight to twelve ounces or 1 to 1–1/2 and psychologically. When I into 5 steps. Here is an overview of the tured foods. For example, instead of cups. This will limit the amount of food realized I could never go back expected post-operative diet: mashing down your steamed vegeta- you can eat at one time. • Step 1: A clear liquid diet, started bles, chew your vegetables really well. to the way I used to eat, I just two or three days after surgery. It In this step, you should focus more One of the changes that patients often started bawling. It was my essentially provides hydration during on your protein intake. The amount comment about is the concept of grieving process.” the initial post-operative period. of protein you consume should be “wasting food.” After surgery your eyes Examples of clear liquids are chicken, half the amount of a small side salad and head still work the same way as they beef or turkey broth, water, jello and plate. The rest of the plate should con- did before. However, because of the new options, there are many options and clear sport drinks. sist of salads or vegetables and a small stomach pouch, you will be satisfied with preferences post-operatively. However, • Step 2: Once you are able to tolerate amount of carbohydrates. Remem- much less. It is critical that you listen to most programs agree that the primary clear liquids, you will begin a full ber to focus on making healthy food your body’s signals of fullness and not source of nutrition should be protein. 70 liquid diet for one week. A full liquid choices to get the maximum amount to your eyes that see food left on your to 75% of all calories consumed should diet usually contains more texture of nutrition from such a small amount plate. be protein based (eggs, fish, meat, etc.), than a clear liquid diet. Keep in mind of food. Also, incorporate exercise into You may also be surprised at how the carbohydrates (bread, potatoes, etc.) that these foods should all be sugar your daily life to help with the weight surgery changes your wants and desires should make up only 10 to 20%, and fats free and fat free. Some food choices loss and maintenance. for certain foods. Foods you may have (butter, cheese, etc.) only 5 to 15% of the include milk, yogurt, strained soups, previously loved, you may now find you calories that you eat. A diet consisting sugar free popsicles and fudgesicles. nutritional expectations are less interested in. of 600 to 800 calories and 75 grams of • Step 3: In step three, you will advance After gastric bypass you will need to protein should be the goal for the first to a pureed diet. Step 3 usually lasts make changes to your eating patterns. It is common to see some variation 6 months. Protein drinks can be helpful about two weeks. In this step, you will The diet after surgery progresses from from program to program related to to fulfill your protein requirements, consume foods that have the con- a liquid diet, to a pureed diet to a soft nutrition. Just as there are many food

16 17 there are many to choose from. Look for • Stop eating when feeling full or if our bariatric surgerY prograM teaM protein drinks that are low calorie, low feeling any discomfort. sugar and have a good taste. • Always cut food into small pieces Mark Grief, M.D., FACS and chew food very well to prevent Avoid foods which contain sugar. Not Bariatric Surgeon, Bariatric Program Medical Director blockage. If food should stick, try a only will they slow down your weight teaspoon of Adolf’s meat tenderizer in He was trained by renowned bariatric surgeon loss, but they can make you sick! Sugar a glass of warm water, sipped slowly. Dr. Ninh T. Nguyen, uC Irvine, pioneer in laparoscopic may cause “dumping syndrome” in • Concentrate on eating protein rich Roux-en-Y Gastric Bypass. He is a board certified patients who have had the gastric foods such as fish and seafood, surgeon and has been in practice for more than bypass procedure. Dumping, in short, cheese, eggs and poultry. At meal- 20 years. is when sugars go directly from your time, eat protein foods first before stomach pouch into the small intestine any other food. Christi Keliipio, R.N., M.S.N., FACHE causing heart palpitations, nausea, • Do not snack between meals. Bariatric Surgery Program Director abdominal pain, and diarrhea. Symptoms • Avoid very sweet food, candy, may very among patients. Dumping lasts chocolate and high-sugar beverages She is a former bariatric surgery patient, having about 30 minutes to an hour and can to prevent the unpleasant effects of lost more than 100 pounds. She has the firsthand take place 30 to 60 minutes after eating. dumping syndrome. experience to understand and guide patients to success. She received her master of science in To maintain a healthy weight and to • Sip liquids slowly, drinking at least 1/2 nursing from the university of Hawai‘i. prevent weight gain, you must develop cup every hour between meals to total and keep healthy eating habits. You will 8 eight-ounce cups per day to avoid need to be aware of the volume of food dehydration. Maria Akagi, R.N., B.S.N. that you can tolerate at one time and • Minimize alcohol intake as it is high in Registered Nurse calories, may cause an ulcer, and the make healthy food choices to ensure She has worked in the nursing field for over effects may be felt much more quickly. maximum nutrition in minimum volume. 12 years and received her bachelor of science • Take a supplement, B12 A remarkable effect of bariatric surgery in nursing from the university of Phoenix. is the progressive change in attitudes vitamin and calcium every day. towards eating. Patients begin to eat Foods tHat MaY be diFFicult to live – they no longer live to eat. As Sasha Goto, MBA, MAOC to tolerate well, exercise must be part of your daily Program Liaison • Bread products routine. She has worked in health care for more than • Cow milk products 5 years and received her master in business general recoMMendations • Pasta products from Hawai‘i Pacific university. • Drink fluids before the meal. Do not • Fatty foods and fried foods drink liquids with meals. Then wait 20 • Candy, chocolate, any sugary foods Lianne Metcalf, MS, RD, LD minutes after meals before resuming and beverages Clinical Dietician fluids to prevent pouch stretching and • Carbonated beverages vomiting. • Bran cereal and other bran products She received her master of science in clinical • Eat three tiny, protein-focused meals • Corn, whole beans and peas nutrition from New York university. per day at regular times, sitting at a • Dried fruits and skins of fresh fruit table. Eat slowly, savoring your food. • Coconut Do not eat when feeling rushed or For questions about our Bariatric Surgery Program, stressed as this may cause gastric please contact us at (808) 485-4173. upset.

18 19 98-1079 Moanalua Road • Aiea, Hawai‘i 96701 • (808) 485-4173 www.palimomi.org/bariatrics

rev. 01/14