BARIATRIC NUTRITION GUIDE
November 2015
TABLE OF CONTENTS
INTRODUCTION 3
DIGESTION – BEFORE AND AFTER THE SURGERY 3
THE DUMPING SYNDROME AND HOW TO AVOID IT 3-4
NUTRITION AT A GLANCE 4
DEHYDRATION RISK 4
HOW TO UNDERSTAND INGREDIENT LISTS 4-5
HIDDEN SUGARS AND SUGAR SUBSTITUTES 5
HOW TO READ A FOOD LABEL 5
DIETARY GUIDELINES AFTER SURGERY 6-8
GENERAL RULES AFTER SURGERY 8
GENERAL GUIDELINES FOR PORTION CONTROL FOR MEALS 9
BEHAVIOR MODIFICATION 9
YOUR BODY’S PROTEIN NEEDS 10
PROTEIN SOURCES 11
VITAMIN AND MINERAL SUPPLEMENTS 12
DINING OUT AT RESTAURANTS 12
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INTRODUCTION
Bariatric/Metabolic Surgery has been developed to help you lose weight. However, it is not magic; 50% of the attainable results are dependent on your postoperative compliance. The surgery requires a major change in your eating and exercise habits to achieve and maintain your desired weight loss. It is essential that you follow the nutritional plans that are outlined in this handout. Your team: doctor, nurses, counselor, and dietitian are available to answer questions and provide any other support you may need. By using your surgically reduced stomach pouch effectively, you will have a positive impact on your overall health. Staying within the guidelines and following the dietary protocol will help you maximize the benefits of your surgery.
HOW DOES NORMAL DIGESTION WORK?
Digestion starts in the stomach, which receives chewed and swallowed food. Typically the stomach stores food for up to four hours and initiates digestion by breaking down protein and killing bacteria with strong acidic gastric juice. From here, it moves into the first part of the small intestine. The duodenum functions to break down food into simple nutrients and absorb a variety of nutrients, including iron and calcium. The next stop is the jejunum, which functions to absorb our nutrients. Digestion continues in the ileum and finishes in the large intestine with a bowel movement.
HOW WILL DIGESTION WORK AFTER THE GASTRIC BYPASS SURGERY?
By creating a small pouch in the stomach and reattaching the jejunum to this pouch, food intake is significantly reduced and the duodenum is bypassed. As explained above, the main function of the duodenum is digestion and absorption of iron and calcium. Therefore, it's important to chew food thoroughly and take vitamin and mineral supplements to prevent nutritional deficiencies of these nutrients. There are no digestive changes after the sleeve gastrectomy or lap-band procedures.
WHAT IS THE DUMPING SYNDROME?
A potential side effect of the Gastric Bypass surgery, the dumping syndrome is caused by stomach contents moving too rapidly through the small intestine. Your body compensates by sending fluids from the bloodstream to dilute the food causing a rapid decrease in the volume of circulating blood and a rapid increase of fluid in the intestine. Symptoms include:
• Feeling faint • Nausea • Sweating • Diarrhea • Weakness • Rumbling stomach • Rapid pulse • Anxiety
To prevent the dumping syndrome, it is recommended that you avoid consuming foods with high sugar and fat content, eat more slowly, and allow 30 minutes between consuming food and fluids. A list of foods that can potentially cause the dumping syndrome is provided on the next page.
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AVOID THESE POTENTIAL DUMPING FOODS:
• Sugar • Cake • Frozen yogurt • Honey • Soda • Ice cream • Syrup • Pie • Milkshakes • Jam/Preserves • Cookies • Creamy salad • Candy • Donuts dressings • Chocolate • Sherbet • Pudding • Fruit yogurt
NUTRITION…AT A GLANCE
Food serves as an important vehicle for taking nutrients into the body. Food is broken down into specific nutrients that the body requires. These nutrients are called carbohydrates, fats, proteins, vitamins, and minerals.
• Protein – helps build, maintain and repair body tissue. • Carbohydrate (starches and sugars) – provide energy. Eat more complex carbohydrates such as whole grains and fruits/vegetables. Avoid simple sugars. • Fat – provides energy and fat-soluble vitamins • Water – supports all body functions. It carries nutrients through the body and removes waste.
Protein and water will be the most important nutrients you consume after your surgery. Protein is necessary to help heal and preserve muscle tissue while you're losing weight. A lack of fluid can result in dehydration.
DEHYDRATION RISK
After bariatric surgery you are at risk for dehydration because you cannot consume large quantities of fluid quickly, instead you will have to sip on fluids during the day. This may be a challenge for some and a new habit to create. Your fluid goal is 6-8 cups per day or 48-64 oz. You can achieve this goal by sipping on 1 oz of fluid every 15 minutes or 4 oz every hour. Symptoms of dehydration include: increased thirst, dry mouth, dizziness, confusion, headache, decreased urine output, or dark urine.
HOW TO UNDERSTAND INGREDIENT LISTS
Ingredient declaration is required on all foods that have more than one ingredient. The ingredients are listed in order of predominance by weight; so the ingredient that weighs the most is listed first and the ingredient that weighs the least is listed last. The common or usual name for ingredients is listed unless there is a regulation that provides for a different term.
Protein may be listed on labels as caseinate, whey, soy, pureed meat or individual amino acids. Fat may be listed as partially-hydrogenated oil, soy, canola, corn, sunflower, safflower or medium chain Bariatric Nutrition Guide November 2015 - FHSH/ALSA 4 triglyceride oils. Carbohydrates have many different names. Be sure to read ingredient lists to look for foods with high sugar content. The scientific names for sugars often end in “ose”. The following list provides different names of sugars. If these ingredients are listed within the first five, it’s probably a significant source of sugar and should be avoided.
HIDDEN SUGARS
• Sucrose • Molasses • Dextrose • Turbinado • Maltose • Corn sweetener • Fructose • Malt • Lactose • Sorghum • High fructose corn syrup • Fruit juice concentrate • Dextrin • Evaporated cane juice • Crystallized cane sugar or juice • Agave nectar
SUGAR SUBSTITUTES
Sugar substitutes can be tolerated by most patients after surgery and contain little to no calories, however they are not recommended long term because repeated exposure creates a preference for sweetness. Here are some examples: The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location. • Splenda® (Sucralose) • Equal® (Aspartame) • Sweet-N-Low® (Saccharin) • Stevia (herbal supplement) - Truvia
HOW DO YOU READ A FOOD LABEL?
A Nutrition Facts Panel is a requirement on most foods. It gives specific nutrient and calorie information. Here’s how to read it:
Serving size – • Based on the amount of food that people typically eat. • The nutrition information is based on one serving size only. • Remember that you will be eating much smaller portions, so the nutrition information will need to be adjusted.
The nutrients 1. Look for food items high in protein 2. A good source of protein is between 7-10 grams/serving 3. Sugars – most GB patients can tolerate 10-15 grams/serving 4. Look for products low in fat, cholesterol, and sodium.
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DIETARY GUIDELINES AFTER SURGERY
CLEAR LIQUIDS DIET – FIRST WEEK
For the first week after surgery you will be on a Clear Liquids diet. You need to consume 48-64 oz of fluid. Your liquid diet will include things such as:
• Broth (chicken, beef, vegetable) • Crystal-Light® • Water • Propel Zero® • Sugar-free gelatin (Jell-O®) • Powerade Zero™ • Sugar-free popsicles • Sugar-free Vitamin Water™ • Decaffeinated coffee/tea (no • Sugar-free Life Water® creamer) • G2® (low sugar Gatorade) • Diluted juice (half juice/half water) – • Diluted Gatorade® (half apple, cranberry, or grape Gatorade®/half water) • Unflavored coconut water
Plain water may be a problem, but is better-tolerated if “flavored” with some lemon juice or Crystal- Light® mix. Strained soup will be tastier than broth, however both may be too salty for your taste. Remember you will be able to consume only a few ounces at a time. In order to prevent dehydration, you should try to sip one ounce of fluid during a 5-15 minute period, with a goal of at least 6-8 cups (48-64 ounces) of fluid each day. Alternate between the items listed above.
FULL LIQUIDS DIET – SECOND WEEK
After you have tolerated the Clear Liquids diet for about a week, your surgeon may allow you to start adding Full Liquids to your diet. This Full Liquids diet provides liquids/foods that are easy to consume and digest. You will continue to consume foods that are at room temperature, caffeine-free, non- carbonated, and sugar-free to avoid discomfort.
RECOMMENDED FOODS – SECOND WEEK:
• Soups: tomato, butternut squash, • Plain non-fat Greek yogurt pureed split pea or lentil • Unsweetened applesauce • Cream of Wheat (thinned) • Sugar-free pudding • Low sugar instant oatmeal (thinned, • Vegetable juice (no pulp) no fruit chunks) • Homemade low-sugar fruit • Light yogurt (no fruit chunks) smoothies (no store bought or • Fat-free lactose-free milk or 1% Jamba Juice; can use applesauce, lactose-free milk pureed pears/peaches, or banana) • Plain soy milk (no vanilla/chocolate)
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PUREE DIET – THIRD & FOURTH WEEK
After you have tolerated the Full Liquids diet for about a week, your surgeon may allow you to start adding puree foods to your diet. This puree diet is suggested to let your digestive system get used to semi-solid foods. After the surgery, the opening (stoma) emptying your stomach pouch may be slightly swollen. If your food is not soft, it may cause a blockage and make you vomit. Remember the following are guidelines and it is recommended that you use judgment and common sense when advancing your diet. Everyone tolerates foods differently. You will be consuming 2-3 oz of food at this time, no more than 1/3 of a cup.
RECOMMENDED FOODS – THIRD AND FOURTH WEEK:
• Low-fat refried beans • Mashed hard-boiled eggs (egg salad • Mashed potatoes/yams consistency mixed with low fat • Low-fat cottage cheese mayo, mustard, yogurt, or mashed • Hummus avocado to moisten), poached, or • Smooth low-fat peanut butter / soft-scrambled (minced) almond butter • Tofu • Avocado (1-2 Tbsp) • Pureed vegetables • Lentil soup • Pureed fruit
RECOMMENDED FOODS – FIFTH WEEK:
• Low fat ground beef or turkey, soft • Steamed/soft vegetables such as moist chicken, fish, deli meats, & carrots, squash, zucchini, spinach, water-packed canned chicken/tuna cauliflower. Avoid stalks of broccoli, • Beans: navy, soy, pinto, kidney, asparagus, celery & limit white black potatoes, green peas, and corn. • Fruits: (peeled) apple, pear, peach, • Salad (romaine or spring blend, as nectarine tolerated w/ vinaigrette dressing) • String cheese / low-fat cheese • Seeds and nuts – almonds, peanuts, cashews
RECOMMENDED FOODS – SIXTH WEEK:
• Crab, shrimp, lobster • Quinoa (1-2 Tbsp) • Lean pork or steak
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FOODS TO AVOID FOR SIX MONTHS:
• Bread • Muffins / Bagels • Pasta • Dry cereal
• Rice • Crackers • Tortillas • Popcorn • Waffles / Pancakes
After 6 months, you may gradually reintroduce whole grains such as brown rice, whole wheat pasta, barley, bulgar, or WHOLE grain breads such as: Country Hearth or Orowheat, 100% whole wheat. Remember these need to be in very small portions, usually just 1-2 ounces.
GENERAL RULES AFTER SURGERY
1. Do not consume more than 3 oz of food at any one time (1/3 cup). Most people feel full after eating 2 oz. The medicine cup used to measure liquid and food contains 1 oz. 2. Chew all food until it becomes pureed and EAT SLOWLY. Swallowing foods that are not chewed thoroughly may block the stomach opening or cause vomiting. Each bite should be chewed 20 to 30 times. 3. It should take at least 30 minutes to eat every meal. Enjoy the flavor and texture of foods. 4. Introduce solid foods gradually. Try only one new food at a time. 5. Avoid eating and drinking at the same time as this may cause vomiting or stretch your pouch. It can also “wash” the foods through your pouch too quickly which will make you hungry again or cause the dumping syndrome. Start sipping fluids slowly 30 minutes after a meal and stop drinking 30 minutes before the next meal. This is referred to as the 30/30 rule. 6. Do not skip meals. This may cause you to overeat at the next meal, which can stretch your pouch, cause discomfort, or vomiting. It is important to eat 3 small meals (meal = 1/3 cup portion) daily to ensure adequate nutrition. 7. Concentrate your diet on protein and healthy carbohydrates. Eat your protein foods first. 8. All patients, especially gastric bypass patients, must avoid sugar, ice cream, milkshakes and all other food or drinks with sugar products. Beverages should be sugar-free and non- carbonated. Select low-calorie beverages such as water, tea, Propel Zero®, or Crystal Light®. 9. Avoid bread, pasta, rice, tortillas, waffles, pancakes, muffins, bagels, dry cereal, and crackers for 6 months as it forms a gummy, pasty ball in your tiny stomach and may cause pain, nausea, and/or vomiting. 10. Drink 6-8 cups (48-64 oz) of fluid per day to prevent dehydration. Remember to sip. 11. Take your chewable multi-vitamin with mineral supplement daily (see details on page 12). 12. Avoid using straws or chewing gum for several months. 13. Avoid alcohol and carbonated beverages.
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GENERAL GUIDELINES FOR PORTION CONTROL FOR MEALS
Time frame from surgery Portion size for meals, eat NO MORE THAN: First 3 months 1/3 cup Months 3-6 1/2 cup Months 6-9 3/4 cup Months 9-12 1 cup 12 months and beyond NO MORE THAN 1 cup with 1-2 small high protein snacks (depending on weight goals and activity level)
BEHAVIOR MODIFICATION
þ Always chew foods thoroughly and sip fluids slowly. þ Do not use straws. þ Stop eating prior to feeling full; overeating may cause discomfort, vomiting and diarrhea. þ Use a smaller glass and consume beverages between meals. þ Use a small plate at home (salad or bread plate) to insure small servings and give the impression of having more food on your plate than there really is. þ Small bites are necessary. The use of baby utensils may assure small bites. þ Put your fork down between bites. þ Sit up straight while eating and always eat at the table. Avoid talking and watching TV while eating. þ Never eat on the run. þ Only eat when you are hungry.
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YOUR BODY’S PROTEIN NEEDS
Protein is the nutrient that helps promote new cell and hair growth and heals the stomach. Protein is necessary to help heal and preserve muscle tissue while you're losing weight. Slight hair shedding is normal in the months immediately following bariatric/metabolic surgery and is rarely a sign of nutritional complication. If additional hair loss occurs after six months this may be a sign of protein deficiency. Protein needs are based on an individual’s height – to obtain your individual protein needs, refer to the chart below. It will take you several weeks or even months to reach this goal. If you need assistance with achieving your protein goal, you may request a consultation with the Registered Dietitian.
Women Men Height Protein grams Height Protein grams needed needed 4'8 42 – 46 5'0 48 – 53 4'9 43 – 47 5'1 51 – 56 4'10 44 – 48 5'2 54 – 59 4'11 45 – 50 5'3 56 – 62 5'0 46 – 51 5'4 59 – 65 5'1 48 – 53 5'5 62 – 68 5'2 50 – 55 5'6 65 – 72 5'3 52 – 57 5'7 67 – 74 5'4 55 – 61 5'8 70 – 77 5'5 57 – 63 5'9 73 – 80 5'6 59 – 65 5'10 76 – 84 5'7 61 – 67 5'11 78 – 86 5'8 64 – 70 6'0 81 – 89 5'9 66 – 73 6'1 84 – 92 5'10 68 – 75 6'2 86 – 95 5'11 71 – 78 6'3 89 – 98 6'0 73 – 80 6'4 92 – 101 6'1 75 – 83 6'5 95 – 105 6'2 77 – 85 6'6 97 – 107
Excess protein is not advised and can lead to kidney failure, liver failure, and calcium loss from bones. You are also at greater risk for dehydration because it takes a lot of water to breakdown protein. Stick with your individual goal and don't go overboard!
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PROTEIN SOURCES
When consuming your meals, always eat the protein foods first to ensure adequate protein intake. Remember, a good source of protein is between 7-10 grams per serving. The following list is provided to help in improving your knowledge of good protein sources.
Food Category Serving Size Protein
Meat/Vegetable Group Meat, fish, poultry 1 ounce cooked 7 grams Tuna, packed in water, drained 1 ounce 7 grams Beans (lima, kidney, baked) ½ cup 6-7 grams Beans (white or navy) ½ cup cooked 9 grams Lentils ½ cup 9 grams Egg 1 whole 6-7 grams Egg substitute ¼ cup 7.5 grams
Dairy Group Fat-free milk 1 cup (8 fl oz.) 8 grams 1% Light milk 1 cup 10 grams Lactose-free milk - Fat free 1 cup 9 grams Lactose-free milk - 1% 1 cup 8 grams Non-fat dry milk powder 1/4 cup 11 grams Greek/low-fat yogurt, plain 1 container (8 ounce) 8-13 grams Low-fat cottage cheese ½ cup 15.5 grams Low-fat cheese 1 ounce 7 grams
Miscellaneous Peanut butter (smooth, low-fat) 2 tablespoons 7 grams Tofu, soybean product ½ cup, raw, firm 20 grams Soy milk 1 cup (8 fl oz.) 11 grams Almond milk* 1 cup (8 fl oz.) 1 gm Rice milk* 1 cup (8 fl oz.) 1 gm Nuts (cashews, walnuts, mixed) 1 ounce 4-5 grams Nuts (peanuts, pistachios, almonds) 1 ounce 6 grams Soybeans ½ cup 11 grams Vegetable/soy patty 1 patty 11 grams Pumpkin seeds 1 ounce 8.5 grams Sunflower seeds 1 ounce 5.5 grams
*Not recommended due to low protein content Reminder: You must avoid bread, pasta, rice, tortillas, waffles, pancakes, muffins, bagels, dry cereal, crackers, and popcorn for 6 months. Source: https//www.nutritioncaremanual.org/client_ed_id=154. Accessed 3/6/15
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VITAMIN AND MINERAL SUPPLEMENTS
Vitamin/mineral supplementation will be discussed at your first post-operative appointment. Do not take these supplements for the first week after surgery.
• A chewable multi-vitamin with mineral supplement is mandatory after surgery to meet 200% of the Recommended Dietary Allowances. • Take 1500 mg of Calcium Citrate daily (chewable or liquid). Take 500 mg three times per day. • Take 500 micrograms of Vitamin B12 sublingual daily. • Iron and calcium supplements should be taken at least 2 hours apart. • It is recommended that you continue taking a multi-vitamin with mineral supplement daily for the rest of your life.
DINING OUT AT RESTAURANTS
• Eating out with family and friends is an important social experience and you should not be afraid of it. Use the following guidelines to help make dining out a relaxing and enjoyable experience. • Think about what you will eat before you go out. Planning ahead will make you more likely to select appropriate foods. Select “safe” foods you know you can tolerate. Sometimes it is hard to tell what is in an item on a menu by its name. Do not be afraid to ask. It is wise to stick with foods you know when dining out. • Order child-size portions if possible, however do not order from the child’s menu. You may have to give a simple explanation of your dietary needs. Our office can provide you with a card you can carry in your wallet stating you have had stomach surgery and cannot eat normal size meals. Most restaurants will honor this card. • Ask to have dishes served without special sauces or dressings. • Avoid fried foods. If it is fried, ask if it can be baked or steamed instead. • Share a meal. Ask for a small plate and take small portions from your dining companion’s meal. • Avoid alcohol as it contains a large amount of calories and the surgery itself significantly lowers your tolerance.
Good luck in this new adventure! Remember, your motivation and compliance with these nutritional guidelines will help you maximize the benefits of your bariatric surgery!
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