Weight Loss Surgery Care Guide

Table of Contents Resources 3 Contact Information 3 Appointment Tracking 5 What to Expect on Surgery Day 7 Choosing Bariatric Surgery 10 Building Lifestyle Change 15 Nutrition 18 Meal Plan Progression 20 Liver Shrinking Diet 21 Enhanced Recovery After Surgery (ERAS) 22 Day of Surgery 22 After Surgery 23 Eating Progression 24 Stage 1 25 Stage 2 meal plan 27 Stage 3 meal plan 29 Stage 4 meal plan 31 Stage 5 meal plan 33 Stage 6 meal plan 35 Post-op week 6 and Beyond - Continued Guidance 37 Vitamins and Minerals 39 Protein Supplements 43 Portion Size Guidelines 46 Bariatric Meal Planning 47 Reading the Nutrition Facts Label 48 Identifying Hidden Sugars 49 Label Lingo 50 Food Quality 51 Mindful Eating 53 Hunger Fullness Scale 54 Making Smart Choices When Dining Out 55 Keeping a Food Journal 57 Optimizing Meal Duration 59 Keeping Liquids Separated from Meals 60 Nutrition Goal Worksheet 61 Setting Good Goals 63 Guidance Beyond Nutrition 66 Weight Loss Expectations 68 Medications 69 Physical Activity 71 Sleep 73 Common Concerns After Surgery 74 Dehydration 75 Dumping Syndrome 76 Constipation 77 Addressing Unhealthy Behaviors 79 Building Wellness through Self Awareness 80 Strategies for Lifelong Success 81 Learning More 82 2020 Bariatric Support Group Meetings 83

Updated November 11, 2020

Resources Contact Information For medical medical concerns, contact: Saint Joseph Weight Loss Center at Downtown Surgery Specialists 1960 Ogden Street, Suite 550 Denver, CO 80218

Phone 303-318-3240 Fax 303-812-6859 SaintJosephDenverWeightLoss.org

Office hours: 8:00 A.M. to 4:30 P.M.

If you have a question or concern outside of normal office hours that cannot wait until the office reopens, call and follow the instructions to have an on-call surgeon return your call. For emergencies call 911 or go to the Saint Joseph Hospital Emergency Room

Surgeons Dr. Amir Heydari Dr. John Raheb Dr. Emily Speer Dr. Jason Johnson

Nurse Coordinator Lisa Swendener, Bariatric Program Coordinator 303-318-3240 [email protected]

Dietitians 303-812-6869 Kaylan Crowther, Registered Dietitian Nutritionist [email protected] Kelly Elliot, Registered Dietitian Nutritionist [email protected]

Support Group Call 303-318-3240 for dates Second Tuesday of every month 6:00-7:30 p.m. at Midtown Medical Office, Suite 595 Third Tuesday of every month 4:30-6:00 p.m. at Good Samaritan Medical Center, Conference room A

Billing and Financial Information: Carmen Hochhausen, Billing and Financial Counselor 303-812-6863 [email protected]

Saint Joseph Hospital Financial Counseling 303-812-2655 or 303-812-3478

Congratulations!

This is the next step on your journey towards better health!

This care guide was designed by your weight loss surgery team. Your surgeon, nurses, dietitians, and coordinators are here to assist in your success. They will help you prepare mentally and physically for weight loss surgery. Weight loss surgery is a powerful tool that has helped hundreds of thousands of people lose weight, but it is just that: a tool that you will need to learn to properly yield for lasting results.

As you begin your journey, start making a list of questions you have about lifestyle, eating, and activity changes that happen after surgery. Begin to identify your support network for making these changes. Who are your allies in health? Find friends, family, or co-workers who support you in making the decisions necessary for your health. Explore what led up to being overweight and the habits that cause you to overeat. When you begin to unravel this history, it can help you to move forward.

We are so excited to be a part of this life-changing opportunity! Just remember, learning to make healthy habits are the key to permanent success.

Sincerely,

Your Weight Loss Surgery Team at Saint Joseph Weight Loss Center at Downtown Surgery Specialists

Appointment Tracking

Visit Type Date

Initial Visit

Behavioral Health Assessment

Pre-operative Nutrition class - Units 1&2

Pre-operative Nutrition class - Units 3&4

Surgeon Consultation

Primary Care Preoperative exam

Surgery Preparation Class

Surgery Date

Post-operative 1-2 Week Follow-up

Post-operative 6 Week Follow-up (Dietitian)

Post-operative 4 Month Follow-up

Post-operative 6 Month Follow-up

Post-operative 9 Month Follow-up

Post-operative 1 Year Follow-up

After 1 year, plan to visit annually after surgery

What to Expect on Surgery Day What should I bring on my surgery day? ● Insurance card ● Photo identification ● A form of payment for your post-operative prescriptions ● Wear something loose-fitting and comfortable ● Glasses ● Hearing aids ● Dentures ● Toiletries ● Bi-Pap machine ● Leave any valuables at home ○ Do not wear or bring jewelry or piercings ○ Please remove nail polish or any artificial nails

How do I check-in on my surgery day? There is free valet parking available at the main entrance of Saint Joseph Hospital – 1375 E 19th Avenue Denver, CO 80218. Please check-in on the second floor at your scheduled time, typically two hours prior to surgery.

Who will I see before my surgery? A team of nurses and doctors will help in your care at the hospital prior to your surgery. You will meet your anesthesiologist to discuss any concerns you have. It is a good idea to prepare a written list of questions, because it is easy to forget if you feel nervous. Your surgeon will also meet with you before surgery.

How long does surgery take? Surgery varies for each patient, procedure, and surgeon. Once you have left the preoperative area, your family can expect to wait about two to four hours before being able to visit with you again.

How long will I be in the hospital? Although the length of time varies for each patient and procedure, after laparoscopic surgery, most patients stay only one night. If you need more care, this would lengthen your stay.

Should I bring my home medications? No. Unless you have been specifically instructed otherwise, you can leave your home medicines at home.

Choosing Bariatric Surgery Bariatric Surgery Bariatric Surgery encompasses a few different surgical procedures. The three surgeries that are performed at Saint Joseph are Gastric Bypass (Roux-en-Y), Laparoscopic Sleeve Gastrectomy, and Laparoscopic Adjustable Gastric band (Lap Band). Your coverage may allow all of these options, however.

Roux‐en‐Y Gastric Bypass Surgery (RYGB) The most commonly performed procedure in the United States, Gastric Bypass has existed in various forms for more than 30 years and has the strongest evidence for long term results. In this open or laparoscopic procedure, a two-tablespoon sized pouch is created from the stomach by dividing the stomach with surgical staples. Part of the small intestine, the jejunum, is attached to the small pouch with a half-inch-sized surgical connection called an anastomosis. This section of the intestine is called the roux limb. The remaining portion of the stomach is bypassed by food and the remaining part of the intestine are linked back to the roux limb, forming a ‘Y’. The small pouch does stretch over time. Most of the weight loss is obtained in the first two years.

How Food is Digested After Surgery After surgery, food travels from the mouth, down the throat and into the small pouch that was created, through the anastomosis, into the upper small intestine. Prior to surgery, the stomach worked to grind up foods. The newly created stomach pouch cannot work in this same way, and so thorough chewing is crucial to avoid pain or malabsorption. At the junction of the Y, digestive enzymes from the remainder of the stomach, pancreas, and liver empty into the roux limb. This helps with absorption and prevents symptoms like diarrhea, gas, and discomfort.

How Gastric Bypass Surgery Helps You Lose Weight This surgery is both malabsorptive and restrictive. When food stretches the stomach pouch walls, messages of fullness or satiety are sent to the brain. After surgery, a much smaller amount of food is needed to stretch the pouch walls to send the signal of fullness to the brain. After a while, your brain signals to your body to eat smaller amounts of food to feel satisfied. If you eat a larger amount of food, you will feel stuffed, nauseous; you may vomit and even feel pain. This sudden limitation of how much volume you can eat will allow you to learn to make better choices and choose more nourishing, higher quality foods rather than foods that simply fill you up. Our team of dietitians will help you to learn these skills. Gastric bypass also affects hormones produced by the stomach and intestine. One hormone affected is ghrelin, sometimes called the hunger hormone. Ghrelin sends messages of hunger to the brain, increases absorption of calories, and promotes fat storage. The amount of ghrelin produced is greatly reduced after surgery causing a decrease in appetite. Another effect of surgery is a condition called dumping. Before surgery, high-fat and high-sugar processed foods are diluted and begin to be digested in the stomach. The stomach controls the release of this partially digested food into the intestine so not too much is emptied into the intestine at once. After surgery, the valve in the stomach that controls this release is bypassed. This means high-fat or high-sugar foods enter the intestine undiluted at a much faster rate. When this happens, water permeates the intestinal walls to try to dilute these foods. This can cause diarrhea, weakness, sweating, shakiness, sleepiness, and/or a racing heart. This discomfort serves as a strong reinforcement to avoid highly processed foods.

Results of Roux‐en‐Y Gastric Bypass Surgery Although weight loss is the most notable change after surgery, improved health is the truest measure of success. As weight is lost, improvements in diabetes, hypertension, hyperlipidemia, gastric reflux, arthritis, and sleep apnea occur. The surgery serves as a powerful tool to promote change in eating and exercise regimens. Many patients can discontinue or decrease the medications they need for these conditions, sometimes even before discharge.

Laparoscopic Vertical Sleeve Gastrectomy (LVSG) Laparoscopic sleeve gastrectomy as a weight loss surgery is newer than the Roux-en-Y Gastric Bypass. Over the past ten years, it has proven to be an effective bariatric procedure. In this procedure, surgical staplers are used to cut and seal off a large section of the stomach to create a smaller, tubular stomach. The remaining tube is less flexible and cannot hold as much food as the pre-surgical stomach. Unlike the gastric bypass surgery, the intestines are not altered.

How Food is Digested After Surgery After LSG surgery, food travels from the mouth, down the throat and through the smaller, tubular stomach. The smaller curvature of the stomach is less stretchy than the removed part of the stomach and holds less food. The food travels out the bottom of the stomach and continues through to the small intestines as it did before the surgery.

How Laparoscopic Sleeve Gastrectomy Helps You Lose Weight This surgery is purely restrictive. In LSG, about 75% of the stomach is removed, causing restriction. This causes earlier satiety when eating. After a while, your brain signals to your body to eat smaller amounts of food to feel satisfied. If you eat more food than your stomach can hold, you will feel overly full, ill, and discomfort. This limitation of volume will allow you to learn to choose healthier foods, instead of less nourishing foods that simply fill you up. Dietitians are available to help you to learn what sorts of foods to eat. Sleeve gastrectomy also reduces the production of the intestinal hormone Ghrelin. Ghrelin is sometimes known as the hunger hormone, and this decreases appetite.

Results of LSG Surgery The tubular stomach created in LSG cannot hold a large volume, and so food is released more quickly into the intestine. Improvements in health related to diabetes, sleep apnea, hypertension, and arthritis are found with weight loss after LSG. Acid reflux may worsen after LSG due to the decreased volume the stomach can hold.

Gastric Banding (Lap Band) Laparoscopic Adjustable Gastric Banding (LAGB) or the Lap Band procedure is also newer than the roux-en-Y gastric bypass, but also has proven to be an effective bariatric procedure. In this procedure, a hollow band is placed around the stomach around its upper end, creating a smaller stomach pouch. The band is attached to a tube that is connected to a port, which allows access to the band. The band can be filled with saline to tighten the tube around the stomach. This makes the stomach pouch smaller. No parts of the intestine are altered in this procedure.

How Food is Digested After Surgery After LAGB, food travels from the mouth, down the throat and to the small section of the restricted stomach. The food is then slowly released through the remainder of the stomach and out the bottom of the stomach and continues through to the small intestine as it did before the surgery.

How Gastric Banding Helps You Lose Weight In LAGB, the band causes restriction as its means of causing weight loss. This causes earlier satisfaction when eating. With time, your body receives messages from your brain to eat smaller portions to feel full. If you eat too much food, you will feel too full, unwell, and uncomfortable. The abrupt decrease in volume you can comfortably eat will encourage you to opt for higher quality foods in smaller volumes. The dietitian can help you identify these quality foods.

Results of Gastric Banding The small banded section of the stomach can only hold a very small volume, and food is released very slowly into the remainder of the stomach. After surgery, there are improvements in diabetes, sleep apnea, hypertension, hyperlipidemia, and GERD.

Building Lifestyle Change Obesity is a chronic disease that requires ongoing effort and permanent lifestyle changes. Weight loss surgery is not a cure nor is it to be considered a “one and done” approach to treating obesity. It is a tool to help you achieve a healthier weight and lifestyle.

In order to have a successful long‐term outcome, it is necessary to make a number of permanent lifestyle changes. You will need to change your eating habits, behaviors, mindset, stress management strategies, and physical activity. While the nutrition plan is one of the most important parts of this journey, it is not the only component to success. Establishing healthy self‐care habits is the key. Weight loss and optimal health is more than diet and exercise; it is an accumulation of habits that are integrated into your daily life.

Recovering Regardless of which procedure you are having, it is recommended that you take two to four weeks off work for recovery. This allows adequate time to physically recover, adjust to new eating patterns, build up your exercise routine, and adjust to a pattern of selfcare. Take the time to heal and recover without the stress of work. The office can help you complete FMLA forms, time-off request forms, time-off letters, and return-to-work requests. Please provide the documents in a timely manner, as it can take some time to process these forms.

Create a Support Network ● The length of stay after surgery varies for each patient and procedure, but most patients only stay one night after laparoscopic surgery. ● In the unlikely case your surgery is converted to an open Roux‐en‐Y (RYGB), you should expect to stay three to four nights in the hospital. ● You will need someone to drive you home on the day of discharge. ● You should plan to have someone help for one to two weeks after surgery with: ○ Care of your home ○ Care of your children and/or pets ○ Grocery shopping ○ Meal preparation ○ Transportation ● If you cannot identify someone who can help you, ask to speak with the social worker from your primary care clinic. They may be able to recommend resources.

Changing the Way You Eat Before Surgery ● Start making small lifestyle changes now in preparation for the surgery. The sooner you start, the more prepared you will feel for the surgery, recovery, and for the rest of your life. ● Before surgery, you will need to eat a specific way to shrink your liver. This makes the surgery safer and lowers the chance of needing to convert to an open operation. It also gets you to identify some of the challenges you may need to overcome to be successful after surgery. ● Remove food that will be inappropriate after surgery from your home and go shopping prior to your surgery for the foods you will need after surgery. ● Practice new eating behaviors before your surgery. Eating slowly and chewing your food well, reducing portion sizes, and stopping when you first feel full are the only ways you will be able to eat without causing problems following surgery. ● Start a food journal. This will be expected following surgery, so start this habit before surgery. See your binder for guidelines on choosing a good food journal. ● Purchase a set of measuring cups and measuring spoons, a food scale, smaller plates and utensils to assist in tracking food portions. ● You will begin with drinking sugar-free clear liquids in the hospital, full liquids once you are home, soft/puree diet at about 2‐3 weeks post op. You may want a blender or food processor to help you prepare foods to the proper consistency. ● Certain things will change once you have surgery; such as separating fluids from meals (avoid drinking 15 minutes before and 60 minutes after meals), but the fundamentals are the same: healthy habits create a healthy body and life.

Disordered Eating Many patients with morbid obesity may have one or more eating disorders, which, if not addressed appropriately can complicate their postoperative safety and success. It is important to consider if you use food as a way of dealing with stress, anxiety, depression, boredom, or as a coping mechanism. It is then very important that you identify and use healthier ways of coping, such as exercise, meditation, and/or support groups.

During the pre-op behavioral assessment, eating disorders or eating behaviors may be revealed and may require further intervention and treatment prior to surgery.

Nutrition

Meal Plan Progression What you are able to eat after surgery will change through different stages. These stages are designed to provide enough for your body to properly heal and lose weight at the same time. After weight loss surgery, you must carefully follow the recommendations outlined below in order to maximize your weight loss success, prevent complications, and prevent weight gain. You may hear of guidelines given to other patients that are different from yours. It is important to remember that each surgery is slightly different and individualized to each patient. What is most important is that you adhere strictly to your surgeon's recommended guidelines. You will need to temporarily supplement your intake with protein supplements in order to achieve optimal nutrition. Post-operative meal plans are separated into stages. It is imperative that you follow the progression and adhere to the prescribed regimen to maximize healing and minimize the risk for complications. Here is a brief overview of the stages:

For Roux-en-Y Gastric Bypass and Sleeve Gastrectomy When Stage Description

10 days before surgery Start__/__/__ Liver Shrinking Diet Pre-surgery plan to reduce size of Until day before surgery End__/__/__ See page 2 1 liver ERAS Night before surgery and day of Day before Surgery On__/__/__ see page 2 2 surgery preparation

My Surgery Date ___/___/___ See page 2 2

Post-op days 1 and 2 to Start__/__/__ Stage 1 one week, depending on Sugar-free clear liquids End__/__/__ see page 2 5 surgeon Post-op day 3 or Post-op day 7(depending on Start__/__/__ Stage 2 Full liquids; begin supplementation surgeon) through Post-op End__/__/__ see page 2 7 day 14 Start__/__/__ Stage 3 Post-op week 3 Pureed meal plan End__/__/__ see page 29 Start__/__/__ Stage 4 Post-op week 4 Soft and moist meal plan End__/__/__ see page 3 1 Start__/__/__ Stage 5 Soft and moist with cooked Post-op week 5 End__/__/__ see page 3 3 vegetables and/or fruit Post-op week 6 Stage 6 Healthy solid food meal plan Start__/__/__ and beyond see page 3 5 with supplementation

Liver Shrinking Diet (Pre-Surgery Diet)

When

10 days before surgery Start __/__/_ Until day before surgery Until the day before surgery Before surgery, a liquid meal plan is needed for 10 days to help shrink the liver. This helps the surgeon move the liver out of the way during the surgery, which can reduce your time under anesthesia and reduce the risk of complications. Meal Menu Notes One high protein drink* * See page 4 3 200 calories or less; Breakfast for list of protein 15 grams protein or more drinks 5 grams sugar or less AND One s mall piece of fresh fruit One high protein drink* (tennis ball sized) * See page 4 3 200 calories or less; Lunch OR for list of protein 15 grams protein or more 2 cups of raw or cooked drinks 5 grams sugar or less non-starchy vegetables (no potato, no corn, no peas, no beans) 6 oz yogurt (less than 100 calories) Afternoon snack OR This snack is (Optional) ½ cup cottage cheese optional OR 2 ounces lean protein (see Dinner for examples) AND 4 ounces protein 2-4 cups of raw or cooked Lean turkey, chicken breast, Dinner non-starchy vegetables pork, roast beef, fish - baked, (no potato, no corn, grilled, or broiled no peas, no beans) Evening snack 1-2 cups of raw or cooked non-starchy vegetables This snack is (Optional) (no potato, no corn, no peas, no beans) optional *See page 4 3 for a list of protein drinks Liquids Drink at least 64 ounces (8 cups) of sugar-free liquids throughout the day to prevent dehydration. See page 25 for more examples of these liquids. You will not be receiving any caffeinated beverages in the hospital. You may want to wean from caffeine before surgery. If you choose to add coffee after surgery, do not use sugar or creamer. Consider adding a few drops of vanilla extract or cinnamon to your coffee for flavor.

Avoid processed foods such as gravy, BBQ sauce, cheese, salad dressing, mayonnaise, ketchup, teriyaki, and peanut butter. Avoid fried or breaded foods.

Enhanced Recovery After Surgery (ERAS) (Pre-op clear liquids)

When

On __/__/_ 1 day before surgery (the day before surgery) This clear liquid meal plan is designed to help your body be ready for surgery and recover quickly afterwards.

The night before surgery, drink 12 ounces of filtered apple juice or Gatorade® G2, unless you are diabetic. ● This is part of your ERAS or Enhanced Recovery After Surgery program ● Your pre-operative nurse may ask you if you have completed this program ● If you are diabetic, drink Gatorade® G2 or water and follow any special insulin dosing instructions given to you

Day of Surgery (Surgery prep)

When

Day of surgery On __/__/_

The day of surgery, drink 12 ounces of filtered apple juice or Gatorade® G2, unless you are diabetic.. ● You need to finish drinking it four hours prior to surgery ● This is part of your ERAS or Enhanced Recovery After Surgery program ● Your pre-operative nurse may ask you if you have completed this program ● No other food or drink is allowed ● Do not use mints, cough drops, or chew gum ● No tobacco-neither cigarettes or chewing tobacco ● If you are diabetic, drink Gatorade® G2 or water and follow any special insulin dosing instructions given to you

4-6 hours after surgery, drink clear liquids, sip 1 ounce every 15 minutes. Your team may line up 1-ounce medicine cups to help you.

After Surgery

Here are brief descriptions of the eating progression after surgery. You will need to make changes to your eating patterns. The size of your stomach pouch is small. You may find that only two to three teaspoons of food will fill you up. You may also find that you are able to eat more of one type of food than another. Over time, the swelling will resolve. By nine to twelve months after surgery, it may enlarge to eight ounces or one cup. Long term, the size of your pouch is likely to be eight to twelve ounces or 1 to 1 ½ cups. This will limit the amount of food you can eat at one time.

One of the changes patients often comment about is the concept of “wasting food”. After surgery your eyes and head still work the same way they did before. However, because of the new stomach pouch, you will be satisfied with much less. It is critical that you listen to your body’s signals of fullness

It is common to see some variation from program to program related to nutrition. Most programs agree that the primary source of nutrition should be protein. Protein drinks can be helpful to fulfill your protein requirements. There are many to choose from. Look for protein drinks that are low calorie and low sugar and taste good. The Registered Dietitians can assist you in finding an appropriate supplement.

Avoid foods that contain sugar. Not only will they slow down your weight loss, but they can make you sick. Sugar may cause “dumping syndrome” in patients who have had the gastric bypass procedure. Dumping, in short, is caused by sugars going directly from your stomach pouch into the small intestine. Symptoms vary among patients but may include heart palpitations, nausea, abdominal pain, shakiness, sweating, sleepiness, and/or diarrhea. Dumping lasts about 30 minutes to an hour. See page 76 for more information.

To maintain a healthy weight and to prevent weight gain, you must develop and keep healthy eating habits using real food. You will need to be aware of the volume of food you can tolerate at one time and make healthy food choices to ensure maximum nutrition in minimum volume. A remarkable effect of bariatric surgery is the progressive change in attitude towards eating. Exercise must be part of your daily routine.

Eating Progression After Gastric Bypass and Vertical Sleeve Gastrectomy

Post-op days 1 and 2 to week 1: S tage 1: Post-op sugar-free clear liquid or bariatric clear liquids This consists of foods that are liquid, as well as low sugar or sugar free. This meal plan is low in calories and protein, but is designed to provide hydration and electrolytes.

Post-op day 3 to 7 through post-op day 14: S tage 2: Bariatric full Liquid or post-op full liquid This meal plan consists of liquid and semi-liquid foods. The foods allowed are low sugar, and primarily milk based. Protein and micronutrient supplementation begins at this time.

Post-op week 3: Stage 3: Pureed This meal plan consists of foods that are naturally smooth in consistency (foods should be the texture of white glue or smoother when it is swallowed) or pureed, or stage 1 or 2 baby foods. Pureed food has no lumps and feels very soft and smooth in the mouth. No solid pieces or parts should be in the food. Low sugar food selection and protein supplementation continue to be important.

Post-op week 4: S tage 4: Soft, moist This meal plan consists of foods that can be easily chewed to a smooth texture, but thicker than Stage 3. Meats are ground or minced into pieces no larger than a quarter inch. All pieces are moist, stick together slightly, but can be easily mashed apart with a fork. It includes deli meat and tender flaky fish. Low sugar food selection and protein supplementation continue to be important.

Post-op week 5: S tage 5: Soft, moist with cooked vegetables and fruit This meal plan consists of foods that are the same texture as Stage 4, but now includes small amounts of soft, cooked vegetables and some fresh fruit without peels. Protein remains the priority.

Post-op week 6: S tage 6: Bariatric Regular meal plan This meal plan consists of whole tender-cooked foods in the beginning and gradually includes all foods.. Tender raw vegetables that are not fibrous are added. Portion control, chewing foods well, low sugar food selection and protein play an important role in continued successful weight loss.

Stage 1 (Post-op sugar-free clear liquids or Bariatric Clear Liquids)

When

Post-op days 1 and 2 to one week, Start__/__/__ depending on surgeon End__/__/__ This clear liquid meal plan is designed to help your body stay hydrated. It does not meet all of your needs for nutrition, and is designed to be temporary only. Goals for this stage Throughout the day, you may drink any of the following liquids at any time. Drink at least 64 ounces (8 cups) to prevent dehydration. Try sipping 1 ounce of liquid every 10-15 minutes. Red versions are okay.

Choose from these liquids ● Water ● Decaffeinated tea without sugar or cream ● Decaffeinated herbal teas ○ Peppermint, Celestial Seasonings™ teas ● Decaffeinated coffee without sugar or cream ● Broth or stock (any flavor) ● Bone broth ● Sugar-free, calorie-free flavored drinks such as: ○ Crystal Light® ○ MIO™ (Caffeine-Free varieties only) ○ Sugar-free Kool-Aid™ ○ Vitamin Water™ Zero ○ Propel™ Zero ● Sugar-free popsicles ● Sugar-free Jello™ gelatin ● Isopure™ Zero Carb (this is a clear liquid protein drink, maximum one per day) ● Premier Protein™ Clear Protein Drink (this is a clear liquid protein drink) ● Sugar substitutes/artificial sweeteners are okay at this time ○ Splenda™ ○ Equal™ ○ Sweet n Low™ ○ Stevia™- some stevia sweeteners contain sugar alcohols, which can cause gas, bloating or dumping syndrome. Choose these in moderation. Avoid liquid Stevia. ● No alcohol - Avoid alcohol until six months post-op ● No carbonated drinks - Avoid carbonation until 3-6 months post-op, you may resume calorie-free carbonated beverages in small amounts, only if it does not cause pain. It can be uncomfortable for many individuals. ● No caffeinated drinks - Avoid caffeinated drinks until you are successfully drinking 64 ounces of non-caffeinated beverages daily on a regular basis.

Stage 1 (Post-op sugar-free clear liquids or Bariatric Clear Liquids)

Sample Menu Day 1 Meal Serving Size Food

Breakfast 1 cup Decaf herbal tea- peppermint flavor ¼ cup Sugar-free gelatin

Snack 1 popsicle 1 sugar-free popsicle

1 cup Isopure Zero Carb Lunch 1 cup Chicken broth

1 cup Decaf herbal tea – hibiscus flavor Snack 1 popsicle 1 sugar-free popsicle

1 cup Decaf herbal tea – orange and spice flavor Dinner 1 cup Beef Broth

Snack ½ cup Sugar-free Kool-aid™

Day 2 Meal Serving Size Food

Breakfast 1 cup Decaf coffee 1/2 cup Vegetable broth

Snack 1 cup Premier Protein™ Clear Protein Drink

1 cup Crystal Light® Lunch 1/4 cup Sugar-free gelatin

Snack 1 cup Vitamin Water™ Zero

1 cup Beef broth Dinner 1 cup 1 sugar-free popsicle

Snack 1 cup Decaf herbal tea –lemon flavor

Stage 2 meal plan (Bariatric full liquid or post-op full liquid)

When

Post-op day 3 or Post-op day 7(depending on Start__/__/__ surgeon) through Post-op day 14 End__/__/__ This meal plan consists of liquid and semi-liquid foods. The foods allowed are low sugar and primarily milk based. Vitamin, and mineral supplementation begins at the end of this stage with bariatric vitamins and minerals. This meal plan may meet all of your nutritional needs.

Goals that remain the same from the last stage ● Drink up to 64 ounces (8 glasses) of fluid per day. You may have any of the liquids from page 25 AND you may add 24-32 ounces of protein-rich liquids in this stage as meals

New goals for this stage ● Eat 3 small meals a day. Allow 20-30 minutes per meal. Drink 1 or 2 8-ounce servings of protein shake to ensure you are meeting your protein goal. ● Remain upright for 15 minutes before and 60 minutes after eating ● Portion size is 1-2 ounces (2 tablespoons to ¼ cup) of plain yogurt OR up to 8 ounces (1 cup) protein shake. Start at just 2 tablespoons of yogurt, and only increase to ¼ cup, if comfortably tolerated. See page 46 for help with portion sizes. You may allow up to an hour to drink 8 ounces of protein shake. ● Aim for a minimum of 30-45 grams of protein per day.

Examples of foods to add in this stage: Food Serving Size Protein (grams)

Milk -You may add 25-30g protein powder to each 8 ounces (1 cup) 15-25g serving. Whey, whey isolate, or soy protein powders (allow one hour to drink)

Light yogurt, plain 2 Tablespoons – ¼ cup 2-5g [12g sugar or less per 6 ounce container]

Greek yogurt, plain 2 Tablespoons – ¼ cup 2-5g [12g sugar or less per 6 ounce container]

Any protein drink from page 4 3 8 ounces (1 cup) 5-10g (allow one hour to drink) Begin vitamin and mineral supplementation two weeks after surgery. See page 3 9. For the first month, you can use chewable vitamins, but after the first month, most patients tolerate traditional capsules with ease. 1. Chewable multivitamin with minerals: 2 per day 2. Chewable Calcium Citrate with Vitamin D: 1,500-2,000mg per day (take 500mg 3-4 times daily). Certain multivitamins will have sufficient Vitamin D and B-12 already in them, but if they do not have this level, you may need to add separate supplements. 3. Vitamin D: 75mcg or 3,000 I.U. per day (including what is in the calcium supplement) 4. Vitamin B-12: 750-1,000 mcg per day

Stage 2 (Bariatric full liquid or post-op full liquid)

Sample Menu Day 1 - 3 meal, 3 snack option

Meal Serving Size Food Protein (grams)

Breakfast 4 ounces Muscle Milk Shake 8g

Snack 4 ounces Premier Protein Shake 8g

Lunch 4 ounces Slim Fast Low Carb Shake 8g

Snack 1/4 cup Plain Greek yogurt 2g

Dinner 4 ounces Orgain protein shake 8g

Snack 2 Tablespoons Plain yogurt 2g

Total Protein 36g

Day 2 - 3 meal, 1 snack option

Meal Serving Size Food Protein (grams)

Breakfast 2 Tablespoons Plain yogurt 2g

Lunch 8 ounces (drink Slim Fast Low Carb Shake 16g over 1 hour)

Dinner 8 ounces (drink Premier Protein Shake 16g over 1 hour)

Snack 2 Tablespoons Plain Greek Yogurt 2g

Total Protein 36g

Stage 3 meal plan (Pureed meal plan)

When

Post-op week 3 Start__/__/__ End__/__/__ This meal plan consists of pureed foods. This meal plan may meet all of your nutritional needs. Food should be slightly thicker than Stage 2. Pureed food has no lumps and feels very soft and smooth in the mouth. Foods should be processed in a food processor or blender to a very smooth consistency or texture. No solid pieces or parts should be in the food.

New goals for this stage ● Use measuring cups or a food scale. See page 4 6 about portion sizes ○ Each meal should be about 1/4 cup of food ○ Start with just 2 tablespoons, and only increase if comfortably tolerated ● Slow, mindful eating is essential (page 5 3) ● Do not drink with meals. Wait 15 minutes before and 60 minutes after eating to resume drinking liquids. ● Aim for a minimum of 45 grams of protein per day ○ Eat about 15 grams per meal ○ Eat protein first ○ 1 cup (8 ounces) of protein shake as one of your meals to reach this goal ■ You may take up to an hour to drink it ● F ull liquids can be switched to soft, moist, or pureed protein sources, as tolerated. ● Continue vitamin and mineral supplementation (page 3 9)

Examples of foods to add in this stage: Food Serving size Protein (grams)

Eggs, scrambled or soft boiled, light mayonnaise may be 2 Tablespoons – ¼ cup 4-8g added to moisten. Baby food or pureed meats 2 Tablespoons – ¼ cup 7-14g Pureed poultry 2 Tablespoons – ¼ cup 7-14g Soft, moist fish 2 Tablespoons – ¼ cup 7-14g Light yogurt, plain [12g sugar or less per 6 ounce] 2 Tablespoons – ¼ cup 2-5g Greek yogurt, plain [12g sugar or less per 6 ounce] 2 Tablespoons – ¼ cup 2-5g Any protein drink on page 4 3 4 ounces (1/2 cup) 5-10g

Stage 3 (Pureed meal plan)

Sample Menu Day 1

Meal Serving Size Food Protein (grams)

Breakfast 1 egg One egg, scrambled 8g

Lunch 8 ounces Slim Fast Low Carb Shake 16g

Snack ¼ cup Plain Greek yogurt 7g

Dinner ¼ cup Poached tilapia 14g

Total Protein 45g

Day 2

Meal Serving Size Food Protein (grams)

Breakfast 8 ounces Premier Protein Shake 22g

Snack ¼ cup Turkey and Gravy baby food 5g

Lunch ¼ cup Pureed ground turkey 15g

Dinner ¼ cup Plain Greek yogurt 7g

Total Protein 49g

Stage 4 meal plan (Soft, moist meal plan)

When

Post-op week 4 Start__/__/__ End__/__/__ This meal plan consists of soft, moist foods. Meats are ground or minced into pieces no larger than a quarter inch; all pieces are moist, and stick together slightly. This meal plan meets all of your nutritional needs.

Goals that remain the same from the last stage ● Drink up to 64 ounces (8 glasses) of fluid per day. You may have any of the liquids from page 2 5. ○ Your urine should be pale, straw-colored or even colorless, except immediately after taking your multivitamins, which may turn your urine bright yellow. ● Eat 3 small meals a day. Allow 20-30 minutes per meal. ○ Add a snack only if you are unable to otherwise meet your protein goal. ○ Use measuring cups or a food scale. See page 4 6 about portion sizes ○ Each meal should be about 1/4 cup of food ○ Start with just 2 tablespoons, and only increase if comfortably tolerated ● Aim for a minimum of 45 grams of protein per day ○ Eat about 15 grams per meal ○ Eat protein first ○ ½-1 cup (4-8 ounces) of protein shake as one of your meals to reach this goal ● Slow, mindful eating is essential (page 5 3) ● Remain upright for 15 minutes before and 60 minutes after eating ● Do not drink with meals. Wait 15 minutes before and 60 minutes after eating to resume drinking liquids. ● F ull liquids can be switched to soft, moist, or pureed protein sources, as tolerated. ● Continue vitamin and mineral supplementation (page 3 9)

New goals for this stage ● Increase thickness of foods. Allow for more texture. ● Control portion sizes ○ Set your fork down in between bites ○ Use a small plate or a saucer and small utensils such as a baby spoon or fork ○ Take dime-sized bites and chew food well – to a mushy consistency Examples of foods to add in this stage: Food Serving size Protein (grams)

Eggs, scrambled or soft boiled 2 Tablespoons – ¼ cup 4-8g Finely chopped ground meats 2 Tablespoons – ¼ cup 7-14g Ground or pureed poultry 2 Tablespoons – ¼ cup 7-14g Soft, moist fish 2 Tablespoons – ¼ cup 7-14g Cooked bean, mashed 2 Tablespoons – ¼ cup 5-10g Cottage cheese 2 Tablespoons – ¼ cup 3-8g

Stage 4 (Soft, moist meal plan)

Sample Menu Day 1 Protein Meal Food Serving Size Recipe (Grams) Protein shake 8-11 ounces Premier protein Breakfast 20-30 (drink in 1 hour) Chicken & 2.5 ounces 2 ounces of rotisserie chicken Cheese (1/2 of a leg, no skin) + Lunch 16 1 Tablespoon cheese + pinch of dry sage Chicken salad 1/4 cup total ¼ cup rotisserie chicken breast + Dinner 1 Tablespoon mayonnaise + 16 small splash of white vinegar Total Protein 52-62

Day 2 Protein Meal Food Serving Size Recipe (Grams) Protein shake 8-11 ounces Premier protein Breakfast 20-30 (drink 1 hour) Tuna Salad ¼ cup total 2 ounces canned tuna (half of a can) + pinch of thyme + Lunch 14 pinch dry mustard powder + 1Tablespoon Vinegar Fiesta salad ¼ cup total 3 Tablespoons chopped chicken + Dinner 18 1 Tablespoon black beans (pureed) Total Protein 52-62

Stage 5 meal plan (Soft, moist with cooked vegetables)

When

Post-op week 5 Start__/__/__ End__/__/__ Advance meal plan as tolerated. Once protein is well tolerated, add well-cooked, soft vegetables and soft and/or peeled fruit. Add fruits and vegetables in a texture that is tolerated. A lways eat protein first.

Goals that remain the same from the last stage ● Drink up to 64 ounces (8 glasses) of fluid per day. You may have any of the liquids from page 2 5. ● Eat 3 small meals a day. Allow 20-30 minutes per meal. ○ Use measuring cups or a food scale. See page 4 6 about portion sizes ○ Each meal should be about 1/4 cup of food or 12 ounces protein shake ○ Add a snack only if you are unable to otherwise meet your protein goal. ● Aim for a minimum of 45 grams of protein per day ○ Eat about 15 grams per meal ○ Eat protein first ● Remain upright for 15 minutes before and 60 minutes after eating ● Do not drink with meals. Wait 15 minutes before and 60 minutes after eating to resume drinking liquids. ● Slow, mindful eating is essential (page 5 3) ● Continue vitamin and mineral supplementation (page 3 9)

New goals for this stage ● After eating protein, if you still have room, add very tender, cooked vegetables. ○ Choose non-fibrous, non-starchy vegetables ○ Chopped, cooked leaves of any type (cooked, chopped spinach in soups or sauces) ○ Cooked carrots, parsnips, rutabaga, tomatoes, zucchini, or mushrooms tend to go better than broccoli, cauliflower, asparagus, celery, cabbage, or artichoke ○ Avoid hard, tough peels ● After eating vegetables, if you still have room, add fruits ○ Avoid fruits that are very hard or fibrous and peels, like those on grapes ○ Cooked fruits tend to go better (applesauce, canned fruits in juice) ● Use condiments such as mustard, light mayonnaise, plain Greek yogurt, broth to moisten food

Examples of foods to add in this stage: Food Serving size Protein (grams)

Tender cooked carrots (able to mash easily with a fork) 1-2 Tablespoons 0 Tender cooked parsnips (able to mash easily with a fork) 1-2 Tablespoons 0 Canned, diced tomatoes 1-2 Tablespoons 0 Very ripe pear, diced to ¼ inch pieces 1-2 Tablespoons 0 Applesauce 1-2 Tablespoons 0 Very ripe banana, 2-inch section, mashed 1-2 Tablespoons 0

Stage 5 (Soft, moist with cooked vegetables)

Sample Menu Day 1 Meal Food Serving Size Recipe Protein (Grams) Chocolate 11 ounces 11 ounces Premier Protein Shake Breakfast Peanut butter (drink in 1 (chocolate flavor) + 32 Shake hour) 1 Tablespoon PB2 3 Tablespoons canned tuna + 1 Tablespoon mayonnaise + 5 Tablespoons Lemon pepper Mrs. Dash + Lunch Spicy Tuna salad 12 total 1 teaspoon hot sauce + 1 Tablespoon tender cooked mashed carrots 1 ounce chicken breast + Chicken Cordon Dinner ¼ cup total 1 slice Swiss cheese + 13 bleu ½ ounce Canadian Bacon Total Protein 57

Stage 6 meal plan (Bariatric regular meal plan)

When

Post-op week 6 Start__/__/__ And beyond Advance meal plan as tolerated. Once well-cooked, soft vegetables and soft and/or peeled fruit are tolerated, add small amounts of raw vegetables. A lways eat protein first.

Goals that remain the same from the last stage ● Drink up to 64 ounces (8 glasses) of fluid per day. You may have any of the liquids from page 2 5. ● Eat 3 small meals a day. Allow 20-30 minutes per meal. Add a snack only if you are unable to otherwise meet your protein goal. ○ Use measuring cups or a food scale. See page 4 6 about portion sizes ○ Each meal should be about 1/4 cup of food ● Remain upright for 15 minutes before and 60 minutes after eating ● Do not drink with meals. Wait 15 minutes before and 60 minutes after eating to resume drinking liquids. ● Slow, mindful eating is essential (page 5 3) ● Continue vitamin and mineral supplementation (page 3 9)

New goals for this stage ● Aim for a minimum of 60 grams of protein per day ○ Eat about 20g per meal ○ Eat protein first ● After eating protein, if you still have room, add raw or cooked vegetables ○ Start with small amounts of non-fibrous, non-starchy, vegetables ○ Raw carrots, parsnips, rutabaga, tomatoes, zucchini, or mushrooms tend to go better than broccoli, cauliflower, asparagus, celery, cabbage, or artichoke ○ Avoid hard, tough peels ○ Avoid potato, corn, and peas, as these are starchy vegetables ● After eating vegetables, if you still have room, add fruits or whole grains ● Chew foods to a paste-like texture ○ Start with a dime-sized bite

Examples of foods to add in this stage: Food Serving size Protein (grams)

Raw or cooked carrots 1-2 Tablespoons 0 Raw cucumber, peeled 1-2 Tablespoons 0 Diced tomatoes, raw or cooked 1-2 Tablespoons 0 Apple, peeled and diced into small pieces 1-2 Tablespoons 0 Banana, 2 inch section 1-2 Tablespoons 0

Stage 6 (Bariatric regular meal plan)

Sample Menu Day 1

Serving Protein Meal Food Recipe Size (Grams)

Breakfast Protein Shake 11 ounces Atkins protein shake 30g

1/4 cup canned lentil soup + Lentil Soup Lunch ½ cup total 2 ounces finely chopped ham + 15 with ham 1 Tablespoon cheese

Snack beans ¼ cup ¼ cup white beans, lightly mashed 5

1 ounces cooked white fish (tilapia, bass) with Cheese fish 2 ounces paprika, lemon pepper, or dill + Dinner filet with 13 total 1 ounce cheese melted on top + cucumber 1 slice cucumber, peeled

Total Protein 63

Day 2

Serving Protein Meal Food Recipe Size (Grams)

For a batch of 12 muffins: scramble 12 eggs + 12 ounces lean turkey meat + 1 cup cooked spinach + 1 each red and green diced bell peppers + Breakfast egg Breakfast 1 muffin 1 jalapeno + 10 muffin 1 clove minced garlic + 1 tsp onion pepper. Divide veggies and meat evenly amongst muffin tin holes, bake until eggs are solid. Cottage ¼ cup cottage cheese Snack ¼ cup 8 cheese 3 medium grilled shrimp + Asian shrimp 3 leaves spinach + Lunch ¼ cup total 12 salad 2 canned mandarin orange slices, + 1 Tablespoon vinaigrette dressing

Dinner Protein Shake 11 ounces Premier Protein, vanilla flavor 30g

Total Protein 60

Post-op week 6 and Beyond - Continued Guidance (Bariatric regular meal plan)

When Post-op week 6 and beyond Start__/__/__ Advance meal plan as tolerated as hunger increases. Eat a healthy, balanced meal plan consisting of adequate protein, vegetables, fruits, and whole grains. See page 4 7. A lways eat protein first.

Guidance for post-op week 6 and beyond ● Advance your diet as your stomach size allows ○ At 6 weeks post-surgery, portion size of a meal should be about ¼ cup ○ At 3 months post-surgery, portion size of meal should be about ¼ to ½ cup ○ At 6 months post-surgery, portion size of meal should be about ½ to ¾ cup ○ At 1 year post-surgery, portion size of meal should be about 1 cup ● It is important to know how much your stomach size should allow for each meal ○ Eat 15-20 grams of protein at each meal ○ If you are still hungry, eat the volume of vegetables your stomach currently should hold. ○ If you are still hungry after the vegetables, you may have fruit or grains. ■ Fruit or grains should not exceed your vegetable volume. ■ If you are hungry enough to eat more fruits or grains, increase your vegetables. ● Drink 64 ounces (8 glasses) of fluid per day. You may have any of the liquids from page 2 5. ○ You may resume alcohol after 6 months post-surgery ○ You may resume carbonation 3-6 months post-surgery ■ You may resume calorie-free carbonated beverages in small amounts, only if it does not cause pain. ■ It can be uncomfortable for many individuals. ○ You may resume caffeinated drinks when you are successfully drinking 64 ounces of non-caffeinated beverages daily on a regular basis. ■ Do not count caffeinated beverages toward your fluid goal for the day. ● Read the nutrition facts and ingredient labels for sugar alcohols, which can cause dumping syndrome. See pages 4 8 to 5 0 for more information. ● Track your calorie and protein intake with a food journal or an app on your phone ○ See page 5 7 for more information about choosing a food journal ● There may be certain foods, including some fruits or vegetables that you may never tolerate because they make you feel sick or cause diarrhea because of their fibrousness ○ Artichokes ○ Corn ○ Broccoli stems ○ Potatoes ○ Coconut ○ Rhubarb ○ Celery ○ Gristly meat ● Each person will have different intolerance, some that may last six months after surgery ● You may need a soluble fiber supplement such as Benefiber™ ● Avoid very processed foods that do not provide nourishment (page 5 1) : ○ Fried foods ○ Baked goods ○ Bologna, sausage ○ Chips ○ Ice cream ○ Cracker

Post-op week 6 and Beyond - Continued Guidance (Bariatric regular meal plan)

Sample Menu Day 1 Protein Meal Food Serving Size Recipe (Grams) Breakfast Protein shake 11 ounces Ensure max protein 30 1 ounces chicken breast + Lunch Greek salad ¼ cup total 1 tablespoon chickpeas + 10 1 cherry tomato 2 ounces salmon burger (half a patty) + Snack Salmon burger 2 ounces 14 Dijon mustard 1 1-ounce bison meatballs [combine 1 pound each ground bison and ground turkey + Italian spice + 1 egg + Meatballs ¼ cup bread crumbs + Dinner 1 meatball 10 parmesan ½ cup grated parmesan cheese = to make 16 meatballs], + 1 floret steamed broccoli + 1 Tablespoon marinara (less than 5g sugar per ½ cup) + Pinch of parmesan cheese Total Protein 64

Vitamins and Minerals After weight loss surgery, you will have to take vitamins and minerals every day for the rest of your life to prevent deficiencies. You will be at risk for deficiencies due to your decreased intake of food and surgically modified gastrointestinal system. Even if you are eating a balanced meal plan, you will still need supplementation with vitamins and minerals. Some people need a little more or less of a particular vitamin or mineral based on their lab results. The dietitian will help you know if you should change your supplements, but the best place to start is with the guidelines from the American Society for Metabolic and Bariatric Surgery (ASMBS).

Iron Iron is important for creating red blood cells, which carry oxygen in your body. After surgery, your iron levels may become low, causing anemia. Iron deficiency can happen because of difficulty tolerating high-iron foods and shorter intestinal length, resulting in less absorption of iron. Menstruating women are most at risk. Take your iron separately from calcium for best absorption (2 hours, if possible). Taking iron with vitamin C helps improve absorption. Iron may be included in your daily bariatric multivitamin. Iron can be found in different forms. Some forms are absorbed more easily, such as ferrous gluconate or ferrous fumarate; other forms are less absorbed, like ferrous sulfate. ● 45-60mg of elemental iron per day ● Menstruating women may need more

Calcium Calcium is important for bone health. Your calcium levels may become low because you are not absorbing as much calcium as the food is bypassing part of the digestive system. Take calcium spread out, with meals to reduce the risk of oxalate stones. Take calcium separately from iron supplements. ● 1,500-2,000mg of calcium citrate per day ● Take 500mg three to four times per day

B-12 B-12 is important for having enough energy. After surgery, your levels can become low because of low intake and poor absorption due to the surgical changes to your stomach. B-12 may be included in your daily bariatric multivitamin. ● 750-1,000 mcg per day

Thiamine (B1) Thiamine is important for having enough energy. It may be included in your daily bariatric multivitamin. It can turn your urine bright yellow. ● 12-13 mg per day

Folate (folic acid) Folate is important for having enough energy. It may be included in your daily bariatric multivitamin. ● 800mcg per day

Vitamin D Is important for building healthy bones and immune health. After surgery, your vitamin D levels may become low because you have less stomach acid. ● 75mcg or 3,000 I.U. per day ● If deficient, 1,250mcg or 50,000 I.U. once or twice a week for 5-8 weeks

The best way to be certain you are not lacking any vitamins or minerals is to continue regular lab tests. If you develop a deficiency, you will need to take vitamins or adjust the way you eat. You should start your vitamin and mineral supplements two weeks after surgery.

Vitamins can be purchased here, but even over-the-counter vitamins can be used: ● Bariatric Advantage – www.bariatrica dvantage.com ● Bariatric Fusion – www.bariatricfusion.com ● Celebrate Vitamins – www.celebrate vitamins.com ● Centrum Vitamins – www.centrum.com ● Opurity Vitamins – www.unjury.com

Vitamin (best form) Amount needed

Vitamin B1 (Thiamin) 12-13 mg per day

Vitamin B12 (Cobalamin) 750-1,000 mcg per day

Folate/Folic acid 800 mcg per day (or 0.8 mg per day)

Iron (Ferrous fumarate not ferrous sulfate) 45-60 mg per day

Vitamin D 75 mcg or 3,000 I.U. per day

Vitamins A,E and K Ideally 2 times the RDA per day

Zinc and Copper Ideally 2 times the RDA per day

Calcium (Calcium citrate not calcium carbonate) 1500-2000 mg (taken as 500 mg 3 or 4 times per day) Wait 2 hours between calcium and iron, as they can compete for absorption.

Bariatric vitamins ought to meet all of the above guidelines, but not all do. It is important that you check your multivitamin has all of the above amounts and contain the form of the vitamin written above. If your multivitamin does not contain the amounts listed, you will need to purchase and take a separate supplement of that pill to reach the goal amount. The correct forms, written in parenthesis above are absorbed best and minimize side effects, including stomach upset. Prenatal vitamins and general adult vitamins do not contain the amounts needed. Avoid gummies, patches, or liquid vitamins, even if they say ‘complete’ as they often lack the vitamins needed after surgery.

Timing of vitamin supplementation is important. It is critical to separate your bariatric multivitamin from your calcium by at least two hours. It is also critical to take each of the 500mg servings of Calcium at least two hours apart from each other. Here are two example schedules that would meet these goals: Option 1 Option 2 Time of day Vitamin Time of day Vitamin

Breakfast Calcium citrate Breakfast Bariatric multivitamin

Lunch Calcium citrate Lunch Calcium citrate

Dinner Calcium citrate Dinner Calcium citrate

Bed time Bariatric multivitamin Bed time Calcium citrate

Optional:

Probiotic ● May start as early as 1 week post-surgery ● Probiotics are live microorganisms (bacteria and yeast) that have health benefits. Probiotics help your body function properly, especially your digestive system. The body is full of bacteria, both good and bad. Bacteria that naturally reside in your intestines help your body digest food, produce vitamins (specifically vitamin K), and play a role in immunity. These “friendly” bacteria help your body maintain a healthy balance and keep bad bacteria from overwhelming your system and causing problems.

Fiber ● May start as early as 1 week post-surgery ● Daily insoluble fiber supplement such as Benefiber™

Protein Supplements For Liver shrinking diet (pre-surgery plan) and Stage 2 (bariatric full liquid or post-op full liquid)

Ready-to-Drink Protein Shakes Shake Bottle size Calories Protein Sugar Fiber Flavors Coconut, pineapple, orange, Isopure Zero Carb 20 ounces 160 40 0 0 grape, apple melon, peach, berry, punch, mango Slim Fast High Protein 10 ounces 180 20 2 1-2 Chocolate, Vanilla (20g protein) Boost Glucose Chocolate, Vanilla, 8 ounces 190 16 4 3 Control Strawberry Chocolate, Vanilla, Atkins 11 ounces 160 15 1 1-4 Strawberry, Mocha Optisource 8 ounces 200 24 0 0 Caramel, Strawberry Muscle Milk Light 11 ounces 160 20 0 4 Chocolate, Vanilla Pure Protein 12 ounces 190 23 1-2 2-3 Chocolate, Vanilla Chocolate, Vanilla, Strawberry, Cookies & Premier Protein 11 ounces 160 30 1 3 Creme, Bananas & Creme, Strawberries & Creme, Caramel Premier Protein Orange, Raspberry, Tropical 17 ounces 90 20 1 0 Clear Punch, Peach

You may choose any protein supplement that meets these three requirements: ● 200 calories or less ● 15 grams protein or more ● 5 grams of sugar or less

Protein Supplements For Liver shrinking diet (pre-surgery plan) and Stage 2 (Bariatric full liquid or post-op full liquid)

Protein Powders Mix with water, milk, or unsweetened almond milk Protein Powders Portion Calories Protein Sugar Fiber Flavors 365 Whey Protein Vanilla only (chocolate 1 scoop 90 16 1 0 Powder contains too much sugar) Unjury Protein 1 scoop or Vanilla, Chocolate, 100 21 2 0 Powder packet Strawberry, Unflavored Solgar Whey to Vanilla only (chocolate 1 scoop 90 20 <1 0 Go contains too much sugar) GNC Lean 25 2 scoops 200 25 3 8 Many flavors Vanilla, Chocolate, Isopure Zero or 1 scoop 110 20-25 0-1 0-2 Strawberry, Cookies & Low Carb Creme, Banana, Apple, etc. Vanilla, Chocolate, Jay Robb Whey 1 scoop 110 25 0 0 Strawberry, Pina Colada, Protein Tropical Jay Robb Egg Vanilla, Chocolate, 1 scoop 120 24 0 0 White Protein Strawberry, Unflavored Vega All-in-one Vanilla, Chocolate, Coconut, 1 scoop 150 20 1 6 Shake Powder Chai, Mocha Pure Protein 1 scoop 160 25 2 0 Vanilla, Chocolate Original Whey Beneprotein* 1 scoop 25 6 0 0 Unflavored

*One scoop (1 ½ Tbsp) of Beneprotein is 6 grams of protein and can be used to supplement meals to increase the total protein amount. One scoop of Beneprotein by itself is an insufficient meal.

You may choose any protein supplement that meets these three requirements: ● 200 calories or less ● 15 grams protein or more ● 5 grams of sugar or less

Protein Supplements For Stage 6: Regular bariatric meal plan

Protein Bars Bar Calories Protein Sugar Fiber Flavors

Chocolate almond caramel, vanilla pecan, Atkins 180-210 15-16 1-3 8-13 raspberry chia, peanut fudge, almond mocha Meal or coconut, chocolate peanut 0-2 Choose Chocolate, chocolate peanut butter, chocolate Pure 16 in the 180-200 20 2-4 chip, chocolate cookie dough, blueberry, Protein PLUS calorie bars strawberry, mocha brownie, red velvet bars Chocolate mint, espresso, coconut, raspberry, NuGo Slim 180-190 16-18 3 6-7 peanut butter, brownie Birthday cake, s’more, blueberry, cookie Quest 180-200 21 1-2 14-15 dough, cookies & creme, oatmeal chocolate, rocky road, mocha Brownie, caramel, maple almond, white Think Thin 230 13-20 0-5 0-3 chocolate, cookies & creme, lemon, mint chocolate, sea salt almond chocolate coconut, banana, mint brownie, black cherry, Built 110 15 4 6 salted caramel chocolate, double chocolate mousse, orange, vanilla, raspberry Chocolate peanut butter, vanilla almond, Premier 230 20 1 2 chocolate brownie, chocolate caramel, yogurt Protein peanut crunch

Protein bars are a processed food that tends to provide protein as a low-bioavailability source. It is much preferred to choose meat, poultry, fish, or dairy sources of protein.

Portion Size Guidelines

Learning how to accurately estimate portion sizes is a critical skill after weight loss surgery. It is impractical to carry around measuring cups and a food scale all of the time, so you can use your hand or common objects as a guide.

Using your hand A small woman’s f ist is about 1 cup The t ip of a pinkie finger is about ½ teaspoon The t ip of a thumb is about 1 teaspoon The t humb is about 1 ounce of meat or cheese The p alm of the hand is about 3 ounces of meat

Using common objects A t ennis ball is about 1 cup The t oothpaste shown on a toothbrush on a commercial is about 1 teaspoon The d eck of cards is about 3 ounces of meat

Bariatric Meal Planning

Using this portion plate guideline can help create balanced meals. You likely may not be eating enough volume of food to need to use this tool until six months post-surgery.

● Eat 3 meals per day ○ Add a snack between meals if you are not reaching your protein goal ○ Keep the number of meals and snacks you eat in a day consistent from day-to-day ● Serve foods from the stove or counter top, not at the table ○ Serve and eat one portion at a time ○ Use smaller plates and bowls ○ Use measuring cups or a food scale ● Choose foods from three different food groups for each meal ● Chew your food well and eat slowly ○ Meals should take 20-30 minutes ○ Have start and stop times for all meals/snacks ○ Eat your protein first; next, non-starchy vegetable, last fruit or carb ○ Eat your meals in a relaxed environment ● Try to let no more than 3-5 hours go in between meals ● Avoid liquid 15 minutes before and 60 minutes after meals

*Avoid rice and pasta for the first six months because they can be hard to tolerate and do not contain the desired amount of protein.

Reading the Nutrition Facts Label

Servings and Calories Servings per Container shows the total number of servings in the entire food package or container. One package of food may contain more than one serving. Serving Size is based on the amount of food that is customarily eaten at one time. The manufacturer of the food determines the serving size. All of the nutrition Information listed on the Nutrition Facts Label is based on o ne serving of the food. Calories refers to the total number of calories, or “energy,” supplied from all sources (fat, carbohydrate, protein, and alcohol) in one serving of the food.

% DV (% Daily Value) The % Daily Value (% DV) shows how much of a nutrient is in one serving of the food. The % DV column does not add up vertically to 100%. Instead, the % DV is the percentage of the Daily Value (the amount of key nutrients recommended per day for Americans 4 years of age and older) for each nutrient in one serving of the food. Some of the % DVs are based on a 2,000-calorie daily diet.

Nutrients The Nutrition Facts Label can help you learn about and compare the nutrient content of many foods in your diet. The Nutrition Facts Label must list total fat, saturated fat, trans fat, cholesterol, sodium, total carbohydrate (carbs), dietary fiber, sugars, protein, vitamin D, calcium, iron, and potassium.

Try to limit total s odium p er day to less than 2,300mg per day.

Aim for 20-50g of Dietary Fiber per day. You likely will be unable to reach this goal until a year post-surgery.

Sugars can come from milk or fruit (better-for-you sugars), try to limit other sugars to less than 3 grams per serving. Check the ingredients list to try to figure out where the sugar is coming from. If sugar is in the first five ingredients, opt for a different choice. See also page 4 9 for a list of names sugar goes by.

Aim for 60-80g of Protein per day, or about 20-30g per meal. Your individual protein goal will be discussed at appointments, and you likely will be unable to reach this goal until six months or more post-surgery.

Identifying Hidden Sugars

Sugar and sweeteners go by many names. Try to reduce the amount of sugar you eat (no matter what name it goes by). Avoid foods that have added sugar as one of the first five ingredients. If it does have added sugar, limit this to less than three grams per serving. Here are some names to look for in the ingredient list:

Agave Fruit Juice Concentrate Agave Nectar Galactose Barbados Sugar Glucose Barley Malt Glucose Solids Beet Sugar Golden Sugar Blackstrap Molasses Golden Syrup Brown Sugar Grape Sugar Buttered Syrup Hi-Fructose Corn Syrup Cane Juice Crystals Honey Cane Sugar Icing Caramel Invert Sugar Carob Syrup Lactose Castor Sugar Malt Syrup Confectioner’s Sugar Maltodextrin Corn Syrup Maltose Corn Syrup Solids Maple Syrup Crystalline Fructose Molasses Date Sugar Muscovado Demerara Sugar Organic Raw Sugar Dextrose Raw Sugar Dextran Refiner’s Syrup Diastase Rice Syrup Diastatic Malt Sorghum Syrup Ethyl Maltol Sucrose Evaporated Cane Juice Sugar Florida Crystals Treacle Fructose Turbinado Sugar Fruit Juice Yellow Sugar

Sugar alcohols such as sorbitol, maltitol, mannitol, xylitol should be used with caution. Eating large amounts of these substitutes may cause symptoms similar to dumping syndrome. Sugar alcohols will be listed under sugar on labels

Label Lingo

The following terms are usually on the front of packages and describe the amount of nutrients, cholesterol, fiber or calories in foods. Knowing what these terms mean can help you make quick label comparisons at the supermarket.

Free T he FDA defines “free” as an amount so small it probably will not have an effect on the body. For example: Calorie Free ≤ 5 calories per serving Sugar Free ≤ 0.5 grams sugar per serving Fat Free ≤ 0.5 grams fat per serving

Low is an amount specifically designed for each term as follows: Low calorie ≤ 40 calories per serving Note-there is no definition for “low carb” at this time.

Light indicates a food with 1/3 fewer calories or 50% less fat than the traditional version of the food. Beware-“light” can still be used to describe color (light brown sugar, light soy sauce) or texture (light and fluffy pancakes).

Good Source indicates the product contains 10-19% of the Daily Value for the nutrient.

Lean meat or poultry with <10 grams fat, 4 grams saturated fat, 95 mg cholesterol per 3 ounce portion.

Extra Lean meat or poultry with <5 grams fat, 2 grams saturated fat, and 95 mg cholesterol per 3-ounce portion.

Food Quality

You already know some foods are healthier than others. The next two pages are designed to help you compare foods and put them in perspective. Foods are sorted by their food groups with better choices near the top and less nutritious foods near the bottom.

Factors that make foods l ower in quality include: ● Processing - Does it take many steps to make? Do these steps seem like activities that you would/could do in your home kitchen? ● Added sweeteners – sugar, high fructose corn syrup, dextrose, and non-nutritive sweeteners like sucralose (Splenda® ) , aspartame (Equal® ) , or saccharine (Sweet’N Low® ) . ● Added salt ● Added processed fats, especially trans fats (hydrogenated or partially hydrogenated fats)

Aim to make most of your foods from near the top of the lists for the best health results.

We are what we eat!

Mindful Eating

Mindful eating is eating intentionally and giving meals their proper attention. There are so many distractions in our lives, both external and internal. External distractions include phones, tablets, television, and computers. Internal distractors include stress, anger, and loneliness. All of these detract from our ability to feel satisfied and enjoy our food.

“Mindful eating is a way to become reacquainted with the guidance of our internal nutritionist.” – Jan Chozen Bays, MD

Try this exercise at meals to increase your attention to your meals.

Before my meal

How hungry am I? 1 2 3 4 5 6 7 8 9 10 starving stuffed

Did I limit my external distractions? TV off? Cell away from table? Yes No

Did I address my internal distractions? Yes No

Am I mad, sad, bored, or stressed? Yes No

During my meal

I gave thanks for my meal and acknowledged the meal providers. Yes No

I paused for a moment before eating to smell and appreciate my food. Yes No

I set my utensil down between bites. Yes No

I chewed each bite thoroughly before swallowing. Yes No

After my meal

How long did I take to finish my meal? <5mins 6-20mins 20-30mins >30mins

How full am I? 1 2 3 4 5 6 7 8 9 10 starving stuffed How satisfied am I? Not satisfied Satisfied Blissfully satisfied

Reflection What area of mindful eating did you excel at?

Which area of mindful eating did you struggle with the most?

What can you do to improve the area that you struggled with the most?

Write down any other observations or reflections about this particular mealtime.

Hunger Fullness Scale

The hunger & fullness scale describes different levels or varying degrees of hunger to fullness. It is a tool that can be used to help you identify how hungry or full you are or to help you know when to start or stop eating.

5 - Neutral: Neither hungry nor full. Hunger 4 - Lightly Hungry: Starting to think about food, deciding what sounds good to you, what you would like to eat, and maybe stomach gently growling. 3 - Moderately Hungry: Thoughts about food increase, stomach starts to growl more, need to get something to eat increases. 2 - Very Hungry: Stomach growling, stomach may even hurt, need to get food now, everything starting to sound good. 1 - Ravenous: Difficulty concentrating, low energy, headache, everything sounds good, past the point of comfortable hunger 0 - Empty: Uncomfortably hungry, stomach hurts, headache, difficulty concentrating, fatigue, dizziness, weakness, everything sounds good. Fullness 6 - Lightly Full: Satisfied, comfortable, will likely be hungry again in 1-3 hours. If someone offered you more food, you would possibly say ‘yes’. 7 - Moderately Full: Satisfied, still comfortable, will likely be hungry again in 2-3 hours. If someone offered you more food, you would need to consider what type of food it is to decide if you wanted it or not. 8 - Full: Mildly uncomfortably full. If someone offered you more food, you would say ‘no’. Possibly slightly difficult to move due to fullness. 9 - Stuffed: Past the point of comfort, full, stomach may hurt, clothes may feel uncomfortable, possible lethargy due to fullness. 10 - Sick: Uncomfortably full, feeling ill, nauseous, feeling like you may vomit.

It is normal for your hunger and fullness to go back and forth all day long. Staying in moderate hunger and fullness ranges (from a 3-7) will help you avoid extremes in hunger and fullness (0-10). If you start eating when you are light-moderately hungry, you are more likely to stop eating when you are slightly to moderately full. If you start eating when you are empty or ravenous you are more likely to eat until you are stuffed or sick.

Making Smart Choices When Dining Out

Plan ahead ● Look up nutrition information before you arrive so you are aware of calorie, fat, and sodium contents. Many restaurants put nutrition information on their website ● Never skip a meal when you plan on dining out, you will tend to consume more calories and fat later ● Avoid buffets and all-you-can-eat specials

Eat healthy portions of quality, nourishing foods ● Most portions at restaurants are oversized. Ask for “small” or “lunch” portion, order an appetizer, or share a dish with a companion ● Immediately ask for a take-home box when food arrives and pack half of your dish for home ● Ask your server to take nuts, breads, or crackers off your table to prevent grazing ● Look for a ❤ symbol next to menu selections; these items are usually lower in fat (especially for soups) ● Choose “ baked”, “grilled”, “steamed”, “ poached”, or “broiled” meats and fish ● Use the pepper mill or bring your own no-salt seasoning packets to spice up your food ● Choose fresh fruits and vegetables without added sauces ● Ask that your foods be prepared without added fat ● Watch out for breaded or fried products as these are often fried in oil and are low in quality ● Treat condiments like sour cream, butter, and margarine as condiments, not side dishes ● If selecting a salad, order without bacon or croutons, ask for dressing on the side so you can control the amount you put on your salad, and make sure there is a source of protein like tuna, chicken, beef, salmon, cheese with the salad

Continue healthy habits ● Always eat your protein first ● Avoid drinking while eating – Avoid liquid 15 minutes before and 60 minutes after to resume drinking fluids ● Eat slowly, savor the taste of your food, and enjoy the conversation with friends and family

Keeping a Food Journal Keeping a food journal can help you to track your progress, decipher patterns in your eating habits, and ensure you meet your protein goals. Many studies have shown that keeping a food journal helps lose and maintain weight loss.

Try to log your food intake as soon after eating as possible for more accuracy. Consistent journaling can help you identify patterns more quickly. It may make you feel uncomfortable or guilty to write down foods that are less nourishing; it will give insight into your habits so you can identify possible causes, and create plans to make the changes you want. Food records are a way to create feedback, not identify failures. Many people find that a food journal can help them maintain accountability.

Food journals can be paper, kept online, or using an app on your phone. Use whichever is most convenient for you. Here are some examples of online food journals. There are app versions of many of these: ● Baritastic.com ● Calorieking.com ● Fitday.com ● Myfitnesspal.com ● Mynetdiary.com ● theDailyplate.com

A good food journal will include areas to record the following: ● Time of day ● Food item and amount (ounces, tablespoons, or cups) ● Grams of protein ● Fluids (type and ounces) ● Vitamins and supplements taken

A more detailed food journal will include areas to record the following: ● Feelings or mood ● Hunger level before meal ● Post-meal hunger level ● With whom you dined ● Location of meal (work desk, in front of television, car) ● Calories of foods ● Exercise (type, duration, and intensity) ● Challenges (nausea, vomiting, or pain) ● Food intolerances

Sample Food Journal

Blank Time Location Food Amount Protein Fluid Mood Hunger/Fullness (grams) B = before meal A = after meal

B A

Total

Sample completed Time Location Food Amount Protein Fluid Mood Hunger/Fullness (grams) B = before meal A = after meal

7:55- Din ro Scab eg 2 eg 12g 0 con B = 3 8:25am ta Cher ce 1oz 7g A = 7 pu 2oz (s) 0.5g

9:00- In fot of wa 8oz 0g 8oz Frur B = 6 9:30a cot at (wi wo) A = 5 wo

11:05- Wor be Home 6oz 18g 3oz red B = 4 11:40a ro Tex-sle ci w/ A = 7 Ben, be per, toes sin

12:40- In fot of Dec te 16oz 0 16oz con B = 6 2:00p cot at A = 3 wo

2:15- In fot of Stig ce 0.75oz 7g 0 con B = 3 2:25p cot at A = 5 wo

Total 44.5g 27oz

Optimizing Meal Duration Meals should take between 20 and 30 minutes to increase satisfaction and encourage weight loss. It is important that meals take at least 20 minutes to maximize satisfaction. It takes about 20 minutes for your brain to receive the message of fullness from your stomach. In the early stages after surgery, it may be difficult to make meals stretch to last 20 to 30 minutes because the volume of food you are eating is so small. In later stages, as your stomach is able to hold a larger volume it may be difficult to make meals last 20 minutes, because you are able to eat faster without discomfort. It is also important that meals do not last longer than 30 minutes. It may be tempting to continue eating past 30 minutes, but this can deter weight loss by eating too much at meals. Going over 30 minutes should be avoided, as it is the beginning of grazing. After 30 minutes, some of the food from the beginning of your meal has started to leave your pouch, so there will be room for a few more bites. Think of minute 31 as the beginning of grazing or eating your second portion of food. This will minimize your weight loss success. If you eat too fast, you may eat too much before you start to feel full, resulting in pain after the meal. Eating too fast also decreases the satisfaction you receive from your meals.

Strategies for making meals last 20-30 minutes ● Wait 2-3 minutes between bites, from the time you swallow until the time you put the next bite of food in your mouth. This will help you feel more comfortable and be successful in weight loss. ● Use a smaller fork or spoon. Even a baby spoon or lobster fork ● Use chopsticks ● Set a timer at the beginning of your meal to know when 20-30 minutes is up ● Take dime-sized bites ● Be sure to chew each bite 30-50 chews ● Each bite should be a paste-like or liquid texture when you swallow ● There should be no solid pieces when you swallow ● Set your utensil down between bites ● Stop eating as soon as you start to feel full. Fullness may feel like pressure in your upper stomach. ● Eat mindfully - turn off your television, computer, keep your phone or tablet away from you ● Eat at the kitchen table, not at your workstation, in bed, or in front of the television ● Serve yourself from the stovetop or counter and bring the plate back to the table

Keeping Liquids Separated from Meals

After surgery, it will be important to keep liquids separated from meals to feel satisfied. You need to stop drinking and wait 15 minutes before starting your meal. After your meal, you will wait 60 minutes before drinking again. If you mix your drinks with your meals, the food in your stomach pouch or tubular-shaped stomach will be washed out from your stomach and into your intestines too fast. This will cause you to feel hungry much faster and not achieve satisfaction. Keep in mind that one of the ways that our bodies feel full is when the stomach walls detect the weight of food creating pressure against them. If the food is mixed with fluids and the texture is thinner, the food will leave the stomach sooner, and not send a message of fullness to your brain. Eating and drinking at the same time can also cause discomfort or even pain and vomiting - your surgically-modified stomach simply cannot hold that much volume.

Strategies for separating liquids from meals ● Have scheduled times to make it easier to anticipate when you need to stop drinking before meals ● Stop drinking as you prepare your meal or as you set the table to give yourself 15 minutes before your meal without liquids ● Keep your water bottle or cup away from the kitchen table while you are eating ● Cook protein foods with moisture so they are adequately moist and prevent the need to drink with your meal ● Chew your food for 30-50 chews per bite to mix enough saliva with each bite so it does not feel dry going down ● When you are able to add fruits and vegetables back after surgery at Stages 5 and 6, you can finish your meal with one bite of a moist food such as a cherry tomato or pineapple chunk to moisten your mouth ● A few weeks after surgery, you may chew a small piece of sugar-free gum to keep your mouth moist ● As soon as you finish your meal, set an egg timer or a timer on your phone to know when an hour is passed and you can start drinking again ● Work to sip on liquids between meals so you meet your fluid goals. Aim for at least one to two ounces every 10-15 minutes to prevent dehydration. ● Make a very hot decaf tea right when you finish your meal. It will be cool enough to drink after an hour ● If you have a protein shake as a meal, you do not have to wait to resume drinking, as you are going from a liquid to a liquid

Nutrition Goal Worksheet

Date:______

Goal tracker

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Goal

I ate: Protein: _____grams Of my 60-80g goal

=______%

Vegetables: _____cups Of my ___ cup goal

=______%

Setting Good Goals

1. WHAT is your goal? [box 1] Goals must be specific and measurable. You can’t just say things like, “I will eat better” or “I will exercise more” It should have measurable amounts (for foods), and say how often – two times per day? How many times per week? You should be able to say if you did your goal with a simple yes or no.

All of the boxes under the top one should relate back to the top box!

2. WHY is your goal important? [box 2] Think about all those important things that are motivating you. Specifically, why are you doing THAT part of the goal?

3. HOW are you going to meet your goal? [box 3] To reach your goal, what are some strategies you can employ? Make sure these relate TO THE GOAL. – for instance, I might have put “cut out soda”, which is a good idea, but it doesn’t really help me eat more vegetables. Another way to think of this is to imagine possible barriers you might face and think of ways to overcome them.

4. WHO can help you? [box 4] Support group – don’t put yourself in this box – you are looking to build a support network around you to help you when you do not want to do the best things. Sometimes support people are not very healthy themselves, but they are good nags – look for the nags in your life. Find a person in your life who cares about you and tell them that you need them to ask you about your health goal OFTEN. If they love you, they will.

5. ACCOUNTABILITY – DID YOU DO IT? [bottom tracker] Tracking: every day that you meet your goal (in this case, every day that I eat 1 cup of vegetables at Lunch AND dinner), put a check in the box. Put this sheet somewhere where you can see it and will think about it every day. Tape it to your steering wheel, put it IN your fridge – taped to a shelf, put it on your pillow after you make your bed so it is the last thing you think about each night and the first thing you think of when you wake up in the morning.

Nutrition Goal Worksheet - Completed sample

Date:_W edd, Jun 24, 2020_ __

Goal tracker

Sunday Monday Tuesday Wednesday Thursday Friday Saturday 24 ✔ 25 ✔ 26 27 28 ✔ 29 30 ✔ 1 ✔ 2 ✔ 3 4 5 6 ✔ 7 8 ✔ 9 10 ✔ 11 12 13 ✔ 14 ✔ 15 16 ✔ 17 18 ✔ 19 20 ✔ 21 ✔ 22 23 24 25

Guidance Beyond Nutrition

Weight Loss Expectations Most of your weight loss occurs within the first year after surgery, with most of that occurring in the first six months after surgery. It is important to set realistic long-term weight goals and expectations for success. Most people can anticipate losing 50-60% of their excess body weight at one year after surgery. Excess body weight is about 30-40% of your total body weight. Nutrition, physical activity, lifestyle habits, and attitude towards food are important aspects to how successful you are after surgery. After the first year, weight loss will slow down.

Example: 5’8” woman weighs 350 pounds.

Using a BMI calculator, her healthy weight range is 122-164 pounds.

Her excess body weight is 186-228 pounds.

She can anticipate a weight loss of 93-137 pounds.

Resulting in a target weight of 213-257 pounds at one year.

Studies have found that even just a ten percent weight reduction can have many positive effects on health. To help you calculate your weight loss goals, use the following worksheet.

Calculating Weight Loss Expectations Your current height:_____ ft _____ in

Your current weight (A): ______lbs

Your ideal body weight range (B) – (C):______lbs to _____lbs

You can use the link found at this QR code to calculate a healthy BMI range.

Excess body weight range: (A) ______- (B) ______= ______(D)

TO: (A) ______- (C) ______= ______(E)

Expected weight Loss: (D) ______x 0.60 = ______(F)

TO: (E) ______x 0.50 = ______(G)

Anticipated weight after one Year: (A)______- (F)______= (H) ______

TO: (A) ______- (G)______= (I)______

Expected weight loss: ______lbs (G) to ______lbs (F)

Anticipated weight after one year: ______lbs (H) to ______lbs (I)

Medications

Due to the physical changes you are undergoing with surgery, some of your medications may be adjusted. Do not adjust these medications by yourself! Your surgeon or primary care physician will recommend these changes, if appropriate. The following guidelines are just some changes that may happen.

Pain and Anti-inflammatory medications Seven days before surgery, stop aspirin or aspirin-containing medications, also stop nabumetone or meloxicam. Seven days before surgery, also stop NSAIDS such as Motrin or Advil (Ibuprofen), Aleve (naproxen). NSAIDS are not recommended after surgery because these anti-inflammatory medicines can cause an upset stomach and can increase your risk for ulcers. You can take Tylenol (acetaminophen) or other chronic pain medications approved by your surgeon for pain.

Diabetes Medications Continue to monitor and record your blood sugars daily. Before discharge, you will talk with your surgeon or metabolic-surgical weight management provider and receive specific instructions related to changes to your diabetes medications. Your insulin regimen may be adjusted prior to starting the Liver Shrinking Diet (Pre-Surgery Plan). Check with your primary care physician.

Blood pressure and Cholesterol Medications Continue to monitor and record your blood pressure daily. Before discharge, you will talk with your surgeon or metabolic-surgical weight management provider and receive specific instructions related to changes to these medications.

Medications for other chronic issues Check with your surgeon before discharge about any possible changes to your medications for acid reflux, depression, blood thinning, or other chronic issues.

Birth control Birth control pills should be stopped for two weeks before and for two weeks after surgery. It is generally advised to avoid pregnancy within 12-18 months after surgery, because it can be difficult to ensure the baby receives enough nutrients to grow healthily. Sometimes weight loss surgery can increase some women’s fertility, so it is crucial you use a reliable form of contraception to avoid pregnancy.

Vitamins, herbal supplements, and other complementary medicines All vitamins, herbal supplements, and other complementary medicines should be stopped seven days before surgery and may be restarted two to four weeks after surgery. Ask your surgeon for when these complementary medications may be restarted. This includes herbal supplements, supplement-type herbal teas, fish oil, glucosamine, St. John’s wort, CBD supplements, marijuana, and marijuana-containing products.

Large pills Large pills may become uncomfortable to swallow. Rest assured they will not become stuck; they will eventually dissolve. Some medicines can be crushed or cut, but check with your pharmacist for each medicine first.

Physical Activity

Nutrition and physical activity are more important than ever after bariatric surgery. Physical activity and nutrition work together for better health. According to one study, the people who successfully lost weight and kept it off after surgery cited adopting an exercise program as one of the keys to success.

Benefits of being active ● Obtain or maintain a healthy weight ● Increase your chances of living longer ● Have stronger muscles and bones ● Sleep better at night ● Lower cardiovascular risk ● Move around more easily ● Improved blood sugars ● Be with friends or meet new ones ● Increased energy level ● Feel better about yourself ● Decrease risk of depression

Increase activity ● Take the stairs instead of the elevator ● Park farther away from the building ● Play with your children ● Garden ● Walk during your lunch break ● Dance around the living room with your children and spouse ● Clean- vacuuming, dusting, and scrubbing ● Walk to the mailbox ● Walk the mall ● Visit a hiking trail ● Buy a pedometer and track your steps, try increasing the number you take on a daily basis

How much do I need? For adults: ● 2 hours and 30 minutes per week of moderate aerobic activity ○ Works out to 20 minutes per day, 7 days per week or ○ 30 minutes per day, 5 days per week OR ● 1 hour and 15 minutes per week of vigorous physical activity ● Spreading it over at least three days per week is best ● Working out for at least 10 minutes at a time is best

How do I measure intensity of physical activity?

Light Intensity Moderate Intensity Vigorous Intensity

You can sing while You can talk and say 3-4 You could only say 1-2 words at doing this activity words at a time before a time before needing to catch

needing to catch your breath your breath

Types of physical activity ● Aerobic Activities make you breathe harder and make your heart beat faster. They can be light, moderate, or vigorous. Examples include walking or running. ● Muscle-strengthening activities make your muscles stronger by using resistance. Examples include weight lifting, push-ups. ● Bone- strengthening activities make your bones stronger by using impact. This type of physical activity is especially important for kids and teens for growth. Examples include burpees or jumping jacks. ● Balance and stretching activities make you more stable and flexible to help reduce risk of injuries. Examples include yoga or Pilates.

Safety Physical activity is generally safe for everyone. The health benefits you gain from being active are far greater than the chances of getting hurt, but you should start slow and build up. Choose appropriate activities for your fitness level and use the right safety equipment. Learn about what works best for you and ask an expert in that activity for advice, especially when you are first starting. See a health care provider, if needed.

Sample progression Work to build up both your duration and intensity. If you can already do more than this sample progression, that is great! Continue to build up to the goals of ● 2 hours and 30 minutes per week of moderate aerobic activity OR

● 1 hour and 15 minutes per week of vigorous physical activity

Time Exercise/intensity Duration/frequency Walking at 2mph- moderate intensity (can say 10-20 minutes 5 times per week Pre-surgery 3-4 words before needing to catch your breath) 1 month after Walking at 3mph - moderate intensity (can say 20 minutes 6 days per week surgery 3-4 words before needing to catch your breath) 2 months after Walking at 3.5mph(moderate intensity) 20 minutes 7 days per week surgery Yoga (moderate intensity) 60 minutes 2 days per week Walking (moderate intensity) 30 minutes 7 days per week 3 months after Yoga (moderate intensity) 60 minutes 3 days per week surgery Weight lifting (brief bouts of vigorous activity) 30 minutes 3 days per week Running (vigorous activity) 10 minutes 2 days per week 4 months after Yoga (moderate intensity) 60 minutes 3 days per week surgery Weight lifting (brief bouts of intense activity) 30 minutes 3 days per week Running (vigorous activity) 15 minutes 3 days per week 5 months after Yoga (moderate intensity) 30 minutes 5 days per week surgery Weight lifting (brief bouts of intense activity) 30 minutes 3 days per week Running (vigorous activity) 20 minutes 4 days per week 6 months after Yoga (moderate intensity) 30 minutes 7 days per week surgery Weight lifting (brief bouts of intense activity) 30 minutes 3 days per week

Sleep

Adequate sleep is essential to wellness. Very few people achieve the seven to eight hours per night that people need. Achieving less than seven to eight hours per night has been linked to obesity, diabetes, high blood pressure, heart disease, early mortality. Quality sleep protects your mental and physical health, improves your quality of life and your safety. Sleep affects your immune system, stress response, appetite, blood pressure, and cardiovascular health.

Costs of not achieving seven to eight hours per night: ● Weight gain ● Poor blood sugar control ● Weakens immune system ● Depression ● Decreased ability to focus ● Increased risk of injury ● Decreased creativity ● Poor memory ● Slower reflexes ● Decreased pain tolerance Improving Sleep Hygiene

● Decrease or eliminate the caffeine, alcohol, marijuana, or nicotine you use. These products can disrupt your sleep ● Exercising early in the day can help you fall asleep faster and sleep more soundly. ● Avoid arguments before bed. Save difficult conversations for the next day. ● Turn off as many lights as possible and turn down the others an hour before bedtime. This helps signal to your body that the time to rest is approaching. Even the light from your tablet, phone, and TV can also prevent you from falling asleep. ● Establish a relaxing bedtime routine. Read a book, mediate, journal, or take a bath to wind down. ● Keep your bedroom dark and cool for better sleep. ● If you have sleep apnea, use your C-pap machine. ● Keep your bed for sleep and romance only. Do not watch TV, read, or eat in bed so you only associate your bed with sleep. ● Avoid sleeping in chairs or on the sofa where you will not achieve as restful of sleep.

Common Concerns After Surgery

Low blood sugar ● Symptoms include weakness, nausea, perspiration, hunger, anxiety, and tremors and can occur 1-2 hours after a meal ● Avoid concentrated sweets ● Include a protein source with each meal/snack ● Treat symptoms with ½ cup of skim milk, wait 15 minutes, then retest blood sugars

Low blood pressure ● Symptoms include dizziness, weakness, clamminess ● Dizziness especially upon standing ● Be sure to drink 64 ounces of water per day, including electrolyte-including drinks like sugar-free Gatorade™ or Powerade™ ● Drink a can of tomato juice (not the low sodium) or coconut water or tomato soup

Nausea/Vomiting ● Eat and drink slowly (20-30minutes per meal) ● Avoid eating and drinking at the same time ● Chew foods to a paste/baby food consistency ● Decrease portion sizes ● Avoid lying down after eating ● If nausea and vomiting persists more than 24 hours, call the office at 303-318-3240

Belching ● Eat and drink slowly- meals should take 20-30 minutes ● Avoid carbonated beverages ● Eating and drinking too quickly is the number one cause of belching ● Avoid chewing gum

Changes in Taste/Tolerance ● Avoid foods that cause intolerances ● Eat other foods from the same food group to avoid deficiencies ● Severe vomiting or diarrhea can lead to zinc deficiency, which can also lead to changes in taste perception. Be sure to take a multivitamin to prevent zinc deficiency.

Lactose Intolerance ● Bloating, gas, or cramping after eating or drinking dairy products ● For many people it is a temporary side effect after surgery ● Try dairy alternatives such as soy milk or lactose-free milk such as Lactaid™ milk ● Take lactase tablets such as Lactaid™ when eating dairy

Dehydration See page 7 5

Dumping Syndrome See page 7 6

Constipation See page 7 7

Dehydration Dehydration is when you have a loss of body water and is the most common preventable complication after weight loss surgery. It can become serious, even life threatening if not addressed.

When can dehydration happen? The most common reason for dehydration is not drinking enough fluids. Dehydration can also occur if you have diarrhea or vomiting. If you have diarrhea or vomiting, you may need to drink even more fluids.

Some medications can cause dehydration. Do not adjust medications without consulting your doctor first.

What are the symptoms of dehydration? ● Thirst or dry, sticky mouth or bad breath or cracked lips ● Very dark-colored urine ● Feeling dizzy or lightheaded ● Feeling nausea or vomiting or dry heaves ● Tired, sleepy ● Irritable or anxious ● Muscle weakness ● Fast breathing or fast heart rate ● Constipation

How is dehydration prevented? Drink a minimum of 64 ounces of sugar free liquids per day (Any of the liquids on page 25) . Slowly sip four to six medicine cups (4 to 6 ounces) of fluid each hour. If you struggle, try setting a timer. Track your fluid intake in a written log or in an app. Include broth, water, sugar-free, caffeine-free drinks.

How is dehydration treated? Treatment depends on how severe your dehydration is. Very severe dehydration requires a trip to the emergency department, and can involve a blood draw, IV fluids, and/or taking medications if you have nausea and vomiting. Less severe dehydration can be treated starting by drinking Powerade Zero™ o r V-8 (not low sodium variety) or coconut water or Body Armor Lyte™ . It may be possible to receive IV hydration at the office for less severe dehydration. Your doctor will decide the best course of treatment based on the severity of your dehydration. Call the office at 303-318-3240 if you are concerned about dehydration.

Dumping Syndrome Dumping syndrome is caused by a rush of undigested foods, especially sugar in the intestines, specifically in the jejunum. For some people greasy foods can also cause dumping. Fluid then dumps into the gut to dilute the food. Symptoms of dumping syndrome include abdominal fullness, rapid heart rate, sweating, nausea, abdominal cramping, shakiness, sleepiness, and diarrhea.

Dumping syndrome can occur as soon as 15 minutes after a meal or as late as 1-2 hours after a meal. Some patients may not experience symptoms for weeks after surgery. Dumping syndrome can be prevented.

To prevent dumping syndrome ● Avoid refined sugars and sugar alcohols. See page 4 9. ○ Sorbitol ○ Mannitol ○ Maltitol ○ Erythritol ○ Xylitol ● Read food labels – page 4 8 ● Follow the two guidelines of 3 grams or less of sugar per serving for non-fruit/dairy products and no added sugar in first five ingredients for fruit/dairy products ● Once you begin Stage 3, avoid liquid 15 minutes before and 60 minutes after meals ● Chew foods well to a paste/baby food consistency ● Relax and eat slowly at mealtimes. Meals should last 20-30 minutes

Constipation It is normal for the first few weeks after weight loss surgery to only have one or two bowel movements each week. This is normal and usually not a sign of constipation. It is safe to take a daily stool softener such as Colace® , docusate, or senna starting one week after surgery.

After the first few weeks, if you are not having bowel movements and you have an upset stomach or need to strain very hard to pass stool, you may be constipated. It is easier to prevent constipation than it is to treat it. If you do not drink enough water or have enough physical activity after surgery, you will likely become constipated.

Preventing Constipation ● Choose high fiber foods for meals (20-50g per day) ○ A little less than half of your plate should be vegetables ○ Opt for fruits as your carbohydrates for meals ○ If including grains, choose whole grains ● Drink plenty of liquids (64 ounce minimum) (Any of the liquids on page 2 5) ○ Slowly sip four to six medicine cups (4 to 6 ounces) of fluid each hour. Set a timer, if necessary. ○ Always carry a water bottle with you ● Exercise regularly. See page 71. ○ Walk at least 30 minutes every day ● Add a daily fiber supplement such as Benefiber™

Resolving Constipation If you have not had a bowel movement in three days and you have an upset stomach, cramping or a hard straining when going to the bathroom, do the following steps:

Day 3 ● Drink at least 8 glasses of water ● Take a walk for 30 minutes

Day 4 After completing the steps above, if you still have not have had a bowel movement on the morning of the fourth day: ● Drink at least 8 glasses of water ● Take a walk for 30 minutes ● Drink Miralax® – mix 17g (one capful) of Miralax® to 4 to 8 ounces of liquid

Day 5 After completing the steps above, if you still have not have had a bowel movement on the morning of the fifth day: ● Drink at least 8 glasses of water ● Take a walk for 30 minutes ● Add Miralax® – mix 17g (one capful) of Miralax® to 4 to 8 ounces of liquid ● Add a glycerin suppository or Fleet® enema (over-the-counter at most drug stores) Follow the directions on the label. Do not use more often than recommended on the label.

Day 6 After completing the steps above, if you still have not have had a bowel movement on the morning of the sixth day: ● Drink at least 8 glasses of water ● Take a walk for 30 minutes ● Add Miralax® – mix 17g (one capful) of Miralax® to 4 to 8 ounces of liquid ● Drink 5 ounces (half bottle) magnesium citrate ● Finish the bottle if no results

Day 7 After completing the steps above, if you still have not had a bowel movement on the morning of the seventh day, please call the office at 303-318-3240.

Addressing Unhealthy Behaviors

If you are not nourishing yourself adequately, you may slip back into past behaviors that may cause weight gain. Habits to watch for include:

1. Starting to eat sweets, processed and refined carbohydrates, or salty snacks (or craving them)

2. Increasing in how often you are eating fast food or grabbing little nibbles or snacks “I’ll just have a bite”

3. Skipping meals

4. Eating past the point of fullness

5. Eating quickly

6. Grazing and “mindless” eating

7. Eating when you are angry, lonely, tired, or stressed

8. Avoiding exercise

9. Choosing to eat carbohydrates first

10. Snacking from vending machines

If you find that you are exhibiting some of these behaviors, work at correcting them and building wellness.

Building Wellness through Self Awareness

It is easy to take on too many responsibilities at the expense of your own health. Our culture’s baseline is to push too hard at work, constantly multitask, and overcommitting. Now is a great time to learn to listen to your body. The human body is constantly sending signals to return to wellness, but it is easy to ignore these subtle signs.

● I need to stand up ● I need a hug ● I need to walk around ● I need to take a moment alone ● I need to visit the restroom ● I am ready for a meal ● I am thirsty ● I am ready for a nourishing snack ● My eyes need a break from the ● I need to assess a decision I’ve made computer screen ● I need to look ahead to the next week to ● I need to sit gather my bearings ● I am cold ● I am ready to lay down ● I am warm ● I am sleepy

Realign yourself Try one or more of these strategies to mitigate your stress:

● Take 3-5 long, slow deep breaths ● Color or do a dot-to-dot ● Hug your significant other, kids, or a pet ● Shower or take a bath with essential oils ● Go for a walk ● Blow bubbles ● Decompress for 5-10 minutes in a ● Read a good book stressful situation ● Meditate or pray ● Call a friend or family member ● Tell a corny joke ● Garden ● Try a hobby ● Enjoy nature – smell a flower ● Listen to some calming music ● Take a 10 minute nap ● Exercise

Strategies for Lifelong Success

For lifelong success, we encourage you to adopt the following strategies: 1. Stay hydrated ● Drink 64 ounces (8 glasses) of water or other sugar-free drinks daily ● Avoid processed beverages such as soda, juice, or sports drinks. Do not drink your calories. ● Always carry a water bottle with you 2. Nourish yourself ● Eat 3 meals every day ○ Be consistent from day to day ○ Avoid going more than 3-5 hours without eating, adding a snack between meals, only if hungry ● Eat protein first ○ 20-30 grams per meal, 60-90 grams per day ● Do not skip breakfast ○ Include protein ○ Ideally, within 1-2 hours of waking ● Avoid processed foods (e.g.: crackers, chips, candy) ○ These do not nourish or satisfy you and can cause weight gain ○ If it does not grow that way, it is processed 3. Eat mindfully (See also Mindful Eating handout) ● Be aware of why you are eating (HALTS) ○ Hu ngry ○ An gry ○ Lo nely ○ Ti red ○ St ressed ● Stop eating when you just begin to feel full ● Eat slowly and chew your food well 4. Log your food intake (See page 5 7) ● As soon as you can after eating for accuracy ● Could be paper, journal, online ● Purchase a set of measuring cups and measuring spoons, a food scale, smaller plates and utensils to assist in managing food portions 5. Take vitamins and minerals daily (See page 3 9) ● Prevent nutritional deficiencies ● Opt for a swallow pill or chewable tablet, not gummies, liquids, or patches 6. Exercise (See page 71 ) ● Work up to 30-60 minutes of dedicated exercise/physical activity per day ● Build up to 6-7 days per week ● Work toward at least 10 minute chunks at a time 7. Track your weight ● Does not need to be daily – consider “weight Wednesday” ● Looking for trends, not individual data points ● Write it down

Learning More

Being successful after surgery is more likely if you learn as much as possible before surgery. Here are some resources that can help you understand more about the surgery and how it will affect your life.

● ASMBS.org - American Society for Metabolic and Bariatric Surgery ○ The authority for weight loss surgery ● Baritastic.com ○ Calorie info and tracking specific for bariatric surgery ● BariatricPal.com ○ Comprehensive information on all types of weight loss surgeries. Also includes chat rooms and support groups. ● Calorieking.com ○ Calorie tracker ● Ethicon Endo-Surgery, Inc. (weightlosssurgeryinfo.com) ○ Comprehensive information on all types of weight loss surgery. Also includes interactive tools for viewing the procedures. ● Fitday.com ○ Calorie tracker, articles about nutrition, and forums. ● Makeitalifestyle.com ○ Information on upcoming events, weight loss surgery, message boards and recipes ● MayoClinic.com – Mayo Clinic ○ This site has a section devoted to weight and weight loss surgery. Also includes interactive tools for weight loss surgery information. ● Myfitnesspal.com ○ online resource for calorie info and exercise tracking ● Mynetdiary.com ○ online resource for calorie info and tracking ● Obesity.org- American Obesity Association (AOA) ○ Site includes a variety of resources for weight loss with diet and physical activity information. ● Obesityhelp.com ○ Dedicated to weight loss with or without surgery. This site consists of message boards related to the topic of weight loss surgery. ● Obesityaction.org ○ This site will give information on current research and advocacy movements in the field of obesity. ● Scalesgalore.com ○ Purchase scales ● theDailyplate.com ○ Calorie info and tracking

● The Pocket Protein Counter - book by Natow and Heslin

2020 Bariatric Support Group Meetings

Saint Joseph Hospital Second Tuesday of every month 6:00 – 7:30 P.M. 1960 Ogden Street, Suite 595, Denver CO 80218 Tuesday, January 14 Tuesday, July 14 Tuesday, February 11 Tuesday, August 11 Tuesday, March 10 Tuesday, September 8 Tuesday, April 14 Tuesday, October 13 Tuesday, May 12 Tuesday, November 10 Tuesday, June 9 Tuesday, December 8 Good Samaritan Medical Center Third Tuesday of every month 4:30 – 6:00 P.M. 200 Exempla Circle, Conference Room A, Lafayette, CO 80026

Tuesday, January 21 Tuesday, July 21 Tuesday, February 18 Tuesday, August 18 Tuesday, March 17 Tuesday, September 15 Tuesday, April 21 Tuesday, October 20 Tuesday, May 19 Tuesday, November 17 Tuesday, June 16 Tuesday, December 15

If weather is inclement, call ahead to 303-318-3240 to confirm Support Group has not been canceled.

Saint Joseph Hospital Second Tuesday of every month 6:00 - 7:30 P.M. 1960 Ogden Street, Suite 595, Denver, CO 80218

Tuesday, January 12 Tuesday, July 13 Tuesday, February 9 Tuesday, August 10 Tuesday, March 9 Tuesday, September 14 Tuesday, April 13 Tuesday, October 12 Tuesday, May 11 Tuesday, November 9 Tuesday, June 8 Tuesday, December 14

Good Samaritan Medical Center Third Tuesday of every month 4:30 - 6:00 P.M. 200 Exempla Cir, Conference Room A, Lafayette, CO 80026

Tuesday, January 19 Tuesday, July 20 Tuesday, February 16 Tuesday, August 17 Tuesday, March 16 Tuesday, September 21 Tuesday, April 20 Tuesday, October 19 Tuesday, May 18 Tuesday, November 16 Tuesday, June 15 Tuesday, December 21

If weather is inclement, call ahead to 303-318-3240 to confirm the Support Group has not been cancelled. If we are unable to meet in person, the Support Group will be held virtually. Please call 303-318-3240 for details.