Diet Guidelines After Duodenal Switch Surgery

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Diet Guidelines after Duodenal Switch Surgery

Drs. Leslie and Ikramuddin

The purpose of your surgery is to reduce the amount – After about four weeks, you may eat between of food you can eat and to absorb fewer calories. 1/2 and 3/4 cup of food per meal. To keep the After surgery, your diet will consist of small, high- weight off, you will need to eat small amounts protein meals. It is important for you to eat slowly of food for the rest of your life. and chew well. – The long-term goal is a serving of 1 cup of food at meals. You will eat less food and absorb fewer nutrients. For this reason, you will need to take vitamin and • Stop eating as soon as you feel satisfied. mineral supplements daily. • Eat slowly. Each meal should last 20 to 30 Guidelines for eating minutes. Eating too fast can cause you to eat too much before you feel full. It can also cause • Do not snack all day or graze. Eating throughout nausea (sick feeling in your stomach), vomiting the day may keep you from losing weight. It may (throwing up), pain or pressure in the shoulder or even cause weight gain because you are eating too upper chest. many calories. • Sit down to eat your meals. Try setting your • Keep track of the number of times you eat spoon or fork down between each bite, then wait during the day. Since your meals are small in at least one minute before taking the next bite. size, you may need to eat five meals a day to get enough protein. As your stomach stretches and • Chew all foods into a paste the thickness of you can take in more food at a time, you may applesauce. The opening that leads from your need to eat less often. stomach to your bowel (intestine) is very small. Foods that are not chewed well may block this • Eat small amounts. opening. They can cause discomfort. You may feel – At first, your stomach can hold only up to sick to your stomach or vomit. To prevent this, 1/2 cup of food. If you try to eat more than this, cut your food into small pieces. Then, chew your you may get sick. Your stomach will slowly food well. It may take more time to chew beef, stretch over time. raw fruits and raw vegetables.

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• Eat at least 80 to 100 grams of protein each day. Guidelines for liquids Since you are eating less food, you will need to work harder to get enough protein. Try to include • Do not drink liquids with meals. Stop drinking a good source of protein with each meal (such as 30 minutes before your meals. Then wait 30 eggs, lean meats, poultry, fish, beans and low- minutes after eating to drink liquids again. fat or fat-free dairy products). Protein helps you This will: maintain muscle while you quickly lose weight. – Prevent the stomach from over-filling • Avoid sugar and fat. Do not fill your small – Keep food from flushing out too quickly stomach with junk foods that lack vitamins and – Keep you feeling full longer. other important nutrients. You should eat lean proteins, low-fat milk products, fruits, vegetables • Sip all liquids slowly. Drinking too quickly may and whole grains. cause nausea or vomiting.

• Do not chew gum. Gum chewing may cause gas. • Drink plenty of calorie-free liquids between If you swallow the gum, it may cause a blockage. meals. Plain water is best. Drink at least 6 to 8 cups (48 to 64 ounces) of fluid a day.

• Avoid high-calorie liquids. These add extra calories without making you feel full. For example, do not drink:

– Regular soda pop

– Coffee drinks (mocha, latte, cappuccino or other specialty drinks)

– Kool-Aid

– Smoothies

– Sugar-sweetened drinks

– More than 1/2 cup (4 ounces) diluted fruit juice in a day

• Do not drink any alcohol.

• Avoid carbonated (fizzy) drinks.These can cause gas and bloating.

• Avoid caffeine. Caffeine may irritate your stomach and prevent your body from absorbing iron. Page 3 of 12

Exercise guidelines Stage 1: Clear liquids

Get regular exercise to help you lose weight. It uses Drink only clear liquids for the first 1 to 2 days after energy and burns calories. If exercise is not in your surgery (while you are in the hospital). routine, begin slowly. As you lose weight, moving will get easier. Goal:

Your diet • Slowly sip 6 to 8 cups (48 to 64 ounces) of liquid during the day. Drinking too fast can cause There are five stages to your diet plan. If you have nausea, vomiting, pain or pressure. problems—like throwing up or feeling sick to your stomach—you may need to go back one stage. Tips: For example, if you are having problems with soft • Drink 2 ounces of liquid every 30 minutes. Try foods, go back to a pureed diet. Then, slowly move to increase this over the next 48 hours until you to the next stage in your diet. reach 6 to 8 cups (48 to 64 ounces) of liquid a day.

• Avoid straws. Straws bring air into the stomach, First day after Stage 1 Clear liquids causing gas, bloating, pain or pressure in the surgery shoulder or upper chest.

Stage 2 Day 2 to 13 Low-fat full liquids Suggested liquids: – Water Stage 3 Day 14 to 27 Pureed foods – Decaf, sugar-free iced tea – Sugar-free popsicles Stage 4 Day 28 Begin soft foods – Clear broth Begin regular – Cranberry juice or 100% apple or grape juice (add Stage 5 8 to 12 weeks foods extra water to dilute it; limit yourself to 1/2 cup, or 4 ounces, per day) – Decaf coffee or tea with no sugar or honey (artificial sweeteners are okay) – Sugar-free, enhanced or infused water – Herbal tea – Low calorie sports drink (less than 20 calories in 8 ounces) – Sugar-free gelatin Page 4 of 12

Stage 2: Full liquids (days 2 to 13) Foods allowed:

Full liquids are a little thicker than clear liquids. You – Skim milk, 1% milk, plain soymilk or Lactaid milk will be drinking low-fat full liquids when you leave – Protein drink (as described) the hospital. Stay on this diet until two weeks (13 – Low-calorie or “light” smooth yogurt (no fruit days) after surgery. chunks)

Goals: – Fat-free plain yogurt

• Have no more than 1/2 cup food per meal. – Fat-free Greek yogurt – Sugar-free pudding • Add more liquid choices. – Low-fat cream soup, strained • Keep drinking 6 to 8 cups (48 to 64 ounces) of fluid each day. – Cream of Wheat, Cream of Rice and Malt-O-Meal Any clear liquids allowed in your stage 1 diet. If • Use a protein drink that has (8 ounce serving): you drink juice, have no more than 4 ounces per – No more than 200 calories day (diluted, pulp-free, not sweetened).

– 15 to 30 grams of protein

– Less than 20 grams of carbohydrate Sample Menu for Full-Liquid Diet

– Less than 5 grams of fat Breakfast

– Less than 10 grams of sugar • 1/4 cup Cream of Wheat

• Start taking vitamin and mineral supplements. • 1/4 cup sugar-free custard

Tips: Snack • To make sure you drink enough fluids, you may • 1/2 cup sugar-free pudding want to space them throughout the day. Try drinking about: Lunch 20 ounces before lunch • 1/2 cup strained cream soup 20 ounces before dinner 20 ounces before bed. Snack

• Eat three meals daily at about the same times each • 1/2 cup protein drink (see page 4) day. Do not skip meals. Dinner • Your body may find it easier to handle liquids at room temperature than ice-cold liquids. • 1/2 cup low-calorie yogurt (no fruit chunks) • Freeze liquids in plastic bottles to carry with you. Page 5 of 12

Stage 3: Pureed foods (days 14 to 27) Proteins:

You will start a pureed diet 14 days after surgery. You – Skim or 1% milk will stay on this diet for about 2 weeks. – Protein drink (see page 4)

Goals: – Low-calorie yogurt (no chunks of fruit)

• Add more food choices. Foods are blended – Low-fat cottage or ricotta cheese, mashed with (pureed) so they are the same thickness as a fork applesauce. This will reduce the risk of nausea and – Mashed eggs (poached, soft boiled or scrambled) vomiting. or mashed egg substitute

• Meals should be about 1/2 to 3/4 cup of food. – Mashed tofu

• Keep drinking enough liquids. Remember to stop – Pureed lean beef, lean pork, chicken, turkey or liquids 30 minutes before your meals. Wait 30 fish (or use baby food meats) minutes after eating to start liquids again. – Mashed beans (such as black beans, pinto beans or fat-free refried beans) Tips: – Pureed chili • Add new foods slowly. Try one new food at a time. Grains and starches: • At first, you may only be able to handle 1 to 2 – Hot cereals (Cream of Wheat, Cream of Rice, tablespoons at a time. You may want to use a Malt-O-Meal, oatmeal, grits) small saucer and a baby spoon. Slowly increase your food until you are eating 1/2 to 3/4 cup of food – Mashed potatoes, sweet potatoes or winter squash at each meal. Fruits and vegetables: • Eat the protein part of your meal first. – Plain applesauce (no added sugar) • You may need to add protein powder to your – Mashed bananas food. Your goal is at least 80 grams of protein each day. – Pureed peaches, pears, apricots or other pureed fruit • If you cannot handle food early in the morning, – Pureed carrots, green beans, beets or other try a protein drink. pureed vegetables Page 6 of 12

Stage 4: Soft foods (day 28) Sample Menu for a Pureed Diet If your body can handle pureed foods, you will begin solid foods. Foods should be soft, moist and tender. It Breakfast is important to choose low-fat and low-sugar foods. • 1/2 cup scrambled Egg Beaters Goals: • 2 tablespoons applesauce • Choose soft protein foods. Eat at least 60 grams of Snack protein each day.

• 1/2 cup protein drink (see page 4) • Choose soft fruits and vegetables. • Stop eating when you feel satisfied. Lunch • Meals should be a total of 1/2 to 3/4 cup. • 1/2 cup pureed chili • Keep drinking at least 6 to 8 cups (48 to 64 • 2 tablespoons pureed pears ounces) of liquid in a day.

Snack Tips:

• 1/2 cup cottage cheese • Add new foods slowly. You may have problems with some foods more than others. Take small • 2 tablespoons pureed peaches bites and chew all food well. (Chew each bite 20 Dinner to 30 times before you swallow to make sure the food is about the texture of applesauce.) • 1/4 cup pureed turkey • Always eat the protein part of your meal first. • 2 tablespoons mashed potatoes • Prepare meats using low-fat cooking methods • 2 tablespoons pureed green beans (baking, broiling or grilling).

• Use herbs and spices to season vegetables.

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Proteins: – Tuna fish, salmon or white fish Sample Menu for Soft Diet – Shrimp, lobster or crab Breakfast – Tender, moist lean meats • 1 soft-cooked egg – Lean ground beef or turkey • 1/4 cup chopped ham – Deli-sliced turkey breast, chicken, ham, roast beef Snack – Egg, chicken or tuna salad (use low-fat or fat-free mayo, salad dressing or plain yogurt) • 2 ounces low-fat cheese – Low-fat cheese (such as part-skim mozzarella) Lunch – Hard-boiled, poached, soft cooked or • 1/3 to 1/2 cup baked fish scrambled eggs • 2 tablespoons potato – Tofu • 2 tablespoons cooked carrots – Mashed or well-cooked beans (such as black or pinto) Snack

Grains and starches: • 1/3 to 1/2 cup low-fat cottage cheese – Mashed or baked potatoes or sweet potatoes • 1/4 cup canned pears or soft fresh pear – Hot cereal or cereal soaked in milk Dinner (choose high-fiber cereals) – Low-fat crackers • 1/3 to 1/2 cup chopped or ground turkey – Toast • 2 tablespoons green beans Fruits and vegetables: • 2 tablespoons mandarin oranges – Canned peaches or pears (packed in water or juice, not syrup) – Thawed frozen berries (plain, no syrup) – Bananas – Plain applesauce (no added sugar) – Mandarin oranges – Soft melon – Soft, well-cooked vegetables (carrots, green beans, squash, beets, broccoli florets) Page 8 of 12

Stage 5: Regular foods (8 to 12 weeks) Sample Menu for Regular Diet Starting 8 to 12 weeks after surgery, you can eat most foods. Follow the same goals and tips as in stage 4. Breakfast Only eat foods that contain nutrients and avoid junk foods. • One egg • 1/4 cup fruit, no sugar added Foods you may not be able to eat: Some foods may cause problems. This will vary from person Snack to person. The following foods are more likely to cause problems: • 1 cup protein drink (see page 4) – Tough meat: Use a marinade or tenderizer. Lunch – Fresh bread: Eat toast slices instead. • 2 ounces meat, fish, chicken or turkey – Stringy vegetables: Blend and strain to remove • 1/4 cup vegetable hard-to-digest fiber. • 1/4 cup (or one small piece) fruit, no sugar – Oranges and grapefruit: Remove the white membranes. Snack – Skins of fruits and vegetables: Peel apples, pears • 1 to 2 ounces low-fat cheese or deli meat and potatoes. Dinner – Coconut: Avoid food with coconut. • 2 ounces meat, fish, chicken or turkey – Milk products: Use soymilk or low-lactose milk, such as Lactaid. • 1/4 cup vegetable • 1/4 cup (or one small piece) fruit, no sugar – Sugar: Avoid high-sugar foods.

Remember

• Follow your diet as your surgeon and dietitian have told you.

• Chew foods until they are the thickness of applesauce.

• Stop eating the moment you start to feel satisfied.

• Take 30 minutes to eat your meals.

• Drink 6 to 8 cups (48 to 64 ounces) of liquid each day. Page 9 of 12

• You may vomit (throw up) from time to time as chewable or liquid form. Then switch to whole tablets you move from liquids to solid foods. when your body is ready.

• Crush large pills and tablets for the first 1 or 2 Vitamin A months after surgery. Take 10,000 IU of the dry form so it will dissolve. • Try one new food at a time. Vitamin D • Eat three meals per day. Try to eat at the same times each day. Take at least a total of 3000 IU of vitamin D each day. You may take it with the calcium. If you vomit, stop drinking and eating until you feel better. Then, drink liquids before you try to eat solid Vitamin E foods. Take 400 IU of the dry form so it will dissolve. If you keep vomiting, call the nurse line as soon as possible or go to the emergency room. Calcium University of Minnesota Medical Center: Take 2000 to 2400 mg of calcium each day. Nurse line: 612-626-6666 After hours: Call the hospital operator at 612-273- Choose a brand that includes vitamin D. Calcium 3000 or 800-688-5252. Ask for the resident who is citrate is best. If you cannot find this, take calcium on call for your surgeon. carbonate instead.

Vitamin and mineral supplements • If you take calcium carbonate, take it with food.

You will need to take extra vitamins and minerals • Take no more than 500 to 600 mg of calcium at for the rest of your life. You can buy these vitamins one time. Your body can only take in this amount. and minerals at your local drug store. • Do not take your calcium within 2 hours of your If you have problems finding supplements or your multivitamin or iron supplement. body cannot handle them, call the nurse line (see last page). Vitamin B12 Take 1 tablet of vitamin B12 (1000 mcg) each day. Multi-vitamin with minerals Buy the kind that goes under your tongue. Your adult multi-vitamin with minerals should have OR . . . In one dose??: Take 1 shot (injection) of vitamin B12 • at least 18 mg of iron (1000 mcg) each month. • at least 400 mcg of folic acid • at least 2 mg of copper Vitamin K

• at least 1.5 mg of thiamin Take 300 IU of the dry form so it will dissolve. Take twice the adult dose each day (see the label for how many tablets equal one dose). Start with a Page 10 of 12

Iron Schedule for Vitamins and Minerals Take iron if you are a woman who gets her periods, or if your care team asks you to. • Twice the adult multivitamin with Choose one of the following: minerals • Vitron C or 325 mg ferrous sulfate ☐☐Take 1 tablet of Vitron C each day (includes Morning vitamin C to help you absorb the iron). with vitamin C • 1000 mcg B12 (taken under the OR . . . tongue) ☐☐Take both daily: Mid- • 500 to 600 mg calcium with • 1 tablet of ferrous sulfate (325 mg) and morning vitamin D • 1 tablet of vitamin C chewable (500 mg). • ADEK Afternoon Avoid drinking a lot of tea. Tea contains tannins that • 500 to 600 mg calcium with reduce the amount of iron your body can use. vitamin D • ADEK NOTE: Evening • 500 to 600 mg calcium with • You may buy supplements that contain vitamins vitamin D A, D, E, and K in one pill taken three times a day • ADEK (ADEK). Bedtime • 500 to 600 mg calcium with • Also, you may buy supplements that contain vitamin D multi-vitamins and the required levels of A, D, E, and K in one pill. You take it three times a day. Schedule for Multivitamins with ADEK

Ask your dietitian for details. • Multivitamin with high ADEK • Vitron C or 325 mg ferrous sulfate Morning with vitamin C • 1000 mcg B12 (taken under the tongue) • 500 to 600 mg calcium with Mid-morning vitamin D

• Multi-vitamin with high ADEK Afternoon • 500 to 600 mg calcium with vitamin D • Mulit-vitamin with high ADEK Evening • 500 to 600 mg calcium with vitamin D • 500 to 600 mg calcium with Bedtime vitamin D Page 11 of 12

Coping with problems Diarrhea (loose stools)

Nausea and vomiting (feel sick in your stom- • Limit high-sugar foods, greasy foods, milk and ach or throwing up) milk products, and foods that are very hot or cold. • Eat smaller meals. • Eat and drink more slowly. • Sip fluids between meals. • Chew your food more. • Eat more slowly. • If you feel sick after eating a new food, wait a few days before trying it again. You may have to go Heartburn back to liquids or pureed foods for a while. • Avoid soda pop and other carbonated (fizzy) Dehydration (too little water in the body) drinks.

This can happen when you don’t drink enough • Avoid very cold liquids. liquids. Or it may be due to throwing up or having diarrhea. • Do not use a straw, chew gum or suck on mints.

To prevent loss of fluids, drink at least 6 cups (48 • Limit gassy or greasy foods. ounces) of liquid each day. • Stay upright for 30 to 60 minutes after eating.

Pain in shoulder or upper chest • Avoid eating for at least two hours before going to This may occur when you eat too much, too fast, or bed. when you eat something that is hard to digest. If it Blockage of the stomach happens while eating, stop and wait. Try to eat again after the pain is gone. Signs of a blockage are throwing up, pain or feeling sick to your stomach. If these signs do not go away, Lactose intolerance call your doctor.

Symptoms may occur after you eat or drink milk • Chew your foods well. products. They include diarrhea, bloating and stomach pain. • Do not move to the next stage of your diet until your doctor, nurse or dietitian says it’s okay. • Take lactase enzyme tablets. Stretching of the stomach • Try lactose-free drinks such as soymilk, Lactaid or Dairy Ease milk. • Eat small servings of food.

Bloating • Follow your diet plan.

• Drink only 2 ounces of liquid at one time.

• Sip slowly. Page 12 of 12

Phone numbers

University of Minnesota Medical Center

Main clinic: 612-626-6666 Nurse line: (non-emergency questions): 612-626-4117 Hospital operator: 612-273-3000 or 800-688-5252 Dietitian: 612-273-9221 or 612-273-4991

After hours: Call the hospital operator and ask for the resident who is on call for your surgeon. Or call Unit 7B at 612-273-3072

Emergency room: 612-273-2700 TTY for hearing impaired: 612-273-2702

Fairview Nutrition and Weight Loss Web site: www.fairview.org/weightloss