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 Steps Toward A Healthier Future: A Guide for the Bariatric Surgery Program Group Health Cooperative / Department of General Surgery Updated Feb 2016 (DA‐1940 Rev. Date 2016032) Table of Contents
3. 4. 7. Medications & Vitamin Supplements Welcome Probiotics Overview Protein Supplements Contact Phone Numbers Yogurts Bellevue Group Health (Map & Driving Directions) 8. Post‐Op Concerns Overlake Hospital (Map & Driving Hydration / Dehydration Directions) Nausea / Vomiting Constipation Pre‐Op Checklist Dumping Syndrome Pre‐Op Mandatory Education Weight Loss Requirement 9. Follow‐Up Appointments Psychological Assessment 10. Keys to Success Requirement Food Journaling Nutrition Counseling Requirement Newsletter & Web Page Support Group Requirement Support Groups Metabolic & Bariatric Surgery 11. Exercise Pre‐Paring for Surgery Emotions Birth Control Sleep Apnea Smoking Hair Loss Sleep Apnea Excess Skin Time‐Off for Recovery 12. Resources You Find Helpful My Group Health Hotels 13. Poem 5. Pre‐Op Instructions 14. Glossary of Terms Day of Surgery 15. Document Your Measurements Hospital Stay 6. Nutrition Plan Pre‐Op Diet Post‐Op Phases 1 ‐ 4 3 4 We are pleased to welcome you into the Group Health Bariatric Surgery Program. Please be advised that your approval is for the program. You will need to have your bariatric benefit at the time of surgery, which will be verified once your surgery is scheduled. Please notify us if you have a change in your benefits. Do not be concerned about the expiration date on your letter. Your surgery does not need to be completed by that date. We would like to introduce you to the overall process of this care and the team of health care providers who will be working with you throughout your experience. You are an important part of the team and will be actively involved in your care as you participate in this program. Adequate preparation and planning before surgery and your active involvement after surgery will help you accomplish the best possible results. This notebook is your program information guide. It describes the steps leading up to surgery, what to expect during your hospital stay and recovery, and how to maintain long term benefits from the procedure. Please keep this notebook! You will find the answers to many of your questions, both before and after your surgery. We are committed to helping you throughout this life‐changing and sometimes challenging experience. Working together, we expect a difference in your long‐term health. Keep this worthy goal in mind to help cope with any frustrations you may encounter along the way. In order to continue to improve the care we provide, we ask for your feedback and suggestions. 5 Hello, My name is Julie Grimm. I am an RN CBN (nurse with special certification in bariatric surgery) and the Bariatric Surgery Program / Nurse Case Manager. My job as the Bariatric Surgery Program / Nurse Case Manager includes:  Introducing you to and providing education about this program.  Answering your questions as you progress through the program.  Coordinating your care before surgery, while following physician orders regarding your medical testing.  Providing support systems such as support groups and the newsletter.  Triaging post op phone calls in regards to problems, concerns or questions. As this program becomes busier, my greatest challenge is to reassure you that I am available to assist you in all of the above aspects. Although the medical testing and pre‐op work‐up process can take 2‐3 months to complete, my goal is to make sure you are ready and thoroughly prepared for your surgery. I know that you will be pleased with the care that our Bariatric Surgeons, Dr. Landers and Dr. Gupta, and our Bariatric PA’s, William Young, Kathy Weltzin, and Lynda Crescenzi and Medical Assistant Robin Graham will provide. I look forward to working with you. Sincerely, Julie Grimm, RN CBN Bariatric Case Manager 425‐502‐3454 6 Welcome to the Group Health Bariatric Surgery Program We enjoy this field of surgery as we get to cure more disease than any other field of Medicine or Surgery. With one operation, we achieve resolution or remission of type 2 Diabetes, hypertension, high cholesterol, sleep apnea, morbid obesity, and urinary incontinence (females) in greater than 90% of patients. For less than the average‐annual cost of insulin for a given patient, we induce a remission of the diabetes in 90% or more of patients (96% in the Group Health gastric bypass data base). The Four Pillars of any successful Bariatric Surgery Program are the Surgical, medical, Behavioral, and Nutritional components. The Group Health Bariatric Program is expanding to include pre‐operative and post‐operative help from each of these components. The Group Health Bariatric Program was started in 1994, by Dr. Steven Bock, and Bariatric Coordinator, Harriet Stambaugh. After 18 years of excellence in patient care, Dr. Bock moved from our program in 2012. Julie Grimm took over as the Bariatric Program and Nurse Case Manager, in 2006, and Dr. Jeffrey T. Landers joined Group Health in 2008, after completing Laparoscopic and Endoscopic Fellowships in Bariatric Surgery, at the Cleveland Clinic. Dr. Anirban Gupta joined Group Health in 2016, transitioning his practice from Ohio where he developed a MBSAQIP‐Accredited bariatric program from the ground up. He completed a Laparoscopic and Endoscopic Fellowship in Bariatric Surgery at Johns Hopkins in 2008 and completed his General Surgery training in University of Toronto in 2007. We look forward to continuing the Group Health tradition of Bariatric excellence, with you as our partners! Jeffrey T. Landers, MD, FACS Dr. Gupta Julie Grimm, RN CBN William Young, PA‐C Kathy Weltzin, PA‐C Lynda Crescenzi, PA‐C Robin Graham, CMA 7 Care Team Your care takes place in different settings and is coordinated by the Bariatric Surgery Program team, to make sure you have a successful and safe procedure. The team will provide you with information to make sure you are ready for surgery and assist with your recovery afterwards. Each team member has a special role and responsibility. Bellevue Group Health Bariatric Clinic – Our Bariatric Clinic is a part of the General Surgery Clinic Hours: 8:00am to 5:00pm Monday through Friday Phone: 425‐502‐3450 Toll Free: 1‐800‐995‐5658 Ext 3450 General Surgeon: A physician specializing in surgery. He or she performs surgery and is responsible for your care both while you are hospitalized and as an outpatient in the General Surgery Clinic. Bariatric Surgeon: A general surgeon with specialized training in bariatric surgery. Dr. Landers is a bariatric surgeon in the General Surgery Clinic. Bariatric Surgery Program Manager: A Registered Nurse (RN) who coordinates the care of patients in the Bariatric Surgery Program. (Julie Grimm, RN CBN) Clinic Nurse: A Registered Nurse (RN) working in the General Surgery Clinic with extensive experience caring for surgical patients. Bariatric Physician’s Assistant (PA): PA with special education and experience with bariatric surgery and bariatric follow up care. (William Young, Kathy Weltzin and Lynda Crescenzi) Medical Assistant (MA): Staff trained to assist physician with patient care. Assists with scheduling and takes vital signs. Not qualified to provide medical advice of any kind, but a very vital and knowledgeable participant in your bariatric care. (our MA in the Bariatric Clinic is: Robin Graham) Anesthesiologist: A physician with special training in anesthesia. Inpatient Nursing Staff: RN’s and LPN’s work together to provide nursing care to you while you are in the hospital. Nutritionist / Dietitian: Provide dietary evaluation, education and counseling. 8 Other Team Members: Bariatric Dietitian: Staff trained to support the skills required to lose weight and assist in maintaining long term weight loss. 425‐467‐3957 Consulting Nurse: A Registered Nurse (RN) available by telephone, after clinic hours to answer questions and provide advice for urgent and emergent issues. The nurse will contact the available physician as necessary. Phone: 1‐800‐297‐6877 Clinical Review Unit: Staff who determine eligibility and screen against established criteria by your health benefit plan for bariatric surgery coverage. Behavioral Health Services: Counselors and doctors who assess for and treat mental and emotional health. Phone: 1‐888‐287‐2680 9 10 Bellevue Medical Center 11511 N.E. 10th St. Bellevue, WA 98004 425‐502‐3000 Note: Traffic can be difficult at any time of day, coming from any direction. Please allow enough travel time. From Interstate 405 southbound 
Take Exit 13B for N.E. 8th Street East/West. Turn right onto westbound N.E. 8th Street. Turn right onto 112th Avenue N.E. Turn right onto N.E. 10th Street, driving over I‐405. Turn right into the medical center. From Interstate 405 northbound 
Take Exit 13A for N.E. 4th Street. Turn right onto N.E. 4th Street. Turn left onto 116th Avenue N.E. Turn left onto N.E. 10th Street. Turn left into the medical center. ********** Note: Parking fee runs from $2.00 ‐ $7.00 ********** 11 Overlake Bariatric Clinic Carrie Tollefson, RD CD (Dietitian) Amie Louwers, RD CD (Dietitian) Overlake Specialty Clinic 1231 116th AVE NE
Suite 515 Bellevue WA. 98004 (See map left) Medical Pavilion (above Starbucks) Park on level P1 in Pavilion garage. Take elevator to level floor 5. Suite 515
If you also have an appointment at Group Health, you can park at Group Health and walk to Overlake for your appointment with the dietitian. It’s about 1 block: From Group Health –FLOOR 1  From the elevators, walk past the lobby desk and follow the windows, past Urgent Care, continue to follow the path.  You will enter Overlake Emergency Room Lobby. Continue to walk all the way to the end (about 7‐10 min walk from Group Health elevators).  In the main lobby, you will see Stanza Café on your left. Continue straight.  Go out double sliding door and cross the street to ‘Starbuck’s.  Go to elevator behind ‘Starbuck’s’ (you are on P3)  Take elevator to FLOOR 1  Take RIGHT out of elevator, go to second set of elevators (on your left)  Go to FLOOR 5  Office is on your LEFT 12 Entering the Bariatric Surgery Program Medical research has shown that Bariatric Surgery is a safe and effective way to lose weight and improve health for a specific group of patients. The Group Health Bariatric Surgery Program is structured to help those people reach their health goals. To help you get started and to know what to expect, the steps of the programs are listed below. Primary Care patient identification: You and your primary care physician decide that you may benefit from this surgery. Your doctor submits a Bariatric Referral to the Bellevue Group Health Bariatric Surgery Department, for review. Medical record and coverage review by Clinical Review Unit: Your medical history and individual insurance coverage are reviewed based on the criteria established by your health plan. Welcome and Introduction to Bariatric Surgery Program: After being notified of your approval for entrance into the Bariatric Program, you will receive a packet of information, including this notebook. Bariatric Surgery Process: In the notebook you will find a medical history questionnaire and instructions on how to complete the required medical work‐up and other requirements. You will complete the paperwork (and mail in enclosed envelopes), complete studies, tests and appointments as directed (see checklist in section 2). Evaluation by other medical specialists as needed: Your provider may determine that you need to see additional medical specialists, such as cardiologist, consultative internal medicine, pulmonologist, sleep medicine or gastroenterologist. This further evaluation helps to make sure you are medically ready for surgery. Not everyone in the Bariatric Surgery Program will need all of these evaluations (your provider will instruct you). If required, completing them (and any follow up that is recommended) is necessary to move forward in the process. Pre‐Op Education: This is required to help you learn more about the process, procedures and to help you as you plan for your surgery and recovery. The surgeon, bariatric nurse, psychologist and the bariatric dietitian will all provide you with information that you will need to know and that will assist you to be successful in your weight loss journey, via a 1+ hours power point presentation. Please see Bariatric Surgery Pre‐Operative Education in section 2. 13 Preparing for Bariatric Surgery Once you receive your notebook, please read it through carefully. Failing to review all information may result in missing important information and delaying your progress. Please read through the checklist (section 2) carefully. All things checked on the checklist must be completed. Any follow up that is recommended as a result of consultations, such as the pulmonologist recommending that you have a sleep study; you will need to follow through with those recommendations. You will need to attend at least one support group prior to receiving a surgery date (see section 2 for more information). When all items on the checklist have been completed, it is your responsibility to notify the bariatric nurse (Julie Grimm 425‐502‐3454 or email). Once the above have been completed, a pre‐op appointment with the surgeon and dietitian will be scheduled. Once you have seen the surgeon, a surgery date will be assigned. Contacting the Bariatric Clinic: Calls to the bariatric nurse will typically go to voice mail. Calls are returned based on priority, with post op patients being called back first. You can be assured if you are calling prior to your surgery, you will receive a call back, but it may take a day or two. Please be patient! If you are calling after your surgery, your call will be returned within an hour or two of your voice mail. Post‐op patients can also call the General Surgery nurse at 425‐502‐3450 for assistance. MyGroupHealth email is an excellent way to communicate. If you do not have this option, please see section 4 for more information about it and how to sign up. 14 Pre‐Op Medical Work Up Checklist Please complete items with Red Check Mark: ________Complete and mail the Health History Questionnaire (envelope attached) ________ Psych‐Social Assessment (you will be called to schedule this assessment) ________Make an appointment with your primary care provider, who will order the pre‐op medical assessments required ________Complete all tests / studies / consults ordered (see attached for list) ________Attend at least one Group Health Bariatric Support Group meeting See section 2 for list of groups ________Complete the online education requirement (see next page) You will need to complete all of the ABOVE items by: ________ to remain active in case management. If that is not possible, please contact the bariatric nurse to discuss Once ALL of the ABOVE checked items have been completed:  Notify: Bariatric Nurse, by phone (425‐502‐3454 or email through MyGroupHealth (respond to previous email) You will receive a call from the bariatric clinic to schedule the pre‐op consult with the surgeon. If no appointments are available, you will be placed on a waitlist for a pre‐op consult and called as appointments become available. Once that date is scheduled, please call the dietitian (425‐467‐3957) and schedule the consult with her. ________Pre‐Op Consult with Surgeon (we will call you) ________Pre‐Op Consult with Dietitian (you will call them) ________Loss 5% of your Total Body Weight: ______lbs Start Weight:__________ Goal:___________ ________ Your doctor can refer you to Overlake Nutrition Counseling to assist you in losing ___________ to reach your goal listed below Start Weight: __________ Goal: ___________ See section 2 for more information of this requirement 15 Bariatric Surgery Pre‐Operative Education The pre‐op education is found at: Please log onto:‐patients/ Open the link for the Bariatric Surgery Education. This is a power point presentation with sections by the surgeon, bariatric nurse, dietitian and psychologist. It will take approximately 1+ hours to view in its entirety. Please watch the entire presentation! This presentation will provide valuable information on the surgeries, preparing for surgery, the hospital stay, going home, nutrition pre and post op, and psychological issues to consider. Pre‐Op Consults Every effort is made to schedule the pre‐op consult with the surgeon and dietitian on the same day. It is up to you to make the appointment with the dietitian once you have a pre‐op consult scheduled with one of the surgeons. Each appointment will be approximately one hour. Please arrive about 15‐30 minutes prior to your scheduled appointment time with the surgeon, to allow time for the pre‐op quiz prior to seeing the surgeon. The Medical Assistant will give you the quiz to complete while waiting to see the surgeon. The quiz is not meant to prevent you from being scheduled for surgery, but rather to ensure that you are done your research, read the notebook and viewed the online education. Being as prepared as possible increases the chances of a healthy recovery and successful weight loss journey. Please allow time for travel on the day of your appointments. We know it can be a long drive for many of you and traffic patterns vary throughout the day. If you are unable to make your scheduled appointment, please notify the bariatric clinic. It is possible that your appointment can be rescheduled in a timely manner, however just failing to come for your scheduled appointments may result in your appointments having to be pushed out a couple of months. We make every effort to fill cancellations, though cannot fill them on the day of, if someone just doesn’t show up. 16 5% Weight Loss Requirement Reason: The 5% weight loss requirement helps to make your surgery safer and more likely to be laparoscopic, as losing weight shrinks the liver. The liver lies over a portion of the stomach that the surgeon will be working on. The term fatty liver refers to fat accumulation in the liver. If the liver is too large and can’t safely be moved out of the way, your surgery may need to be converted to an open procedure, which certainly results in more post‐surgical pain and requires additional healing time. Losing just 5% of your total body weight will result in a decrease of fat in the liver. Making healthy eating and life style changes prior to surgery also shows acknowledgement that this is not a quick fix and will require that you make changes for sustained results and it shows compliance with the recommended changes prior to surgery. How to Make This Happen: There is no particular diet or plan outlined to accomplish the 5% weight loss. Reading through the diet guidelines in section 6 will help you to begin to make some changes in advance of surgery. Most often making these changes will result in weight loss. A good place to start might be downsizing meals, eliminating refined carbohydrates, such as bread, pasta, cookies, crackers and pastries. These are things that will be required after surgery. Making small changes, one at a time helps to develop new habits. This is a good time to begin to make those small changes, as they will help in reaching the 5% weight loss goal. Beginning to add exercise to your daily routine will also assist in meeting this goal. Just adding short walks to your daily routine, burns calories. Add additional exercise as tolerated. Every little bit will make help in establishing new habits and burning calories. You can also sign up with Weight Watchers or possibly try the Paleo Diet. What Does 5% Mean For You? Please see your checklist (section 2) for your 5% weight loss goal. This number is calculated using your weight at the time of your referral into the bariatric program. Other Weight Loss Requirements: Some patients will need to loss more than 5%. This number is calculated using your weight at the time of your referral into the bariatric program and our program and Overlake Hospital’s maximum weight limits and BMI’s. Patients who have a nutrition counseling benefit in insurance benefits, can be referred outside of Group Health, (for instance Overlake Nutrition Counseling in Bellevue. If you do not live in the Bellevue area, your doctor to refer you closer to home) for assistance in meeting the goal outlined for you. 17 Nutrition Counseling You will be seeing the Overlake Bariatric Clinic Dietitian. Please read carefully: The nutrition requirement is as follows:  Pre‐Op Appointment with the dietitian: o Pre‐Op Consult: 1‐hour one‐on‐one consultation the dietitian at her office  Please do not call their office to make this appointment until you have an appointment scheduled with Dr. Landers.  Post‐Op Appointments with the dietitian: o The 1st appointment: Telephonic appointment 2 weeks post‐op o The 2nd appointment: 1‐hour one on one with the dietitian at her office Every effort will be made to coordinate this appointment with the 2‐3 month follow up appointment with bariatric PA, to prevent having to make an addition trip to Bellevue. There may be times that this will not be possible due to conflicting clinic schedules between the bariatric PA and the dietitian Payment: The payment for the required nutrition counseling sessions is $500. o Payment will be at the time of the pre‐op consult appointment (cash or credit card only). o Should you, for whatever reason decide not to proceed with surgery, you will be refunded a prorated amount. No refunds will be made once the surgery has been completed. Please do not call Overlake Nutrition Services – this is not the correct department. Overlake Bariatric Clinic (dietitian): 425‐467‐3957 Call or email Julie Grimm, RN CNB with any questions that you may have about the nutrition requirement 18 Support Groups There are seven Group Health Bariatric Support Groups around the Puget Sound Area. Three of the groups are led by Group Health nurses and four are led by former patients who have been hand selected to lead a group due to their knowledge, experience and professionalism. The bariatric team over sees all 7 groups. These groups are made up entirely of Group Health Bariatric patients in varying phases of this life long journey. Some are just getting started and some are many years beyond their bariatric surgery. The patients who attend these groups are the ones who have ‘walked the walk’. They have experience, tips and ideas regarding foods, recipes, exercise and experience to share that may be very helpful. They can answer questions and provide support. It is required to attend at least one support group meeting prior to being scheduled for surgery. No pre‐registration is required to attend meetings. You are welcome to attend any one of the seven groups. Aside from bad weather, the groups meet very regularly and are very rarely canceled. In case of bad weather, please call the Bariatric Clinic (425‐502‐3454) or check the webpage (‐patients), where any cancellations will be posted. Attending monthly support group meetings will provide a continued source of motivation and support. Research shows that continued attendance increases the chance of long term weight loss success. Two hours a month – it’s worth the time and effort!! See the next page for a list of the seven groups.
19 Group Health Support Groups You DO NOT need to pre‐register for these groups – just show up Bellevue Medical Center 3rd Wednesday of the month, 6‐8 p.m. Room E101‐105 Contact: Julie Grimm 425‐502‐3454 Everett Medical Center 4th Wednesday of the month, 6‐8 p.m. Level 2, conference rooms C, D, E Contact: Andrea Wilcox [email protected] 360‐813‐2029 Federal Way Medical Center 1st Wednesday of the month, 6:30‐8 p.m. Conference room 2 Contact: Joyce Taute [email protected] 253‐922‐2426 Olympia Medical Center 2nd Wednesday of the month, 6:30‐8:30 p.m. 2nd floor conference room Contact: Charlotte Mackie [email protected] Seattle — Capitol Hill Campus 2nd Wednesday of the month, 6:15‐8:15 p.m. South Building, Room A91‐A92 Contact: Phil Hasenkamp [email protected] 206‐947‐1977 Silverdale Medical Center Contact: Theresa Adams 3rd Thursday of the month, 6‐7:30 p.m. 360‐710‐5673 Main entrance conference room [email protected] Tacoma Medical Center 4th Tuesday of the month, 6‐8 p.m. 1st floor, Rooms 2 and 3 Contact: Toni Franklin at 425‐251‐4088 [email protected] Groups do not cancel; they meet each month, unless the building is closed for an emergency situation or holiday. Find current months group dates and emergency closure information at:‐patients/ 20 Undergoing Bariatric Surgery What is Bariatric Surgery? There are several different surgical procedures which are classified as Bariatric Surgery. The three surgeries that are performed at Group Health are Gastric Bypass (Roux‐en‐Y) and Laparoscopic Adjustable Gastric Band (Lap Band) and Laparoscopic Sleeve Gastrectomy. One or more of these operations may not be covered depending upon your bariatric coverage. Roux‐en‐Y Gastric Bypass Surgery (RNY) The Gastric Bypass procedure has passed through several evolutions and modifications before it reached its present state but the operation has been around for more than 30 years and the long term results are well established. This operation bypasses about 97% of the stomach and creates a tiny pouch at the top of the stomach, about one ounce in size. The pouch is created by dividing a small portion of the upper stomach completely from the rest of the stomach, with a stapling/cutting device. The food passageway is re‐established by connecting the upper small intestine, or jejunum, to the small pouch with a 10 – 12mm (1/3”) anastomosis, or connection. In time, this one ounce pouch becomes more pliable and efficient, allowing one to eat larger, but still smaller quantities of food. Over time, usually one to two years, weight loss will stop. The Gastric Bypass Procedure is the most commonly performed bariatric procedure done in the United States. The surgery can be performed via open procedure or by a laparoscopic procedure approach but most procedures are done by the laparoscopic approach. If the surgery is done by an open procedure, the incision extends from the breast done to the navel. If the surgery is done by the laparoscopic procedure, there are 5‐6 small incisions. During the operation, the abdomen is filled with carbon dioxide air and a camera is inserted through one of the openings. The operation is done while watching a high definition picture on a monitor. Occasionally a laparoscopic surgery needs to be converted to an open procedure. The procedure appropriate for you will be determined by the surgeon and discussed with you. See the diagram for the illustration of the anatomy following Roux‐en‐Y Gastric Bypass Surgery. How is food digested after surgery? When food is swallowed it enters the small upper pouch of the stomach. This part of the stomach holds only about one ounce of liquid or 2‐3 small bites of food, at one time. From the upper pouch the food passes through a very small opening (about 1/3” diameter) into the upper small intestine or jejunum, where nutrients are absorbed. Before surgery, the stomach ground the food into digestible portions. The new small pouch stomach does not do this. For the first month after surgery, food must be pureed or blenderized. Thereafter, thoroughly chewing food before swallowing allows easy passage into the small intestine. The digestive enzymes produced by the lower stomach, pancreas, and the liver empty 40‐60 inches from the stomach pouch‐intestine connections. By making the connection close to the stomach, the majority of the small intestine absorbs very well (only about 1/5 of the small intestine does not have bile and pancreatic enzymes mixed immediately with the food). This helps to avoid the unpleasant side effect of malabsorption which can occur with other types of bariatric surgical procedures, such as the Distal Gastric Bypass or Duodenal Switch. 21 How does Gastric Bypass Surgery help you lose weight? This surgical procedure works by creating satiety or the feeling of being full and comfortably satisfied. When the stomach walls are stretched by food, a message is sent to the brain, giving a signal of appetite satisfaction. After gastric bypass surgery, a small meal in the pouch creates the same feeling as if you had filled the whole stomach with a very larger feast‐type meal. This surgery changes the way the appetite center in the brain works. Your brain tells you to eat smaller, healthier amounts of food. The small size of the pouch also prevents you from eating too much at any one time. One small bite beyond satisfaction of hunger will create a stuffed feeling; another small bite will cause nausea; any additional food will cause pain and vomiting. The duration of the feeling of satisfaction when eating small amounts depends not only on the amount of food in the stomach, but also the length of time that the stomach remains filled. If you drink liquids with meals, or within 60 minutes after eating, the thoroughly chewed food is washed through the pouch, causing rapid emptying, resulting in the sensation of hunger returning sooner, long before the next mealtime. The goal for successful weight loss is to fill the small pouch with foods that are nutritious, bulky in volume, and do not empty from the stomach pouch too rapidly. This kind of meal is not difficult to achieve and we will assist you in making these appropriate food choices. High calorie liquids, which readily pass through the small connection, scarred ring of the stomach outlet are absorbed in the bowel and cause weight loss to be slowed or even stopped. For this reason, high calorie liquids must be avoided. The gastric bypass has an effect on a hormone produced in the intestine called Ghrelin which controls appetite in the brain. After gastric bypass the amount of Ghrelin produced in the stomach and small intestine is greatly reduced and this results in a marked decrease in appetite. The third major effect, that occur after gastric bypass that helps in weight loss is a condition called dumping. In the normal stomach foods that have a high fat or sugar content are diluted and processed by the stomach. There is a valve at the end of the stomach that releases this processed food into the small intestine were digestion occurs. With gastric bypass this function of the stomach is bypassed so that if these foods are eaten in any significant amount if causes dumping. When foods that are high is sugar or fats like juice, milk shake, ice cream, cake go directly into the small intestine after gastric bypass, fluid is pulled into the intestine and patients feel weak, sweaty, have a rapid heart rate and can get diarrhea. These effects remind patients that these foods should not be eaten. The amount of dumping patient experience can be quite different, so the best option is to avoid these types of foods. What are the results of Roux‐en‐Y Gastric Bypass Surgery? Success of the surgery is measured by achieving improved health and not specifically upon amount of weight lost. Conditions such as diabetes, sleep apnea, hypertension, reflux and arthritis are expected to improve as weight is lost. This surgery, along with change in eating habits and exercise, has shown to be an effective method for losing and maintaining weight loss in the majority of patients. Gastric bypass has a dramatic, rapid effect on type II diabetes. In patients who have been diabetic for less than 10 years we often will have them off of their oral medications and/or insulin before they leave the hospital. Even with diabetes of greater than 10 years duration we will see dramatic reductions in the amounts of insulin that are needed for excellent diabetes control. 22 What weight loss should I expect? Results of the Group Health Bariatric Surgery Program shows an average of approximately 75% of excess body weight loss and approximately 38% of total body weight loss at 18–24 months after gastric bypass and maintenance of 67% excess weight loss at 5– 10 years after surgery. Rapid weight loss usually occurs in the first six months after surgery, with more gradual loss continuing for another 6 to 12 months. Weight loss plateaus should be expected. Weight regain after 2 years can occur. This can range from no weight gain to regaining all of the lost weight (this is rare). If appropriate lifelong habits are developed in the first 2 years after surgery weight regain can be minimal. If old bad habits return, some weight gain will occur. Working closely with your Bariatric Nutritionist after surgery and your bariatric team beyond the first year after surgery will help continue progress toward your goals. Remember, in addition to the surgery, your food and exercise habits are essential lifelong behavior changes necessary for successful weight loss and maintenance. This program gives you the tools to improve your health. We will encourage you to do so. 23 RNY Gastric Bypass 24 Laparoscopic Sleeve Gastrectomy (LSG) Laparoscopic sleeve gastrectomy was originally performed as a first‐stage bariatric operation for high risk patient who were to undergo a second stage gastric bypass or duodenal switch. Over the past 5‐6 years it has been shown to be an effective primary bariatric operation, but longer term results are not yet available. Using surgical staplers the operation permanently removes a significant portion of the upper stomach creating a long, tubular stomach along the lesser curve of the stomach. This portion of the stomach has a lesser ability to stretch than the portion of the stomach removed. Unlike the gastric bypass there is no rearrangement of the small intestine and food flows in the same direction as it did prior to the operation. How does LSG help you lose weight? The procedure has a number of effects that result in weight loss. With the removal of approximately 3/4 of the stomach, the sleeve gastrectomy causes restriction so patients are more quickly satisfied when they eat. Like gastric bypass, sleeve gastrectomy reduces the production of the intestinal hormone Ghrelin that decreases appetite. What are the results of LSG Surgery? The small stomach created after sleeve gastrectomy empties more quickly and may be responsible for improvements in diabetes after the surgery. Initial results have shown that the effect on diabetes is significant with effects that are close to what is seen with gastric bypass and superior to what is seen with the Lap Band. With significant weight loss, improvement in other co‐morbidities such as sleep apnea, hypertension and arthritis are seen as well. Reflux symptoms can worsen after LSG. What weight loss should I expect? Results from the published medical literature show that approximate excess body weight loss at 3 years is 66‐68% and at 6 years is 53%. The number of patient followed for 6 years is small and longer term results are not yet available at the time. As with gastric bypass: Remember, in addition to the surgery, your food and exercise habits are essential lifelong behavior changes necessary for successful weight loss and maintenance. This program gives you the tools to improve your health. We will encourage you to do so. 25 Laparoscopic Sleeve Gastrectomy 26 Duodenal Switch and Other Malabsorptive Procedures There are a group of bariatric operations that cause a malabsorption of proteins, fats and vitamins that contribute to a patients’ weight loss. Because of the severe nutritional problems that can occur with these operations they are done less frequently in the United States. Currently less than 5% of all bariatric operations done in the US are of these types. The operations include duodenal switch, biliopancreatic diversion, and distal gastric bypass. In the duodenal switch operation the stomach size is reduced as it is for the sleeve gastrectomy but to a lesser degree (remaining stomach is larger). In addition there is a change in the intestinal connections that causes malabsorption of the nutrients mentioned above. With the gastric bypass the digestive enzymes produced by the lower stomach, pancreas, and the liver empty 40‐60 inches from the stomach pouch‐intestine connections. By making the connection close to the stomach, the majority of the small intestine remains functional. In the duodenal switch the segment of intestine where food and enzymes mix is 100 cm or 25 inches long, this results in decreased absorption of fats and protein that help in weight loss but can also result in malnutrition. With the increased risks associated with these operations, we do not recommend or perform them at Group Health. Duodenal Switch 27 What are the risks of Bariatric Surgery? All surgical procedures have some risk. Medical complications such as diabetes, cardiac or pulmonary disease, which effect morbidly obese persons, can increase the risk of surgery. Pre‐operative evaluation is undertaken to reduce unnecessary risk. Being aware of the following risks allows you to make an informed decision about surgery. 
National statistics have shown a 0.5 to 4% death rate related to immediate post‐ operative complications following bariatric surgery. Mortality rates at Group Health has been less than 0.75%. 
Blood clots or Deep Vein Thrombosis (DVT) DVT’s can occur with any major surgery. Blood flow through the legs can be slowed and a clot may form. Pieces of the clot can move from the leg to the lungs and form an embolism. This can be life threatening. Obesity and abdominal surgery increase the risk of this complication. Preventing DVT and embolism after surgery is an important part of your recovery. Getting out of bed and walking, taking anticoagulation medications, and using leg compression devices while in bed are some of the treatments used to avoid this complication. Your surgeon will make a plan for you to reduce your individual risk of blood clots. 
Lung infections or pneumonia General anesthesia, pain following surgery, and obesity contribute to the risk of developing pneumonia. Use the incentive spirometer at least every 1 to 2 hours while awake. Getting out of bed and walking after surgery helps reduce the risk of this complication. Use pain medication, as needed, to help stay comfortable enough to do these activities frequently. Continue these suggestions even after you are discharged from the hospital. 
Heart problems Bariatric surgery can cause major stress to your heart. Confirming your heart’s good health before surgery and close monitoring during hospitalization helps to minimize this complication. 
Weakness in the abdominal wall or hernia With the open procedure, the incision extends from the bottom of the breastbone to the navel. Obesity and a long incision can lead to a weakening of the abdominal wall, which could allow a hernia to develop. This complication occurs in approximately 20 to 25% of bariatric patients who have an open procedure. This risk is reduced when the laparoscopic procedure is used. 
Bleeding Blood less can occur at the time of, or following surgery. Blood replacement or transfusion is not usually required. 
Gallstones Significant weight loss, as occurs after Roux‐en‐Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy surgery, can increase the risk of gallstone formation. 28 Complications that can occur strictly after Roux‐en‐
Y Gastric Bypass 
A leak at the site of the stomach‐intestine connection This usually occurs within the first days following surgery and requires further surgery to correct. This occurs in approximately 1 to 2% of all Roux‐en‐Y Gastric Bypass surgeries. Stricture This complication occurs when the connection between the new small upper pouch of the stomach and the jejunum becomes narrowed and food cannot pass effectively. An outpatient procedure called a balloon dilatation can be performed endoscopically to correct this problem. Strictures will typically occur about 4‐6 weeks after surgery. See illustration of the anatomy following Roux‐
en‐Y Gastric Bypass surgery. Marginal ulcers This is an ulcer that forms in the area of the gastric pouch and jejunum connection. The risk of this complication is low. It can be caused by use of anti‐
inflammatory medications such as ibuprofen (use of these medicines after surgery needs be avoided). Smoking will also result in the development of ulcers. Stomach staple line breakdown or fistula Continuously eating or drinking too much at a time can cause this complication and will create a new connection between the stomach pouch and the remainder of the stomach. This is a rare complication. Dumping syndrome Sweating, rapid heart rate, and a feeling of weakness, nausea, vomiting and/or diarrhea can occur if foods high in simple sugars or fat empty into the jejunum undiluted. This is very unpleasant and reinforces the negative results of inappropriate eating and drinking. 29 Other complications that can occur long term with bariatric procedures 
Vomiting Not chewing adequately, eating too much, or eating too quickly leads to this problem. Constipation Reduced food intake results in less waste products and firmer, smaller stools, which can be more difficult to pass. Eating fiber foods, drinking water, taking probiotics and activity help to avoid this problem. Any sugar‐free fiber supplements, such as Metamucil may be use (once you are drinking at least 64 oz. of fluids per day). Hair loss Consuming fewer calories in the first few months after surgery can also result in some hair loss. This is not usually a permanent condition and the hair grows back as calorie intake increase. Avoid chemical treatments of the hair during the first year following surgery. The use of Biotin, a B vitamin, can be useful. Intestinal obstruction A blockage can form with the new anatomy following this surgery. Frequent vomiting unexplained by over eating, is a symptom of this problem. Informed Consent The surgeon will review the above risks with you at your appointment before surgery. Ask questions about anything you do not understand. You will be asked to sign an informed consent stating that you clearly understand your treatment. Be sure to read the consent form before you sign it. Receiving Anesthesia 
Problems from anesthesia are rare. Your risks will be discussed with you during your interview with the anesthesia provider on the day of your surgery. Be sure you ask any questions and resolve any concerns you might have at that time. 
Your anesthesia provider watches you the entire time that you are in the operating room (OR). Your blood pressure, heart rate and rhythm (EKG), and oxygen saturation are carefully observed and monitored throughout the surgery. 30 Before Your Surgery Arrange for help after surgery 
Your hospital stay is expected to be 2 nights in the hospital. 90% of patients will go home on the afternoon or evening of day 2 after surgery. If your surgery is Monday, you would expect to go home on Wednesday afternoon or evening. 
Open Roux‐en‐Y, your hospital stay is expected to be 3‐4 nights in the hospital. 
On the day of discharge, you will need someone to drive you home. 
During the first 1 to 2 weeks you may need assistance with activities such as: 
o Transportation o Grocery shopping o Meal preparation o Care of your home o Care of your children and/or pets If you do not have someone who can provide this assistance, talk with the social worker from your primary care clinic. They may be able to recommend resources. Time‐Off Work for Recovery It is recommended that you take 2‐4 weeks off work for recovery, regardless of which procedure you are having. This allows for time to recovery from your surgery physically, adjust to new eating patterns, begin exercising and basically spend some time taking care of yourself. This is going to be a time of adjustment and it’s in your best interest to take the time to heal and recover without the stress of work to worry about. We are happy to complete FMLA forms, other time off request forms or write letters for time off and return to work requests; however it saves time and energy if we know what you are asking for in advance. Please complete the FMLA Prep‐Sheet and release of information, found in the back pocket of your notebook, and fax these along with your FMLA forms to 425‐502‐3589. If there are questions about time requests, please call or email the bariatric clinic, 425‐502‐3454. 31 Get ready for eating differently 
Remove inappropriate food types from your home and go shopping prior to your surgery, for foods to be used 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. 
Keep a record of the foods/fluids that you eat/drink each day. This will be expected following surgery, start this habit before surgery. See section 10 for food journaling recommendations. 
Get a set of measuring cups and spoons, a food or postal scale, smaller plates and utensils to assist in tracking food portions. 
Your diet will begin as clear liquids in the hospital, full liquids once you are home, soft/puree diet at about 2 weeks post op. You will need a blender or food processor to prepare the proper consistency. **** Important **** Many patients with morbid obesity have one or more eating disorders which, if not addressed appropriately can complicate their post‐operative safety and success. It is important to think about how you use food as a way of dealing with stress, anxiety, depression, boredom, or in any way as a coping mechanism. It is then very important that you identify and use other ways of coping, such as exercise or support groups. During the pre‐op psych‐social assessment, eating disorders or eating behaviors may be revealed and may require further intervention. It will be a requirement to follow through with any recommendations made. Loss weight prior to surgery 
Weight loss before surgery shrinks the liver which makes the surgery safer and lowers the chance of needing to convert to an open operation. It also gets you prepared to be an active participant in your weight loss success. Please see the weight loss requirement (see section 2). 32 Prepare Advance Directives 
If you are unable to make decisions, your doctor will talk with your family members or significant others or refer to written instructions you have prepared, to try to find out what treatment you would want or would be in your best interest. It is recommended that you complete your advance directives prior to any surgical procedure. A copy of the Consumer Guide to Advance Directives has been included with this booklet. 
Update any Advance Directives you may already have prepared. 
If you are unsure if you already have your Advance Directive documents on file, contact the Group Health Cooperative Registry at 206‐326‐3290. 
Your primary care clinic Social Worker can answer any questions about preparing Advance Directives. 
Completed advance directives can be taken to the business office of your primary care clinic to be scanned into your electronic medical record. NSAID Use  The use of aspirin (above a single daily preventative dose), ibuprofen, naproxen, or other Non‐Steroidal Anti‐Inflammatory Drugs (NSAID’s) will greatly increase your risk of serious complications after bariatric surgery.  If you currently take any of these products routinely, please talk with your primary doctor or prescribing doctor (if they are recommended by a doctor), about an alternative that you can take after your surgery. 33 Birth Control Prior to surgery 
If you are a woman of child bearing years, you will need to be on some form of reliable birth control before and after surgery. 
Birth control pills must be stopped at least 30 days prior to surgery and restarted for at least 30 days following surgery. These increase the risk of blood clot, which can be very serious. We want to do everything possible to avoid blood clots. 
If you are interested in the placement of an IUD, please see your OB/GYN to discuss prior to your surgery. After surgery 
Pregnancy is not recommended for at least 18‐24 months following bariatric surgery. 
If you were infertile or had trouble conceiving prior to surgery, this may change quickly following surgery, with even minimal weight loss. Smoking If you smoke, stop 
There is a nearly 100% ulcer‐formation rate in those smoking or with tobacco exposure after surgery. These ulcers can result in perforation, stricture, bleeding or, all of the above. 
Surgery will not be performed on anyone who currently smokes. You must be completely smoke free for at least 3 months prior to surgery. 
Quit for Life® is a Group Health program to help anyone trying to stop smoking. If this applies to you, please ask for more information on how to join the program. 
If you resume smoking after surgery, the chances of developing ulcers, bleeding and/or intestinal perforation increases dramatically. 34 Sleep Apnea What is obstructive sleep apnea? • Caused by upper airway collapse during sleep • While awake: muscles hold upper airway open • During sleep, airway muscles relax, resulting in airway narrowing • Mild narrowing => snoring • Moderate narrowing => reduced airflow (“hypopnea”) • Severe collapse => absent airflow (“apnea”) How does obstructive sleep apnea affect your health? • Consequences of sleep fragmentation – unrefreshing sleep – excessive daytime sleepiness lead to motor vehicle accidents • Cardiovascular consequences of OSAS – increased risk of hypertension – Probable increased risk of heart disease and stroke • Other consequences of OSAS – night time reflux, morning headaches, gout attacks, frequent urination, leg swelling, impotence Why it is important to treat obstructive sleep apnea? 1. Treatment of obstructive sleep apnea can improve overnight sleep quality, daytime alertness and overall functional status. It may improve blood pressure, cholesterol and blood sugar measurements and it may reduce the risk of heart problems. 2. Automatically adjusting positive airway pressure machines (APAP) stent open your airway to prevent the collapse allowing you to breathe normally. 3. Since anesthesia and pain medications sedate you, that relaxes your airway more so; this in turn can worsen your sleep apnea. So it is very important to bring your APAP/CPAP or BiPAP to the hospital to use post‐operatively. Group Health Outpatient Sleep Apnea Services contact number is 1‐800‐348‐6382 35 MyGroupHealth MyGroupHealth for Members is your personal Web Site that lets you: 
Refill Prescriptions 
Make Appointments and Cancel Appointments 
View Upcoming Appointments 
Review Lab / Radiology Results 
Securely e‐mail your doctor, PA and Nurse o You will not be able to initiate an email until you have been seen in the clinic by the bariatric surgeon. Prior to that time, you can ‘reply’ to Julie’s email to you. After your pre‐op appointment, you can email to the ‘office of’ Dr. Landers. 
View your Medical Records 
Check your Benefits 
Create your Health Profile If you don’t already have an account, here’s how to get started: 
Go to and click “Register now” 
Enter your Member ID # (the number on your membership card), your last name, and your birth date 
Click the submit button 
You will get a “Thank You” screen where you will get a temporary password. In a few days, you’ll receive a verification code in the mail. Once you receive it, just log on and enter code, then you’re ready to access the convenience of MyGroupHealth. The Secure Patient Messaging is a fabulous way to communicate without phone tag. You will receive a response within 1 working day. Note: This e‐mail is only checked during business hours (Mon‐Fri). For more urgent questions or concerns, please call our Bariatric Clinic (425‐502‐3454) or Consulting Nurse (1‐800‐297‐6877) if after‐hours. 36 Hotels If you live a distance away and want to stay in an area hotel, there are several to choose from that are very close, two that offer discounts to patients. Discounts Coast Hotel (Recommended) Less than a block from Group Health and Overlake Offers Shuttle 625 116th Ave NE Bellevue 425‐455‐9444 Red Lion About 4 blocks from Group Health and Overlake Offers a shuttle to and from Overlake 11311 Main Street Bellevue 425‐455‐5240 Other Hotels Courtyard 11010 NE 8th St Bellevue 425‐454‐5888 Silver Cloud 10621 NE 12th St Bellevue 425‐637‐7000 Bellevue Lodge 11011 NE 8th St Bellevue 866‐539‐0036 37 38 General Surgery ˗ at Overlake Hospital ˗ Instructions The Medical Assistant will review this page with you on the day of your pre‐op appointment. Date of Surgery: _________________________________ 
An Overlake Hospital Nurse will contact you, about one week prior to your surgery, to do a pre‐registration. 
Overlake Admitting/Check‐In: will contact you the day before your surgery to tell you your check in time. The following appointments are required within 30 days of surgery: __________ Pre‐Surgery Physical (schedule with your PCP) __________ Labs __________ EKG (if ordered by surgeon) __________ Other If your primary care provider is not located at a Group Health Clinic, please ask the medical assistant for a list of what you need, for you to take to your PCP at the time of you pre‐surgery physical. You will also need our fax number. Please bring a current list of medications to all appointments handout in your notebook 
Avoid Aspirin and Ibuprofen products for one week prior to surgery (Naproxen, Motrin, Aleve, Advil, Excedrin, Midol). Tylenol based products (Acetaminophen) are fine to take. 
Your surgeon will give you instructions for stopping and/or taking certain meds before surgery.  Follow a Full Liquid Diet the DAY BEFORE surgery 
See next page Do not eat or drink anything after midnight (including mints & gum) unless otherwise instructed. You need someone to drive you home, you will not be allowed to drive yourself home or use public transportation. 
Have someone stay with you for at least the first 24 hours after you return home. Your Post‐Op Appointment is scheduled for: ________________________ 39 FULL LIQUID DIET FOLLOW THIS DIET THE DAY BEFORE SURGERY Foods Yes Do Not Eat Soups Broth, Bouillon, Fat Free Consommé, or Strained Cream Soups Soups with vegetables, Noodles, Rice, Meat, or other chunks of food Beverages Protein Shakes (Low Sugar/Sugar Free), Water, Vitamin Water, Decaf Coffee, Tea (Hot or Cold) All Others Sweets & Deserts Sugar Free Jello, Sugar Free Popsicles All Others Milk & Dairy Milk (Nonfat, 1%, & 2%), All Others Fruits/Juices None Vegetables None Bread, Cereal, Grains None Meats, Chicken, Fish, Meat Substitutes, Tofu, Nuts None Oils, Butter, Margarine None 40 Preparing For Your Surgery It is very important that you follow these instructions. Ask – if you have any questions!!! 30 Days Prior To Surgery 
Pre‐Op history and physical within 30 days of your surgery date o If your pre‐op with the surgeon is more than 30 days prior to surgery, you will instructed to make an appointment with your primary care provider 
There are blood tests that need to be done within 30 days of surgery o These will be ordered for you and you will be instructed when to do them 
You may also need an updated EKG. If this applies to you, we will let you know STOP hormones (including birth control pills) 30 days prior to your surgery 2 Weeks Prior to Surgery 
Stop taking all herbal supplements o We know that some herbal supplements can increase bleeding risk or interfere with pain medications / anesthesia, but many have not been tested. 1 – 2 Weeks Prior to Surgery 
You will receive a call from Overlake Hospital for a pre‐registration 
If you do not receive this call within one week of surgery, you may call them at 425‐467‐3752 7 Days Prior to Surgery 
Stop taking Aspirin and other anti‐inflammatory medications (NSAID’s) o i.e. Ibuprofen, Advil, Motrin, Naproxen, Aleve Tylenol is fine to take 1 Day Prior to Surgery 
Start a full liquid diet (liquids only all day the day before surgery) o Anything that is liquid and does not have chunks (no alcohol) o See previous page for a list of full liquid diet suggestions Nothing to eat or drink after midnight or the morning of surgery Follow medication instructions that you have been given by your surgeon You will receive a call from Overlake Hospital with your check‐in time o Or you can call them any time after 9:00am 425‐467‐3752 o If your surgery is on Monday you will receive this call on Friday (this also applies if your surgery is Tuesday and Monday is a holiday). 41 The Day of Surgery 
DO NOT eat or drink anything – other than medications you have been instructed to take, with just a small sip of water. 
Shower or bath the night before or the morning of surgery o Bacteria on your skin can cause infection. Thoroughly wash between skin folds o Do not apply lotion, creams, powders or oils 
Do not wear make‐up, face creams or hair products 
Remove all jewelry (including wedding rings and body piercings) 
Wear loose fitting clothes 
Take medications as directed by your surgeon o Make sure that you know which medications to take and not to take o Taking a medication that you shouldn’t have could get your surgery canceled Do not take vitamins, supplements or non‐prescription medications 
Do not bring medications to the hospital 
Do bring inhalers, eye drops and nasal sprays, if you use these 
Bring your APAP, CPAP or BiPAP machine, is you use one o This is a must!! 
In you have a pacemaker, bring the ID card 
Bring your Group Health card 
Do not bring large sums of money or valuables 
Bring your advance directives, if they are not in your electronic medical record 
Arrive at the given time and place (Overlake will provide this information) 
Report to Overlake Hospital at the check‐in time that you have been given. o Your surgery date may or may not show up on My Group Health as an appointment. Do not go by the time that you will see in My Group Health for the day of surgery. The correct check‐in time is the time that you are given by Overlake Hospital. o It is very important that you show up by the given time. 
Overlake Hospital will tell you where to park and where to report on the morning of surgery. 
You must have a driver arranged to take you home on discharge o You will not be released on your own or to public transportation 42 Arriving at Overlake Hospital You have used the information in this guide to prepare for your surgery. The following information is focused on the next phase of your care; your actual operation and the first days of your recovery. Learning what to expect from your health care team and what you can do as you work with them can give you:  Confidence  A feeling of control as you recover  Will help you achieve a successful outcome The day of surgery is a busy one, filled with many new places and activities. The following information will help you know what to do and what to expect on this important day.  Refer to the map and driving directions to Overlake Hospital (just north of the Bellevue Group Health facility) – see section 1 for map.  Traffic can be difficult at any time of day, coming from any direction. Please allow enough travel time. Overlake Hospital Admission 
Answer questions and complete the hospital admission paperwork. Be directed to the pre‐operative area. In the Peri‐Operative Area you will  Confirm information from your preoperative paperwork  Have your vital signs taken and recorded  Have your weight recorded  Have your oxygen saturation measured by a pulse oximeter  Have an Intravenous line (IV) started  Receive an anticoagulation medication  Given an opportunity to ask any other questions with a nurse or your surgeon  Be encouraged to try to relax and feel comfortable  Meet with the Anesthesiologist Just before you go to the operating room you will  Empty your bladder  Take off items such as underwear, any prosthetics, hairpin, and any metal jewelry including rings. Hands can swell during surgery making it necessary to cut rings off. Jewelry should be given to family or friends for safekeeping  Have visitors wait in the Surgical Waiting Area. The surgeon will speak with your family in this area, after the procedure, while you are recovering in the Post Anesthesia Care Unit (PACU)  Go by stretcher to an area outside the Operating Room, known as the Holding Area 43 Immediately before surgery in the Holding Area you will 
Confirm your consent for surgery May receive antibiotic medication through your IV During surgery in the Operating Room (OR) you will 
Be placed on the operating bed and secured with safety straps similar to seat belts Have a SCD’s placed on your legs. These inflate and deflate simulating the act of walking and stimulate the circulation of the foot and leg to help prevent blood clots from forming. Never be left alone. The surgeon, anesthesia provider (Anesthesiologist or CRNA), and other surgical assistants will be with you. They will be wearing surgical clothes, including hats and masks and you may not be able to recognize them immediately After surgery in the Post Anesthesia Care Unit (PACU) 
A nurse will take your vital signs frequently You may: o Hear a lot of noise and activity o Have an altered feeling of passage of time o Feel as if it takes a lot of energy for you to talk o Not have any visitors You may have: o A foley catheter in your bladder to drain urine. If you do have a foley catheter, it will be removed the day after your surgery. You will not need to urinate while the catheter is in place. This does not usually apply for the Lap Band patients. o A small plastic tube (nasal cannula) with oxygen flowing into your nose. This will be used through the first night after surgery. A pulse oximeter will be attached to your finger or toe to measure the amount of oxygen circulating in your blood. o A dressing(s) covering your incision(s), which have been closed by staples. o Receive pain medicine. See Pain Control for more information about pain relief options. o Be transferred to your hospital room after your anesthesia has begun to wear off and your vital signs are stable. 44 In your hospital room after your surgery you will 
If you have had Roux‐en‐Y Gastric Bypass o Have no food or drink by mouth. You will start to sip small amounts of water usually the day after surgery, following a radiology study to ensure that there are no leaks present. 
If you have had Vertical Sleeve Gastrectomy 
o You will start to sip small amounts of water. Have the head of your bed raised 30‐45 degrees at all times, to increase the amount of oxygen in your blood and to prevent reflux 
Have your vital signs taken and recorded frequently 
Be weighed daily 
Have blood tests, as needed 
Continue to receive oxygen, as needed 
Use an incentive spirometer to take deep breaths to help reduce your risk of pneumonia, as directed by your nurse 
Receive pain medication, as needed to keep you comfortable. Refer to the Pain section, for more information about pain control 
Receive medications by IV to prevent infection, nausea, and excess stomach acid 
Continue to use the SCD’s to help prevent blood clots from forming. The device is worn continuously while in bed, during your hospital stay. Do not remove these yourself. Notify the nursing staff, who will assist you when you get out of bed 
Be encouraged to get up and walk, as able on the day of surgery and at least 3‐6 times each day thereafter 
You will start to take small amounts of water, and remain on clear lquids while in the hospital. 
Your IV will be disconnected from the tubing and capped with a saline lock, as you tolerate your pureed/liquid diet. Refer to the nutrition, for more information on diet and recovery 45 Pain Some level of pain is to be expected 
Postoperative pain is to be expected following a surgical procedure With your help, your pain is managed to keep you comfortable If your pain is not relieved, it is important to tell the nurse or doctor Knowing what to expect and what to do about it, helps you prepare for the pain you experience How you respond to pain is unique to you. You are the only one who really knows how it feels. Your emotions also determine your feeling of pain The pain you experience will diminish as you continue to heal Pain control assists your recovery by 
Providing comfort Improves your ability to be active which helps to prevent complications such as blood clots and pneumonia You will play an important role in achieving good pain control. The following suggestions will assist your health care team as they care for you and your pain  Request pain medicine when you begin to hurt 
Rate or measure your pain using the scale below. This helps to describe what you feel when talking about your pain with your nurse or doctor No pain Mild Pain Moderate Pain Severe Pain Most Severe I‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐I‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐I 0 1 2 3 4 5 6 7 8 9 10 
Ask what to expect after taking pain medication Tell your nurse or doctor if the pain does not improve after taking pain medication Talk with your nurse or doctor about concerns you may have about taking pain medications 46 Types of Pain Control Patient Controlled Analgesia (PCA): 
You control your pain medication through your Intravenous Line (IV). A pump connected to your IV gives you a prescribed dose of pain medication. You will be taught how to use the pump by the nursing staff Intravenous (IV) Pain Medication: 
The nurse gives a prescribed dose of pain medication through your IV line Pain Liquids or Pills: 
The nurse gives a prescribed dose of pain medication in liquid or pill form. You can expect your pain to be managed by liquid or pills taken by mouth when you start taking pureed/liquid diet. It takes about 30‐40 minutes for the oral medication to start to work. As with all other analgesics, planning when to take your medication allows you to achieve maximum comfort. Pills should be no larger than the size of an aspirin or cut in half, if necessary. You will be sent home with narcotic pain medication. Pain Management: 
It’s important to remember that everyone experiences pain differently. Please let your surgical team or nurse know if you are experiencing pain, despite pain medication. This applies to when you are home after surgery as well. Some patients use no pain medication at all once they are home; others need to request a refill of their pain medication. Remember – you are an individual with individual needs. Once home, call the bariatric clinic with any questions. 47 Blood Clots 
After any major surgery there is a chance of developing a blood clot 
A blood clot can happen when the blood flow through the legs is slowed as happens after surgery, when you remain in bed for prolonged periods, or when you sit for long trips in cars or airplanes 
Most blood clot forms in the leg, however they may occur in any other part of the body. A blood clot that develops in, or moves to the lungs is called an embolism. This can be life threatening Blood Clot Prevention The methods used to prevent blood clots for Bariatric Surgery are: 
Fragmin, an anticoagulation medication, given by injection when first admitted to the hospital and once a day until discharge form the hospital 
SCD device is place on both legs. These inflate and deflate, stimulating the walking motion to encourage circulation of the feet and legs to help prevent a clot from forming. SCD’s are worn continuously while you are in bed. Do not remove them yourself. Notify the nursing staff if you need to get out of bed 
Ambulation, getting out of bed and walking at least three times a day, encourages circulation and prevents blood from pooling in the legs 48 Leaving the Hospital 
Patients will leave the hospital typically on the 2nd day after your surgery. On a rare occasion a longer stay may be necessary You will need someone to drive you home from the hospital Before you leave the hospital 
The Surgeon will: o Make a plan for your medical needs, providing information about your incision, diet limitations, medications, activity restrictions, follow‐up appointments and what to watch for. You will receive written discharge instructions in regards to medications and follow up 
The Nurse will: o Review the instructions that your surgeon has given o You are given a written copy of all these instructions 
The Pharmacist will: o Review your medications and make sure there are no drug interactions 
You will: o Make sure your questions have been answered o Know what your discharge instructions are o Know any medication changes that have been made o Know when your post op appointment is scheduled for o Have you driver available at the time of discharge 49 50 NUTRITION PLAN The nutrition plan is one of the most important parts of this journey. Specific instructions are for your safety and help to: • Reduce the risk of major complications. • Make the operation safer. • Reduce the risk of dehydration, leaks, infection, the need for readmission to the hospital or the need for re‐operation. Please make sure to read this part carefully and follow these instructions. You will be reviewing these instructions during your visit with our dietitian. Please be sure to bring this binder with you during your visit. There are two parts to the weight loss surgery diet plan: • The first is the liquid diet right BEFORE surgery. • The second is the diet AFTER surgery which takes you slowly from liquids to solid food over about four to five weeks 51 SHOULD I PURCHASE ANYTHING FOR AFTER THE SURGERY?
Bullet blender Small dishes and utensils (child‐sized) Ice cube trays Crock pot Measuring cups, measuring spoons and a food scale  These items are necessary to determine the exact portion sizes of the food you eat and drink. Food diary  This will help the dietitian better analyze your diet. Use a small tablet or journal to write down when you ate, what you ate and the amount consumed  You may also consider a Mobile App such as MyFitnessPal or LoseIt to record your intake High Protein, low sugar drinks. Recommended drinks will consist of the following  150‐200 calories, 20 grams of protein or more, less than 5 grams of sugar per 8 oz serving. Try a variety—be aware that your taste might change after surgery. See examples on Post‐op Stage 2 Diet page. A few bottles of water or sugar‐free, non‐carbonated, non‐caffeinated beverages  Examples include: Sugar‐Free Vitamin Water (not lemonade flavor), Fruit2O, Diet Snapple—non‐caffeinated, True Lemon or True Lime. Try to avoid Nutrasweet products, try to use more Stevia/Truvia products. Vitamins/Minerals Adult chewable MVI (no gummy)
Vitamin B12 Sublingual Calcium Citrate with Vitamin D
Iron Chewable Gastric Bypass
1 dose daily
500 micrograms daily
600mg twice daily
Ask your surgeon
Sleeve Gastrectomy
1 dose daily X 600mg twice daily
X **Please see vitamin/mineral section of GH binder for further information. 52 PRE‐OPERATIVE DIET Two weeks before your surgery date, you will begin your pre‐op diet. Each day include: 1. 3 high protein drinks. 2. 1 low calorie frozen meal, such as Weight Watcher’s or Lean Cuisine (~250‐300 calories/meal). Your dietitian can help you if you need other options. 3. 1 cup of non‐starchy raw or steamed vegetables (avoid potatoes, corn and peas). 4. Fluids will need to be non‐caloric, non‐carbonated, non‐caffeinated. If you have a BMI greater than 50, you will need to follow this diet for 4 weeks prior to your surgery. Examples of NON‐STARCHY VEGGIES: Artichoke Green Beans Broccoli Cabbage Carrots Cucumber Water Chestnuts Heart of Palm Mushrooms Pea Pods Radishes Spinach Tomato Sauce Greens Asparagus Beets Brussel Sprouts Cauliflower Celery Eggplant Jicama Onions Peppers Snap Peas Tomato Zucchini MY PRE‐OPERATIVE DIET BEGINS ON: _______________________________ The pre‐operative diet is designed to: •
Shrink the liver and make the procedure easier for your surgeon. The liver sits on top of your stomach. When you gain weight, the liver gets larger. The pre‐operative weight loss diet helps to shrink the liver and gives the surgeon greater visibility and more space to work in. Transition to the post‐op phase more easily. Some individuals feel they need to “detox” from their current eating habits. By following the pre‐operative liquid diet, you will not need to focus constantly on food and eating as you will have a specific meal plan. You can start to focus on positive behaviors related to eating and using other coping methods. Prevent the “last meal syndrome” and weight gain. Most people think that having weight loss surgery is the end of eating as they know it. Don’t worry, food won’t go away forever, you will just eat differently. Your eating will change dramatically and you will likely prefer foods that are healthier as you are losing weight. You will focus on quality rather than quantity and you may still have some of the same foods but in different portions and different preparation methods. 53 DIET PROGRESSION AFTER SURGERY Weight loss surgery is only part of the treatment. The diet you follow after surgery and for the rest of your life will affect your ability to control your weight. The weight loss surgery diet is different than any other diet you may have followed in the past. 
It moves forward through a series of stages You will eat smaller portions sizes than you may be used to You must eat on a regular schedule If you overeat, you may become sick to your stomach and/or vomit. After the surgery, many people feel full after eating small portions of food. You will learn to stop eating sooner over time Your dietitian will design a meal plan for you that has enough protein and calories to maintain a healthy weight. You may find other diet progressions on the Internet or from others who have had surgery. Please remember that everyone is different and your dietitian has recommended the diet that is most fitting for you. 54 NEW EATING HABITS Learning new eating habits is one of the most important parts of successful weight loss surgery. Your dietitian will review your diet, weight history and exercise habits with you. She will show you how to keep a food diary to identify problems. Together, you will develop a plan for successful weight loss surgery. Weight loss surgery helps control calories by making it hard for you to eat large portions of food at one time. One can still gain weight by eating and/or drinking high‐calorie foods throughout the day. Try some of these eating tips to stay on track:  Don’t nibble. Constant snacking on high calorie foods and drinks can make you gain weight. Do not take more than 20 minutes/meal.  Be aware of why you are eating. Eating when you are bored, depressed, anxious or unhappy can result in weight gain. Talk to your dietitian about things you can do instead of eating. Some people find it helps to talk to a therapist about emotional dependence on food.  Keep a positive outlook. Permanent weight loss requires a change in how you look at food. Stay positive about making healthy food choices before, during and after your surgery.  Plan for special occasions. Holidays, vacations and social events can be tough when you are trying to lose weight. Your dietitian can help you through these times by putting a plan in place.  Stay active. Exercise burns calories. It can also help control hunger and relieve stress. Weight loss surgery patients who exercise regularly are most successful at weight control. Goals to work towards: >150 minutes of cardio/week and 2‐3 times/week strength training. 55 TIPS FOR SUCCESSFUL WEIGHT LOSS Try some of these ideas to help boost your long term success after weight loss surgery. Make food less visible in your home •
Store all food out of sight. Try to keep food off of the counters Keep tempting food out of the house When serving meals, keep pots or serving platters on the stove – not on the table Store leftovers immediately after meals or immediately throw them in the trash Change your food shopping habits •
Avoid grocery shopping on an empty stomach Make a shopping list and stick to it Shop the supermarket “walls”. Avoid temptation by avoiding the aisles. Most whole foods are found along the perimeter of the store Buy only the items that are necessary for you and your family Avoid buying food items for other people that you may eat Slow down •
Eating slowly and mindfully is very important after you have surgery. If you eat too quickly, you may vomit. Start to become aware of eating patterns before surgery and modify the pace of eating. Try some of these tips to help slow down:  When eating a meal, start with protein first and then vegetables.  Stop eating after 20 minutes. Do not try to “finish” a meal.  Take small bites and chew food to a liquid texture before swallowing, 20‐30 chews per bite.  Savor each bite. Pay attention to flavors, textures and consistency.  Set your utensils down in between bites.  Make a sign that says “EAT SLOWLY” to remind you to do so. Avoid drinking while eating and wait 60 minutes after your meal before you have any liquids. •
This may wash food through too quickly and take away the feeling of being full. This can then lead to overeating. For others, drinking may fill them up and prevent them from getting enough protein or cause pain and vomiting Choose sugar‐free, non‐carbonated (flat), decaf beverages Portions are important •
Carefully weigh and measure your food before eating. Start this before surgery to get used to what a healthy portion looks like Put all extra food away before eating Use small dishes, glasses and child‐size utensils. This will make your portions look bigger Cook just enough Practice leaving something on your plate even before you have surgery Make eating an isolated activity •
Choose a spot at home just for eating. The best bets are the dining room or kitchen table Make a rule to sit whenever you put something in your mouth 56 FAQ Frequently Asked Questions How will I know when I am full? As you try new foods after surgery, you may have trouble knowing when you are comfortably full. Nausea may be your first indication of fullness. Don’t’ let this alarm you. It will take time for your body to adjust to the stomach’s smaller size and return to a normal “full” feeling. You may feel pressure in the center of your stomach or pain in the shoulder area or upper chest when you are full. Initially you may only be able to tolerate 2‐3 teaspoons of food at one time. What will I eat when I go to a restaurant? Restaurant eating will be a very different experience for you after the surgery. Ask the server to prepare your food in a low‐fat manner. Be prepared to bring much of your meal home in a “doggie bag”. Try some of these dining out tips: 
Look online to preview the menu. Don’t be afraid to ask for special orders. Try ordering 1 dinner and splitting it with someone else. Try ordering 1‐2 appetizers instead of a full meal. Ask that your food be broiled or baked with no added butter or fat. Ask that bread and rolls be removed from the table. Concentrate on talking and listening to conversation. Caffeine: You can add back after 2 months post‐op. Try to keep to 1 cup per day. No alcohol for the first year, then only in very small amounts. Remember, the children’s menu is not always the answer for smaller portions. Children’s menu foods are often laden with fat calories How can I have fun at parties or weddings if I can’t eat a lot?  Try to focus on the social aspect of the event. Position yourself away from the food table and catch up with friends or get on the dance floor. Scan the buffet in advance and make a plan as to what you will eat. If it is a served meal, call the facility ahead of time and ask what they will be serving. You may allow yourself 1 or 2 healthy appetizers and a smaller portion of the meal. Your dietitian will provide you with tips to make parties and events more enjoyable and healthful. If I get upset and want to eat, what will I do?  Managing stress is important to your overall health and well‐ being. Try different ways to handle your stress by talking with someone or through exercise, reading or other activities. You may consider talking with a mental health professional if you feel you need additional assistance in dealing with stress. I have heard I might get “dumping” syndrome. What is this?  Gastric bypass and sleeve patients can experience cramping, sweating, pounding heart, feeling lightheaded, feel the need to lie down, or even pass out. This is part of a condition called “dumping” which can happen when food empties too quickly from your stomach pouch into your small intestine. The most common cause of dumping is excessive intake of foods and fluids containing a high amount of sugars. Dumping can also be caused by drinking any liquid too soon after a meal. 57 DIET PROGRESSION AFTER SURGERY STAGE 1
Bariatric Clear Liquid Diet (In Hospital)
You will begin on your bariatric clear liquid diet the day after surgery while still in hospital. This diet is usually limited to 1‐2 days. You will begin with clear liquids such as water, broth, sugar‐
free jello and sugar‐free, decaf beverages. NO STRAWS. You will be instructed to sip slowly, 1oz every 15 minutes as tolerated 58 STAGE 2 Bariatric Full Liquid Diet
You will begin your bariatric full liquid diet upon discharge home. Duration: 14 days. You will be instructed to sip protein shakes, pureed soups, yogurt, and non‐carbonated, decaffeinated drinks and zero‐calorie liquids every 1‐2 hours. Stop if feeling full or nauseated. Alternate pureed soups, yogurt and protein shakes for variety. Fluid goal: 56 oz (7 cups)/day Protein goal: 30‐40 grams/day. Calorie goal: Focus on getting your fluid and protein. You will be gradually adding calories and by the end of the 14 days, you will be getting ~300‐400 calories/day. Broth or Pureed‐broth based soups (no creamed soups and no chunks): Such as Healthy Choice or Healthy Request Lentil, Chicken Noodle or Tomato, or Amy’s Low‐Fat Split Pea, Lentil, Black Bean or Butternut Squash. Add Beneprotein (unflavored protein powder) for extra protein (, or Overlake’s pharmacy). Protein Drinks Milk‐Based, High‐Protein, Low‐Sugar Beverages • Premier Protein Shake (Costco, Amazon) • Orgain Organic Protein • Carnation Instant Breakfast – No Sugar Added (blue box) • Low Carb Diet Slim Fast • Atkins Advantage Shake (Walgreens, Walmart, GNC) Lactose‐Free, High‐Protein, Low‐Sugar Beverages: • Premier Protein Shake (Costco, Amazon) • Syntrax Nectar (Vitamin Shoppe, Amazon) • Lactaid (drops, chewable tablets or milk) • Unjury ( • Optisource ( • Isopure (Vitamin Shoppe) • Vega One (PCC, Whole Foods)—vegetarian/stevia based • Glucerna, Hunger Smart (Target, Walgreens) Yogurt: No chunks, No added sugar, No added fruit: Non‐fat or low‐fat plain, sugar‐free greek Fage Yogurt (add flavor with SF jello or Crystal Light powder). Or Carbmaster Vanilla or Dannon Light and Fit Vanilla. 59 STAGE 2: Tips and important information
Vitamins: •
Bypass and Sleeve: Multivitamin once daily, calcium citrate 2‐3 times per day, B12 once a day. [No gummy vitamins] Getting all your liquids: Sip all liquids slowly, sip 2 oz every 15 minutes to stay on track. •
Avoid gulping; it introduces air into your system and may cause gas pains. Do not force yourself to finish fluids if you feel full It is VERY important to stay hydrated; sip fluids throughout the day. Keep an eye on your urine, if you are well hydrated, it should be light yellow • Avoid drinking too fast. NO STRAWS. Protein drinks: •
Some protein drinks contain aspartame sweetener or Sucralose. Some people cannot tolerate these sweeteners • Plan ahead and have the protein drinks ready to drink • Use a thermos or chill your glasses in the freezer to keep your protein drinks cool while you are drinking them • If you are lactose intolerant, try Lactaid drops (available at your pharmacy), Lactaid milk or lactose‐free protein drinks Your food diary: Write down what you drink in your food diary. STAGE 2: SAMPLE MEAL PLAN TIME 8 am 9 am 10 am 11 am 12 pm 1 pm 2 pm 3 pm 4 pm 6 pm 8 pm LIQUID
Protein drink
SF Fage Yogurt flavored with SF jello
Pureed bean soup with Beneprotein
Protein drink
Protein drink
60 AMOUNT Sips to 4 oz
sips Bites to 4 oz
sips Sips to 4 oz
sips sips Sips to 4 oz
sips Sips to 4 oz
sips 61 STAGE 3
Diced Protein and Soft Foods You will begin this diet 14 days after your discharge from the hospital. Duration: • FOR GASTRIC BYPASS AND SLEEVE GASTRECTOMY: Three weeks (21 days) Fluid goal: 56 oz (7 cups)/day Protein goal: 60‐70 grams/day. Calories: You will probably be eating about 300‐400 calories per day when you begin Stage 3. By the end of the next 3 weeks, you will probably be eating about 600‐700 calories per day. At first, just take 2‐3 bites. Focus on protein sources. Stop if feel full or if you experience any nausea or vomiting. Protein: Choose 4 servings (start with 2‐3 bites) • Chicken or turkey, diced or ground (dark meat) • Fish (canned tuna, sole, haddock, halibut, salmon) • Cheese or soy cheese (<3 grams of fat per oz) • Eggs, egg whites or egg beaters (soft cooked, scrambled or poached) • Deli meat (no roast beef) • Cottage cheese, non‐fat or low‐ fat, small curd or Ricotta Cheese, non‐fat or low‐fat • Tofu Dairy: Choose 1 serving (start with 1‐3 sips or bites) • Smooth, sugar‐free, non‐fat yogurt or plain, sugar‐free, non‐fat Greek yogurt (add pureed, no added sugar fruit, Stevia to sweeten). Look at Stage 2 for good options. • Fat‐free or 1% milk • Sugar‐free pudding • Sugar‐free hot chocolate Fruits/Vegetables/Starch: Choose 3 servings (start with 1‐3 bites) • Applesauce, mashed pears or mashed banana (no added sugar) • Sweet potatoes, mashed or Butternut squash, mashed. • Bean or lentil soup, low‐fat, pureed • Cream of wheat or farina • Refried beans (NO FAT ADDED) • Hummus Fat: Choose 1 serving • 1 tsp oil(prefer olive), butter, or margarine (tub based) • 1 tbsp (3 tsp) light margarine (tub), light salad dressing, fat‐free gravy or light mayonnaise • 2 tbsp mashed avocado 62 STAGE 3: Tips and important information
Vitamins: •
Bypass and Sleeve: Multivitamin once a day, B12 once a daily, calcium citrate 2‐3 times a day. Getting your liquids: •
It is VERY important to stay hydrated; sip fluids throughout the day. Keep an eye on your urine; it should be a light yellow. • AVOID HIGH CALORIE BEVERAGES ‐ Like juice, soda and sweetened beverages. • Do not force yourself to finish fluids if you feel full. • Do NOT drink while eating. Wait 60 minutes after eating before drinking. Protein: •
Your body must get the protein it needs from your diet. It is important for you to eat the recommended dietary protein. The diced protein and soft foods stage gradually re‐introduces solid food to your system. You may want to consider having one protein shake per day in the beginning of stage 3 to help increase protein intake. Increase the protein content of your fruits/vegetables by adding protein powder or dry skim milk powder. Whey Protein Isolate is an excellent source of protein and well tolerated by people who are lactose intolerant. Weigh food on a scale after it has been cooked to be sure you are getting adequate protein. If you do not own a food scale, cook a piece of protein the size of a deck of cards. Hair loss is inevitable due to the effects of major surgery and decreased calorie intake. You should see improvement after six months. Meats: •
Meat should be tender and moist. Marinated meats, boiled meats and the dark meat of chicken tend to be well tolerated. Fibrous meats such as dry turkey, dry chicken breast, steak or hamburger can be difficult to digest. Microwaving and grilling dries out meats, making them difficult to tolerate. Try adding broth before microwaving to make the meat juicier. Crock pots can be very useful. Avoid ground beef, shrimp, scallops and lobster. They are very difficult to digest. Wait until at least 4 months after surgery to try them. Do not fry your meats. Frying adds calories and can make foods hard to digest. Some people may experience dumping with fatty foods. 63 Tips for success: •
2‐3 bites of food may be all that you can tolerate initially. •
AVOID overeating or drinking too fast! This may lead to staple line disruption. •
If you are feeling constipated, try Miralax, a stool softener or add some Benefiber to your foods. •
It is important to get on an eating schedule—Set alarms on your phone or computer to remind you to eat. If you are not hungry, take a few bites just to stay on schedule. Also, review the sample meal plans for each stage for more details. •
Avoid raw vegetables. •
Some condiments are okay in moderation (1‐2 tbsp): ketchup, light or fat‐free mayonnaise, mustard, fat‐free gravy, herbs and spices. •
Eat slowly; use 10 minutes per ounce as a guideline. Take VERY small bites of food and chew the food well until it is liquid/paste in your mouth. Stop eating if you are full. Take maximum 20 minutes per meal. •
AVOID PICKING OR GRAZING. This will lead to weight gain. •
Avoid very hot or very cold foods as they may cause dumping syndrome. •
Continue with your chewable vitamin supplements. •
No Straws. •
Do not chew gum or suck on hard candy. If swallowed, it can obstruct your outlet. •
Continue your food diary. Write down the amount of fluid you drink. The food diary at this stage is critical to ensure that you are eating enough protein. 64 STAGE 3: SAMPLE MEAL PLAN Start with only small bites at first, advance slowly. TIME FOOD
7 am 8 oz decaf tea 7:30 am 1 scrambled egg, ¼ cup applesauce
9 am 1/2 cup cottage cheese
11:15 am 14
8 oz propel 12 noon 2 oz tuna with 1 tsp light mayo, 4 inch mashed banana 1:15 pm 14
8 oz water 2:30 pm 3 oz non‐fat Greek yogurt, 1/4 cup pureed pears (<5 grams of sugar) 3:45 pm 1/2 cup chicken broth with 1/2 packet Beneprotein 4:45 pm 9
4 oz soup 3
8 oz water 14 2 oz diced chicken, ¼ cup mashed sweet potatoes, 1 tsp fat free gravy 12 oz water 7:30 pm to bedtime 7
8 oz water 10 am 6 pm PROTEIN 56 ounces (7 cups) 65 61 grams
Stage 3 – Only small bites at first BREAKFAST LUNCH SUNDAY Egg—soft cooked Refried Beans (NO FAT ADDED) MONDAY Cream of Wheat mixed with NF milk and Beneprotein Low‐fat pureed lentil soup (< 3grams of fat) mixed with Beneprotein Canned Chicken
Light Mayo Pureed Fruit (<5 grams sugar) TUESDAY Protein Shake ( for 8 oz: 150‐200 calories, about 20 grams protein, < 5 grams sugar) WEDNESDAY THURSDAY FRIDAY SATURDAY DINNER SNACK Greek Yogurt, sugar‐
free, non‐fat Pureed fruit (<5 grams sugar) NF milk
Turkey Deli Meat Sugar Free Pudding Cottage Cheese—
fat free or low fat Applesauce (<5 grams sugar) Hummus
Beneprotein String Cheese Scrambled Eggs Low‐Fat Cheese Pureed fruit (<5 grams sugar) Greek Yogurt mixed with Crystal Light Powder Cottage Cheese—fat free or low fat Pureed fruit (<5 grams sugar) Canned Tuna
Light Mayo Applesauce (<5 grams sugar) Smoked Salmon Pureed veggies Cream of Wheat mixed with NF milk and Beneprotein Low‐fat black bean soup (<3 grams of fat) mixed with Beneprotein Refried Beans (NO FAT ADDED) Low fat cheese Mashed avocado Protein Shake (for 8 oz: 150‐200 calories, about 20 grams protein, < 5 grams sugar) ½ cup SF pudding
Greek Yogurt, sugar‐free, non‐fat Pureed fruit (<5 grams sugar) Turkey deli meat
Applesauce (<5 grams sugar) White Fish Mashed Sweet Potatoes Scrambled egg ½ mashed banana Canned Tuna
Light Mayo Pureed Fruit (<5 grams sugar) Low fat split pea soup (< 3 grams fat) mixed with Beneprotein 66 Protein Shake (for 8 oz: 150‐200 calories, about 20 grams protein, < 5 grams sugar) Greek yogurt, sugar‐free, non‐fat, mixed with SF jello STAGE 4
Reduced Calorie Solids
You will begin this diet about 5 weeks after surgery. This will be your long term meal plan. Vitamins •
Bypass and Sleeve: Multivitamin once a day, B12 once a daily, calcium citrate 2‐3 times a day. (see page 61 for list) Fluid goal: 56 oz (7 cups)/day Protein goal: 60‐70 grams/day Calories: When you start this stage, you will be eating about 600‐700 calories per day. For the first year, you will want to try to stay below 1000 calories, if possible. After the first year, you will probably be eating about 1000‐1200 calories. These are guidelines, you may need additional calories if you are very active. Please discuss your specific calorie needs with your dietitian. 67 STAGE 4: Tips and important information
About this stage  The Reduced Calorie Solids stage gradually re‐introduces solid food to your system.  Start to move away from soft, mushy foods and liquid protein. These are SLIDER FOODS.  Solid foods will be more filling.  Snacks: At Stage 4, try to keep to 3 meals per day with just 1‐2 snacks per day. Listen to your own body and what your own needs are for snacks. Protein  Your body must get the protein it needs from your diet. It is important for you to EAT the recommended dietary protein. Not everyone will be able to eat all of the recommended foods, especially at first. Listen to your body and do not overstuff your pouch or sleeve. Only when you are unable to eat enough of the protein requirements should you supplement with liquid protein.  Hair loss is inevitable due to the effects of major surgery and decreased calorie intake. You should see improvement after six months. Meats  Meats should be tender and moist. Marinated meats, boiled meats and the dark meat of chicken tend to be well tolerated. Fibrous meats such as dry turkey , chicken breast, or steak can be difficult to digest.  Microwaving and grilling dries out meats, making them difficult to tolerate. Try adding broth before microwaving to make the meat juicier. A crock pot may be useful.  Do not fry your meats. Frying adds calories and can make foods hard to digest.  Weigh food on a scale after it has been cooked to be sure you are getting adequate protein. If you do not own a food scale, cook a piece of protein the size of a deck of cards. 68 Foods to avoid  Membranes of oranges, tangerines and grapefruit (they can obstruct your outlet)  Cores, skins and seeds of fruits and vegetables  Fibrous vegetables such as celery  Popcorn, nuts, rice, grapes, pea pods  Avoid spongy, starchy foods such as breads, cakes and bagels. They expand in your stomach and may cause pain or blockage. They can also be easy to overeat.  Be careful with chewing gum or hard candy. If swallowed, it can obstruct your outlet. Fruits and vegetables  Start with canned fruits (packed in their own juice) and then advance to fruit with the skin peeled off. Watch out for seeds. Start with well‐cooked vegetables and cook for less time as you progress. Corn and peas count as starches rather than vegetables. Tips for success:  Try to have just 2‐3 bites of any food that you are trying for the first time.  It is important to get on an eating schedule. If you are not hungry, make protein your priority; take a few bites just to stay on schedule. As you are able to eat more at meal time, you will be eating fewer meals.  AVOID PICKING OR GRAZING! This will lead to weight gain.  Some condiments are okay in moderation (1‐2 tbsp): ketchup, light or fat‐
free mayonnaise, mustard, fat‐free gravy.  Some people may experience dumping with fatty foods.  Baby warmer trays or warming plates can be used to keep food warm while you are (slowly) eating your meal.  Try using a smaller plate and child‐size utensils.  Stop eating if you are full.  If eating out and the entrée is the typical portion, plan on bringing most of the meal home in a “doggie bag.”  Continue with your chewable vitamin supplements.  DO NOT DRINK WITH MEALS. Wait 60 minutes after a meal to drink.  Continue your food diary. Write down all of the food you eat and the fluid you drink. The food diary at this stage is critical to ensure that you are eating enough protein  Please feel free to contact your dietitian if you have any questions. Your dietitian wants you to SUCCEED! 69 STAGE 4 SAMPLE MEAL PLAN
Start with small bites. Food tolerances are very individual. Time Food 7 am 8 am 1 egg, 1 oz low fat cheese <3 grams fat, chopped veggies 9:30 am 11 am Noon 2 oz canned chicken Liquid
8 oz decaf tea
Protein 14 grams 8 oz water
8 oz water
14 grams 1 tbsp light mayonnaise ½ cup pears (no sugar added) 1:30 pm 8 oz water
2:30 pm 3 oz Greek Yogurt, ½ cup peaches (no sugar added) 9 grams 4 pm 8 oz propel
5 pm 8 oz water
6 pm 3 oz diced turkey 21 grams ½ cup green beans 1/3 cup quinoa 1 tsp oil 7:30 p.m 8 pm ¼ cup cottage cheese, ¼ cup melon TOTAL 8 oz herbal tea
7 grams 56 OZ (7 CUPS)
Stage 4 – Only small bites at first of each new food. BREAKFAST LUNCH DINNER SNACK Egg, low fat cheese (<3 grams fat) with cooked veggies. Fiber One Cereal mixed in Greek Yogurt (SF and NF), Stevia Sliced peeled apple Creamy peanut butter (no added sugar) Canned chicken with light mayo Strawberries Salmon
Quinoa Cooked veggies NF milk
Veggie Burger Patty
Sweet Potato Wedges (baked in 1 tsp olive oil) Cottage Cheese—fat free or low‐fat Melon TUESDAY Cottage Cheese (small curd—NF or Low fat) Melon Low fat chicken sausage (<3 grams fat) Roasted red potatoes and veggies Greek Yogurt—
sugar free Fruit WEDNESDAY Egg‐soft cooked Peaches (no added sugar) Black beans, low fat cheese (<3 grams fat)and salsa Avocado Canned tuna with
light mayo Soft cooked veggies Banana Turkey deli meat with low fat cheese (<3 grams fat) Melon Low fat lentil soup (<3 grams fat) mixed with Beneprotein Chicken: dark meat, 1 tbsp light Italian dressing. Quinoa Green Beans String Cheese with sliced peeled apple Halibut
Brown Rice Cooked veggies Hummus mixed with Beneprotein Low‐fat string cheese Omelet: eggs, mushrooms, peppers, spinach with low fat cheese (<3 grams fat) SF pudding
Chili with veggies
Deli Meat
Melon SUNDAY MONDAY THURSDAY FRIDAY SATURDAY Oatmeal mixed with NF milk and Beneprotein, cinnamon and Stevia Greek Yogurt, sugar‐free, non‐
fat Pears (no added sugar) ½ banana Creamy peanut butter (no added sugar) Smoked salmon Cooked veggies Sliced peeled apple 71 Grocery List Grocery List Proteins: o __________________________ o __________________________ o __________________________ o __________________________ o __________________________ o __________________________ o __________________________ o __________________________ Non‐starchy Vegetables: o __________________________ o __________________________ o __________________________ o __________________________ o __________________________ Fruits/Starches: o __________________________ o __________________________ o __________________________ o __________________________ o __________________________ Fats: o __________________________ o __________________________ o __________________________ o __________________________ Snacks/Beverages: o __________________________ o __________________________ o __________________________ o __________________________ Label Tips:  5‐2‐1 rule: 5 grams total fat, 2 grams saturated fat, 1 g ram trans fat  5 grams of sugar or less  make sure sugar is not one of the first four ingredients listed Proteins: o __________________________ o __________________________ o __________________________ o __________________________ o __________________________ o __________________________ o __________________________ o __________________________ Non‐starchy Vegetables: o __________________________ o __________________________ o __________________________ o __________________________ o __________________________ Fruits/Starches: o __________________________ o __________________________ o __________________________ o __________________________ o __________________________ Fats: o __________________________ o __________________________ o __________________________ o __________________________ Snacks/Beverages: o __________________________ o __________________________ o __________________________ o __________________________ Label Tips:  5‐2‐1 rule: 5 grams total fat, 2 grams saturated fat, 1 g ram trans fat  5 grams of sugar or less  make sure sugar is not one of the first four ingredients listed 72 Medications & Vitamins after Bariatric Surgery Short Term: Omeprazole: 
20mg a day for 3 months for gastric bypass and possible vertical sleeve gastrectomy patients (may not need it) 
This medication decreases the production of stomach acid allowing better healing of your stomach pouch Ursodiol: No Longer Prescribing Long Term: Vitamin B12: For gastric bypass patients only 
500micrograms a day. Take one per day Calcium Citrate with Vitamin D: 
600mg calcium citrate with 400 IU vitamin D 
Take this dose twice a day 
Many patients require Vitamin D, in addition to what they receive with their calcium. Dose will depend on blood test results Multiple Vitamins with minerals and iron added: 
Take one per day Iron Supplements: 
Separate Iron supplement is prescribed to pre‐menopausal women and as needed for others 
Take iron as prescribed by your surgeon 
Do not take iron and calcium at the same time (separate by 2 hours) 
Vitamin C (250mg) is needed for absorption of some iron supplements Recommended Probiotics: Described in this section 73 Why we take a Vitamin/Mineral Supplement Every Day As you know, it will be necessary to take vitamin/mineral supplements after your bariatric surgery, for the rest of your life. The following are deficiency symptoms of some of the most important vitamins and minerals. If you often forget to take your supplements, you will be at a higher risk of developing these. Your doctor will request that you have vitamin and mineral levels checked periodically. Folate (Folic Acid, Folacin)  Poor growth  Blood disorders  Anemia  Elevated blood levels of homocysteine (a blood chemical linked to the clogging of arteries).  GI tract disturbances Vitamin B‐12 (Cobalamin) It may take 5‐6 years for deficiency symptoms to appear after natural sources of the vitamin are restricted. 
Degeneration of cerebral white matter, optic nerves, spinal cord and peripheral nerves. Symptoms include numbness, tingling, and burning of the feet as well as stiffness and generalized weakness of the legs.  Anemia Calcium  Bone deformities (osteoporosis, osteomalacia and rickets)  Tetany – extremely low levels of calcium in the blood may increase the irritability of nerve fibers and nerve centers, resulting in muscle spasms such as leg cramps (tetany).  Hypertension (high blood pressure). Iron  Malfunction of a variety of body systems  Fatigue, irritability  As iron deficiency anemia becomes more severe, defects develop in the structure and function of the tongue, nails, mouth and stomach. Skin may appear pale, and the inside of the lower eyelids pink instead of red. Fingernails become thin and flat, and eventually spoon‐shaped nails develop. The tongue may burn, and/or appear red, smooth and waxy.  Extreme cases of untreated anemia can eventually result in heart failure. Potassium  Nausea, feeling anxious, drowsy or weak.  Irregular heart beat Magnesium  Tremors  Muscle spasms  Personality changes  Nausea and vomiting 74 Resources for Vitamins 
What is most important is not the brand of supplement that you take, but your consistency in taking the supplements on a daily basis. For the first few months you will not be able to swallow large pills. Your multiple vitamin and calcium will need to be either in chewable or liquid form. Chewable and liquid supplements often contain sugar for flavor, which can result in dumping (especially with liquids) or added calories. The following are some brands and resources that might help you in finding the product that will work for you. Group Health Multiple Vitamins: chewable and pill form Calcium Citrate with Vitamin D: pill form (does not carry a chewable form) Vitamin B12: pill form (these are small pills) Wellesse (liquid vitamins) All of these are liquid vitamins, very little to no sugar added. Taste pretty good. Sold at numerous locations, include Costco, Walmart, Bartels, Amazon Multiple Vitamins Calcium Citrate with Vitamin D Vitamin D Probiotics Glucosamine Super Supplements / Costco / Walmart / / All have a variety of supplements, in various forms Read labels to ensure the correct formula and for sugar content 75 Probiotics Probiotics are live microorganisms that provide health benefits. The human body harbors about 100 trillion bacteria, both good and bad. 80‐90% of these bacteria live in the digestive tract, mostly in the colon. Maintaining the correct balance of good and bad is necessary for optimal health. Things like medications, diet, disease and your environment can upset the balance. An upset balance can result in symptoms. Probiotics supplements are considered safe and effective for preventing and treating irregularity of the gastrointestinal tract, such as diarrhea, constipation, irritable bowel and heart burn. Some studies have shown that probiotics can prevent H.pylori, vaginal candidiasis and upper respiratory infections. Probiotics found in dairy products are typically small in quantity compared to that of a supplement. We recommend that you take a probiotic supplement daily on a long term basis. Since there are a lot of supplements out there to choose from, we are providing you with a list of some of the more comprehensive and better quality products, including where to buy them, how much they cost and what bacteria they contain. See the list of these products on our Group Health web page:‐patients Bowel habits are sure to change after surgery and constipation is a fairly common problem. Taking a probiotic supplement daily and drinking adequate fluids will help to prevent this. Diarrhea is not an expected complication after bariatric surgery. If you are experiencing diarrhea or other concerning digestive symptoms, to include constipation that is not relieved by a daily probiotic, please call the bariatric clinic (425‐502‐3454). See section 8 for more information on constipation. 76 Protein Supplements Protein drinks and powders can vary greatly. Some are very good and others are more like a milk shake. Some have a good amount of protein, some have very little. Some have very little sugar, some have a lot. The calories can also vary greatly. Here are some brands that we recommend and where you can purchase them. Also see protein recommendations in section 6. Premier Protein: 30 grams protein / 160 calories (Available at Costco) Unjury: 20 grams protein / 100 calories (Available at and Bioplex: 20 grams protein / 110 calories (Available at Super Supplements) Optimum: 22 grams protein / 160 calories (Available at Super Supplements) Syntrax Nectar: 23 grams protein / 100 calories (Available at Super Supplements) About Time whey protein: 24 grams protein / 110 calories (Available at GNC) Zero Carb Isopure: 50 grams protein / 210 calories (Available at GNC) Myoplex Light: 20 grams protein / 180 calories (Available at GNC) Muscle Milk Light : 20 grams protein / 160 calories (Available at Costco & many other stores) Glucerna Hunger Smart: 15 grams protein / 180 calories (Available at most grocery stores) Beneprotein: 6 grams protein per scoop / 25 calories Unflavored protein powder, to add to low protein food items or boost protein in others. (Available at Amazon,, Overlake Pharmacy) Bariatric Advantage: 27 grams protein / 150‐160 calories (Available at Bariatric Advantage online only 77 Yogurt As you know, yogurt is very healthy, but different brands and varieties vary greatly in nutrition and calories. Remember to always read food labels so that you know what you are eating. For more information about food labels, talk with your dietitian. Some yogurts have way too much sugar and are likely to lead to dumping syndrome and weight gain. Typically those that have more sugar also have less protein. If the flavored varieties have greater than 5‐10 grams of sugar, buy plain and add fresh or frozen (no sugar added) berries or fruit. You can also add sugar free Jell‐O pudding or gelatin powder (sprinkle to taste). Below is a list of yogurts that are healthy choices. Yogurt Flavor
Activia Greek Light Vanilla
Carb Master (Fred Meyer/Kroger) Varied
Chobani Greek (0% fat) Plain
Chobani Greek Simply 100 Vanilla
Dannon Oikos Greek Plain
Dannon Oikos Triple Zero Vanilla
Dannon Light and Fit Greek Vanilla
Fage Greek (0% fat, 2%) Plain
100 (150)
18 (20)
7 (8)
Nancy’s greek
Siggi’s (0% or 4%, Whole Foods) Plain 120 (100)
23 (11)
6 (3)
Tillamook Greek Nonfat (or 2%) Plain
90 (113)
15 (10)
4 (3)
Wallaby (Whole Foods) Plain
Yoplait Greek 100 Vanilla
78 Post Op Concerns What they are and how to prevent them Many of the symptoms that can arise following surgery can be prevented. In the next couple of pages, we will review some of the more common issues that patients can experience and steps that you can take to help prevent them. There are rare post‐surgical concerns that can arise and are mechanical or structural in nature, that may require a surgical or endoscopic solution. There may also be medical issues that arise and require treatment with medications. All of these are review as well. It’s very important that you be journaling your food and fluid intake. See the Journaling in section 10 for an explanation of how to journal affectively. Following the guidelines that have been provided, in regards to eating and drinking, (to include what you eat/drink, how much and how fast), can nearly always prevent symptoms that are not the result of a mechanical/structural or medical issue. However, it’s very important that you know what symptoms to watch for and when and who to call with questions or for advice. Always, always, always call if you have a question, concern or symptoms that do not resolve quickly or are more urgent. We can help to determine the cause and/or seriousness of your symptoms and provide you with advice. This is all new for you and we would not expect you to not have questions. Your symptoms may be something what we can help you to resolve by making some changes to your diet or medications or we may advise that you see your primary care provider, see your bariatric surgeon or go to Urgent Care. 79 Hydration / Dehydration It’s very important that you drink at least 32 oz of fluid per day initially. By the time you are three months past your surgery date, you should have increased this amount to at least 56 oz per day. More is even better. Low or no calorie fluids are best. Artificial sweeteners are not recommended. They are thought to increase hunger. It will be necessary to sip fluids all day long, with the exception of the 60 minutes after meals. You may need to experiment with different temperatures and fluids to see what’s best tolerated. Some patients don’t tolerate cold fluids, especially early on. Warm or room temperatures may go down better. As you lose weight, your body needs to rid of the waste products that weight loss creates. Kidneys are vital for this process. In order for your kidneys to function properly, they need plenty of fluids. Dehydration can increase constipation, nausea and pain and can just all around make you feel lousy. Symptoms of dehydration can include: Decreased urine output Dry mouth Dizziness / light headedness Increased heart rate Low blood pressure Fatigue Headache Constipation Once you get depleted, it can be very difficult to resolve dehydration on your own. Always call the Bariatric Clinic 425‐502‐3454 (Consulting Nurse if after hours 1‐800‐297‐698772) if you are experiencing any of the above symptoms. Our best advice is to do your best to get in the required amount of fluids each day. 80 Nausea / Vomiting Contrary to popular belief, nausea and vomiting are not expected consequences of bariatric surgery. There are numerous reasons that one might experience these symptoms following surgery. The reason is often behavioral and can be resolved with some changes to either what or how one is eating. On occasion your symptoms may require medication. Much less often, the reason can be mechanical or structural, meaning that a procedure or surgery may be required to resolve the symptoms. Behavioral reasons that might result in nausea or vomiting include: Eating the wrong foods It’s very important to read labels. Some foods that seem as though they are very healthy may have ingredients that are not tolerated. See dumping syndrome for further information on foods that are less tolerated. It’s very important to read and understand food labels. Eating too much Your stomach pouch is about 30 cc. This is about the size of a shot glass or an egg.. Eating too much can result in foods to stack up and cause nausea and often vomiting. Just one bite too much may set you over the edge. If you are experiencing nausea and vomiting after meals, try reducing the size of your meal by a bite or two and see if your symptoms resolve. Eating too fast You will need to take small bites, chew well and eat slowly. Concentrating only on your meal (without distractions like TV or reading) will help you to eat slowly. Using small utensils will remind you to take small bites. Meals should take about 15‐20 minutes. Not chewing well enough It’s important to chew your food very well. At first you may want to use a timer or watch the clock for all solid foods and chew each bite for at least 30 seconds. This will also ensure that you are eating slowly. Less frequently nausea and vomiting can be the result of a structural or medical problem. Stricture A stricture is a narrowing of the new connection that was created to connect your new stomach pouch to your small intestine. If this is going to happen it is usually between 3 weeks and 3 months post op. Symptoms are progressive and typically begin with nausea, vomiting and a feeling that foods are stacking up, first with solid foods and progressing to difficulty with soft foods and liquids. The treatment is dilatation during endoscopy. If you develop the above symptoms, you need to call the Bariatric Clinic. Ulcer Stomach ulcers can develop in the pouch or at the new connection. The first symptoms are usually nausea, vomiting and stomach pain. Sometimes the symptoms are improved following a meal. Anti‐inflammatory medications and smoking are the most common causes of stomach ulcers. Call the Bariatric Clinic is you are experiencing the above symptoms. 81 Constipation Constipation is a very common complaint after surgery. It’s important to remember that bowel habits will change following surgery. You are eating less food and different types of foods than before surgery. Your body responds accordingly, producing fewer and smaller bowel movements. The initial post op period can be challenging. You are without any food for a couple of days, and then it’s just water and few tiny bites of pureed foods (or just liquids if you have a lap band). Add to that the narcotic pain medication that you are given and you have a recipe for constipation. It’s best to be proactive, in the initial post op period and beyond. Fluids: Initially following surgery you should be drinking at least 32 oz. of fluid per day, increasing so that by the time you are 3 months post op, you are drinking at least 56‐64 oz. of fluid every day. Exercise: Movement decreases the amount of time it takes for food to move through the large intestine and stimulates the natural contractions of the intestinal muscles. This helps to efficiently move the stool out. Walk 10‐15 minutes several times a day to help keep the digestive track working optimally. Fiber: Fiber supplements, such as Benefiber & Metamucil can be used, but only after you are drinking 64 oz. of fluid per day. You will get fiber from the fruits and vegetables you eat. Supplements to Prevent Constipation:  Probiotics This supplement helps to regulate the digestive track.  Stool Softeners (such as DOSS)  Magnesium (200mg / day)  Smooth Move Tea  Fiber Supplements (once you are drinking >64 oz of fluid a day) o Metamucil (sugar‐free) o Benefiber o Efferpsyllium o Fiber One Supplements to Treat Constipation:  Milk of Magnesia  Miralax 82 Dumping Syndrome Your stomach no longer has a valve that releases stomach contents slowly into the small bowel. Dumping syndrome is the result of the rapid emptying of foods high in sugar or fat into the small intestine. When high concentrations of sugar or saturated fat hit the small intestine, it causes an influx of fluid into the small bowel. Symptoms can result within 10‐30 minutes and can include:  Nausea  Diarrhea  Vomiting  Abdominal cramps  Bloating  Epigastric fullness  Sweating  Headache  Flushing  Lightheadedness  Palpitations (rapid heart rate)  A strong desire to lie down Prevention Simply avoid foods that are high in sugar or saturated fats. Some patients may experience symptoms with full fat dairy products, though low fat dairy is typically fine. Ice cream is typically not well tolerated. High fat meats, like hot dogs may result in dumping. Hypoglycemia Reactive hypoglycemia or postprandial hypoglycemia (low blood sugar after meals) is a medical term describing recurrent episodes of symptomatic hypoglycemia occurring 2‐4 hours after a high carbohydrate meal. The reason for this is that the body is producing more insulin than is needed in response to a carbohydrate load. Symptoms can vary and can include:  Increased or sudden hunger  Feeling shaky, dizzy or nervous  Pounding heartbeat  Drowsiness or feeling tired  Sweating (cold and clammy)  Numbness or tingling around the mouth  Headache and/or stomachache Prevention To prevent hypoglycemia, one should not eat carbohydrates without a protein. If you are experiencing the above symptoms, try having a low fat dairy product, which contains a combination of complex carbohydrates and protein. String cheese or low fat plain yogurts are good choices. 83 When to Call Call 911 for any unusual symptoms such as: 
Chest pain 
Severe shortness of breath 
Severe dizziness 
Severe headache Call the General Surgery Clinic 8:00 am – 5:00 pm Mon‐Fri 425‐502‐3450 Toll‐free 1‐800‐995‐5658 Ext. 3450 
Nausea, vomiting 
Inability to eat or drink 
Symptoms of dehydration 
Constipation or diarrhea 
Symptoms of wound infection 
Any time you have a question or concern o If you are concerned – it’s reason enough to call! Consulting Nurse (after hours) Toll‐free 1‐800‐297‐6877 If you experience any of the following: 
Pain, tenderness, cramping, redness, tightness, or swelling in any part of your leg or foot 
Large amounts of drainage from your incision at anytime 
Fever over 100.5 and/or shaking chills 
Persistent nausea or vomiting 
Severe diarrhea 
3 to 4 day of constipation 84 Follow‐Up Appointments & Lab Schedule All follow up bariatric patients will follow the same schedule for Follow‐up labs: Visit Labs
Post‐Op 2‐3 Months 6 Months 12 Months 2 Years 3 Years 4 Years 5 Years No Yes (Fasting) No Yes (Fasting) Yes (Fasting) Yes (Fasting) Yes (Fasting) Yes (Fasting) Notes Also need to see the dietitian All Bariatric Patients:  Please do Fasting Labs at least 5 days prior to your appointment.  Labs are ordered in advance. There is no need to call for them to be ordered, simply go to any Group Health Lab for these to be done. If no order is in, please call 425‐502‐3454 You’re follow visit will be with one of the PA’s. All appointments are equally important. These appointments are never done by phone. The expectation is that patients commit to this follow appointment schedule. They are important for your healthy recovery, they are important for us to know that you are doing well and they are a requirement of the Center of Excellence for Bariatric Surgery. Please call to make appointments a month or two in advance. 85 Labs needed: 
Prior to all follow up appointments, except the 6 month visit CBC Comp. Metabolic Panel PTH‐intact Lipoprotein Panel – (Fasting) Vitamin B12 Vitamin A Copper Thiamin 25‐hyroxy (Vitamin D) Iron/TBIC (as needed) HgbA1c – (if diabetic) TSH Prealbumin Cooper Zinc If you see a non‐Group Health (contracted) provider:  You may do your labs with your own PCP  Please take this list of regularly ordered labs with you to that clinic/lab  Please do about 10 days prior to your appointment, if possible  Please remind provider that these need to be faxed to us, in advance your appointment: Fax Number 425‐502‐3570  Your doctor may need to know the:  Diagnosis Code: V45.86 86 Keys to Success after Bariatric Surgery Use the TOOL you have been given Listen to your body: When full – STOP eating Follow the guidelines you are given 
3 small evenly spaced meals a day 
Do not go more than 5 waking hours without eating 
Eat appropriate types Protein first Avoid refined carbohydrate foods Healthy snack is ok  Separate foods and fluids Wait 60 minutes after eating to drink fluids  NO GRAZING Nibbling or snack throughout the day will add un‐necessary calories and is a poor life style habit  Work with your dietitian during the first year Additional visits can be purchased if desired  Exercise Start immediately after surgery Find something that you enjoy Make this a habit  Sleep Get at least 6 hours of regular sleep Helps to prevent weight regain 
Make and keep your follow up appointments Get follow up labs are directed See section 9  Attend support groups monthly See section 2  Read the monthly newsletter‐patients/ 87 Food Journaling Food journaling is one of the most powerful tools you can use to help you lose weight. Your surgeon, PA, dietitian, and bariatric nurse will all ask you about fluids, proteins, and calories at just about every appointment or phone interaction. The reason for this is easy – it’s vital that you know the grams of protein, the ounces of fluid and the number of calories that you are taking in every day. There are many different forms of journaling. You use a purchased food journal in book form, any number of online journaling resources, a word document or excel sheet (there is one on the next page) or simply a pad of paper and a pen. What to track:  Grams of Protein  Ounces of Fluid  Calories  Snacks  Food Portion (¼ cup, ½ cup, etc.)  Symptoms (nausea, pain or vomiting after eating, etc.)  Exercise Other things that may be helpful if you are experiencing symptoms:  Amount of time spend on the meal  Where and who you were with during the meal o Sometimes we are most tempted in certain environments or with certain people  Emotions o You are more likely to over eat when stressed or unhappy, etc. Journaling can help you to:  Ensure adequate nutrition  See patterns  Be accountable Yes, it takes time and effort, but the benefits that you will get out of this time and effort are well worth it. 88 Web Page and Newsletter‐patients Bariatric page on the Group Health web site. What you’ll find on this Web Page:  Monthly Newsletter (new one out on the first of each month)  Electronic copy of the Bariatric Notebook (Step’s to a Healthier Future)  Support Group listing  Food Journal printable document  Probiotic List o Brands o Where to buy o Cost  Email link for questions o (do not e‐mail with personal medial questions to this e‐mail address – use My Group Health or call) Newsletter Monthly newsletter covers a different topic each month. These are topics that the bariatric team, social workers and Accomplish dietitians feel are important to discuss.  The dates of that months support groups are listed  Guest speakers  Upcoming newsletter topics are listed  New recipes each month  Book reviews  Back on Track page, for those that are struggling with weight regain or to maintain their weight loss 89 90 Active
at Any Size
NIH…Turning Discovery Into Health®
National Institutes of Health NIH Publication No. 10–4352 June 2014
Introduction ....................................................................................... 1
Why should I be active? .................................................................. 2
How can I be active safely? ........................................................... 3
What kinds of activities can I do? ................................................. 4
Walking................................................................................................ 4
Dancing ................................................................................................ 6
Bicycling............................................................................................... 6
Water Workouts .................................................................................. 7
Strength Training ................................................................................. 8
Mind and Body Exercise .................................................................... 10
Daily Life Activities ........................................................................... 10
Where can I be active? ................................................................. 11
How can I get past my roadblocks? ............................................ 12
How can I stick with my healthy habits? .................................... 13
Think positive! ................................................................................... 17
Resources ........................................................................................ 18
Additional Reading from the Weight-control
Information Network ......................................................................... 18
Additional Resources ........................................................................ 19
Would you like to make physical activity a part of your life, but
are not sure how to do it?
Good news—you can be active at any size—and have fun and
feel good doing it!
Physical activity may seem difficult when you are overweight or
obese. You may get short of breath quickly. Your feet or joints
may hurt. It may be hard or costly to find the right clothes and
equipment. And you may feel self-conscious working out in
front of others.
Facing these challenges may be hard—but it can be done! This
brochure will give you many tips and resources for being more
active and healthier at any size.
X See the Weight-control
Information Network (WIN)
website at http://www. for more
resources to help you
improve your health.
Active at Any Size | 1
Do I need to see my health care provider before I
Talk to your health care provider if you
„ have a chronic disease like diabetes, high blood pressure,
and/or heart disease
„ have a bone or joint problem (for example, back, knee,
or hip) that could be made worse by a change in your
physical activity
„ are unsure of your health status or have any concerns
that exercise might be unsafe for you
If any of these concerns apply to you, ask your doctor about
ways to safely make physical activity part of your life.
Why should I be active?
Physical activity may help you live longer and protect you from
developing serious health problems, like type 2 diabetes, heart
disease, and stroke. Regular physical activity is linked to many
health benefits. It helps you feel better because it may
lower blood pressure and blood sugar
help build healthy bones, muscles, and joints
help your heart and lungs work better
boost energy during the day, aid in
sleeping at night, and improve mood
When combined with a healthy eating pattern, regular physical
activity may also help you control your weight.
Being active with others can be a lot of fun! It may give you a chance
to meet new people or spend more time with family and friends.
2 | Active at Any Size
How can I be active safely?
The activities in this brochure are safe for most people. But if
you have health concerns or any problems moving or being
steady on your feet, talk to your health care provider before you
start. See the box “Do I need to see my health care provider
before I start?” for more information.
If you have been inactive for a while, start slowly and check how
you are feeling. Avoid high-impact activities, as jumping and
landing on a hard surface could lead to injury. Make your
workouts harder and longer as you feel more comfortable.
When you do physical
activity, your body tries
to cool itself down by
sweating. You can lose
water when you are
working out. To keep
your body hydrated,
remember to drink fluids.
Water is a great choice.
Sports beverages are
also an option, but
they have a lot of sugar
and will give you extra
X Stay safe while working out.
Slow down and stop if you see
any of the warning signs in the
“Tools You Can Use” box on
page 4.
When outdoors, protect
yourself from the sun
by putting on sunscreen
and wearing a hat or
visor and protective
Active at Any Size | 3
What are the warning signs that I should stop?
Stop your activity right away and seek help if you
„ have pain, tightness, or pressure in your chest or neck,
shoulder, or arm
„ feel dizzy or sick
„ are extremely short of breath
„ feel pain in your joints, feet, ankles, or legs. You could
hurt yourself if you ignore the pain
Ask your health care provider what to do if you have any of
these symptoms.
What kinds of activities can I do?
You do not need special skills or equipment to make physical
activity part of your life. Many types of activities may help
improve your health—from things you do every day, like walking
your dog, to planned exercises.
Try different activities that you enjoy. Read on for some ideas.
Anything that gets you moving around—even for a few minutes
at a time—is a healthy start to getting fit.
Walking is the most popular physical activity among adults. It is
low cost, convenient, and generally doesn’t require any special
clothes or equipment.
Walking will help you
improve your fitness
burn calories
feel more energetic
4 | Active at Any Size
Concerns about safety can keep some people from walking.
Choose a safe and well-lit area to walk. Try walking in places you
enjoy, like a park or shopping mall. Bring along a friend or family
member to chat with you, as this type of social support may
help you meet your activity goals. Many malls and parks have
benches where you can take a quick break if it is hard for you to
walk for a long time.
If you don’t have time for a long walk, add short walks instead.
For example, instead of a 30-minute walk, add three 10-minute
walks to your day. This makes it easier to fit your activity into a
busy schedule.
X To learn how to
create your own
walking plan, see
the WIN brochure
Walking…A Step in
the Right Direction,
listed in the Resources
X Tips for Walking
Wear comfortable walking shoes that offer a lot of support.
Warm up by walking more slowly for the first few minutes
of your walk before picking up the pace. When you are ready to
stop, cool down by slowing your pace.
Start by walking short distances and add more as you feel comfortable.
Active at Any Size | 5
What should I wear when working out?
„ Wear clothes made of fabrics that absorb sweat and
remove it from your skin.
„ Wear lightweight, loose-fitting tops that allow you to
move easily. Women should wear a good support bra.
„ Wear stretchy bottoms that are comfortable and prevent
inner-thigh chafing, such as tights or spandex shorts.
Dancing can be a lot of fun. You can dance in a health club, a
dance studio, or even at home. To dance at home, just move
your body to some lively music or to a dance workout on your
TV or computer.
Dancing may help
tone your muscles
make your heart stronger
make your lungs work better
If it is hard for you to stand on your feet for a long time, dancing
while sitting down may be an option. Sometimes called chair
dancing, this activity lets you move your arms and legs to
music while taking the weight off your feet.
Riding a bike does not stress any one part of the body—your
weight is spread among your arms, back, and hips. You can
bicycle indoors on a stationary bike, or outdoors on a road bike.
You may want to use a recumbent bike. On this type of bike,
you sit lower to the ground with your legs reaching forward to
6 | Active at Any Size
the pedals. This may feel
better than sitting upright.
The seat on a recumbent
bike is also wider than the
seat on an upright bike.
For biking outdoors, you
may want to try a mountain
bike. These bikes have
wider tires and are sturdy.
You can also buy a larger
seat to put on your bike.
If you decide to buy a bike,
check its weight rating (the
number of pounds it can
support) to make sure it is
safe for you.
Water Workouts
Swimming and water workouts put less stress on your joints
than walking, jogging, or biking because you do not have to lift
or push your own weight. If your feet, back, or joints hurt when
you stand, these activities may be best for you. If you feel
self-conscious or cannot find a good bathing suit, you can wear
shorts and a T-shirt while you swim.
Exercising in water
helps flexibility. You can move your body in water in ways
you cannot on land.
reduces risk of injury. Water makes your body float. This
keeps your joints from being pounded or jarred and helps
prevent sore muscles and injury.
keeps you refreshed. You can keep cool in water—even
when you are working hard.
Active at Any Size | 7
You do not need to know how to swim to work out in water—
you can do shallow-water or deep-water exercises without
For shallow-water workouts, the water level should be between
your waist and your chest. Try walking in place, moving your
arms from side to side, and throwing punches in front of you.
During deep-water workouts, most of your body is underwater.
For safety and comfort, wear a foam belt or life jacket.
What if I don’t want to mess up my hair in the pool?
If you are worried about damage to your hair from the pool
water or don’t want to mess up your hairstyle, try these tips:
„ A swim cap may protect your hair from getting wet. After
your workout, remove the cap, refresh your style, and go.
„ A natural hairstyle, short braids, or locs may be easier
than long hair to take care of after a water workout.
„ If your hair does feel damaged after a swim, you can find
shampoos to remove chlorine buildup at most drug stores.
Strength Training
This type of activity uses free weights, weight lifting machines,
resistance bands, or your own body weight to strengthen your
Strength training may help you
build and maintain strong muscles as you get older
maintain function in daily activities
keep your bones strong
8 | Active at Any Size
If you are just starting out,
using a weight lifting machine
may be safer than dumbbells.
As you increase your muscle
fitness, you may want to add
free weight exercises.
You do not need weight benches
or large dumbbells to do strength
training at home. You can use
a pair of hand weights or even
two soup cans or milk jugs filled
with water or rice. You can also
use your own body weight—
for example, by getting up and
down from a chair or doing push-ups.
Proper form is very important when lifting weights. You may
want to schedule a session with a personal trainer to learn
what exercises to do and how to do them safely. You may need
to check with your health insurer about whether this service is
covered by your plan.
If you decide to buy a home gym, check its weight rating (the
number of pounds it can support) to make sure it is safe for you.
X Strength Training Tips
Aim for 2 to 3 days per week of strength training activities.
For each exercise, aim for 8 to 12 repetitions. If that’s too hard,
the weight you are lifting is too heavy. If it’s too easy, your weight
is too light.
Give your muscles time to recover. Do not work the same muscles
2 days in a row.
Active at Any Size | 9
Mind and Body Exercise
Your local fitness center may also offer classes like yoga, tai chi,
or Pilates. These types of activities may help you
become more flexible and increase strength
feel more relaxed
improve balance and posture
These types of classes can add variety to your workout routine
and be a lot of fun. If some movements are hard for you to do
or if you have any injuries you are concerned about, talk to the
instructor about ways to adapt the exercises and poses to meet
your needs or start with a class for beginners.
Daily Life Activities
Lifestyle activities, such as
gardening or washing the
car, are great ways to get
moving. Small changes can
add more physical activity to
your day and improve your
health. Try these:
If possible, take 2- to
3-minute walking breaks
at work several times a
Stand or walk in place
during TV commercials.
Take the stairs instead of
the elevator or escalator
whenever possible.
Even a shopping trip can be exercise, because it is a chance
to walk and carry your bags. Doing chores like lawn mowing,
raking leaves, gardening, and housework also count.
10 | Active at Any Size
Where can I be active?
There are many fun places
to be active. Here are
some options:
Join a local fitness
center or community
recreation center (see
the “Tools You Can
Use” box on this page
for questions to ask
when choosing a fitness
Enjoy the outdoors by
going for a walk at a safe
local park.
Work out in the comfort
of your living room by
checking out a workout
DVD at your local public
What questions should I ask when choosing a fitness
„ Do you have exercise equipment appropriate for people
who weigh more? What kind of support will your staff
provide on how to use the equipment?
„ Do you offer any special classes for people who are
starting out, older adults, or people with mobility issues?
„ Can I try out the center before I sign up?
Active at Any Size | 11
How can I get past my roadblocks?
Think about your barriers to being active. Then try to come up
with creative ways to address them. Here are a few examples
to help you get started.
I don’t have
enough time!
Instead of doing one long session of exercise,
build in several short bursts (3 to 5 minutes)
that will not disrupt your day. Try to walk
more while doing your errands and walk in
place during commercials or while on the
phone. Simply standing up instead of sitting
at your desk also has benefits.
I just don’t like
Good news—you do not have to run or do
push-ups to get the benefits of physical
activity. Try dancing to the radio or being
active with friends to make exercise more
enjoyable. Many people find that they like
exercise better the more they do it.
I’m worried about
my health or injury.
If you have a hard time being active because
of your health, talk to a health care provider
first. A certified fitness professional can also
guide you on how to be active safely.
I feel self-conscious
working out in
front of others.
Start with exercise at home until you feel
confident. Be active with friends who will
support and encourage you. Having someone
“in your corner” may make you feel less selfconscious.
(Add your barrier.)
(Add your solution.)
(Add your barrier.)
(Add your solution.)
12 | Active at Any Size
How can I stick with my healthy habits?
Keeping an activity journal
is a useful tool to help you
stay motivated, stay on
track, and reach your goals.
It may be helpful to set a
short-term goal, a long-term
goal, and rewards for meeting
those goals. Use the sample
activity journal on page 16
to help you stick with your
healthy habits.
Set short-term and longterm goals. Getting started
with a doable goal is a great
way to form a new habit. A
short-term goal may be to
walk 5 to 10 minutes, 5 days
a week. A long-term goal may be to do at least 30 minutes of
physical activity at a moderate intensity level (activity that makes
you breathe harder but does not overwork or overheat you) on
most days of the week.
To get you started, write down a goal in the sample activity
journal. Be specific. For example, instead of “I will be more
active,” set a goal like “I will go for a walk after lunch at least 2
days per week.”
Set rewards. Whether your goal was to be active for 15 minutes
a day, to walk farther than you did last week, or simply to stay
positive, recognizing your efforts is an important part of staying
on track. Some ideas for rewards include new music to charge
you up or 30 minutes of quiet time to yourself.
Active at Any Size | 13
Write down how you will reward yourself in “My Activity
Journal“ on page 16.
Get support. Get a family member or friend to be physically
active with you. It may be more fun and your buddy can cheer
you on and help you stick with it.
Write down who will support you in “My Activity Journal.”
Track progress. You may not feel like you are making progress
but when you look back at where you started, you may be
pleasantly surprised! You can make copies of the blank activity
journal to keep track of your efforts.
14 | Active at Any Size
Sample Activity Journal
My short-term goal: Walk at least 3 days this week.
My long-term goal: Get 30 minutes of physical activity every day.
My reward: I will watch an episode of my favorite TV show with
my friends while my wife and kids are out.
My support: My coworker Bob will go for a walk with me.
Total Time
How I Felt
5 minutes
20 minutes
It was hard, but it
felt good to finish.
Washing the
60 minutes
Fantastic! What a
gorgeous day to be
outside. Car looks
great now!
5 minutes,
2 times each
Went with Bob at
8 minutes
15 minutes
A little hard to
8 minutes
10 minutes
Good way to start
the weekend.
20 minutes
Pumped up the
music and got
Did I meet my goals? Why? If I didn’t, what will I
change next week?
I did meet my short-term goal, but not my long-term
goal. There just doesn’t seem to be enough time
in the day. I will keep working toward it by taking
longer walks and asking my wife to help me make
and stick to a schedule.
Had fun walking
through the produce
section and picking
out fresh fruits and
veggies for lunch.
Active at Any Size | 15
Print out this journal page to keep track of your efforts and
My Activity Journal
My short-term goal:
My long-term goal:
My reward:
My support:
Total Time
How I Felt
Did I meet my goals? Why? If I didn’t, what will I
change next week?
16 | Active at Any Size
Think positive!
Making regular physical activity part of your life is a big step!
Start slowly and applaud yourself for every goal you set and
Be patient. If you cannot achieve your goal the first time or you
only stick to the goals for part of the week, remind yourself
that this is part of establishing new habits. Review your goals—
were they doable? Did you hit a barrier to meeting your goal?
Brainstorm some options to overcome it in the future. Reach
out to a friend or family member to help support your goals.
Remember to pat yourself on the back for trying, and focus on
what you will do differently moving forward. Most importantly,
do not give up. Any movement—even for a short time—is a
good thing! Remember, each activity you add to your life is
another step toward a healthier you.
Active at Any Size | 17
Additional Reading from the Weight-control Information
The following publications are available online at and also
by calling WIN toll-free at 1–877–946–4627.
Changing Your Habits: Steps to Better Health explains
how people can take small steps to become more physically
active and consume healthier foods and beverages (available
online at
Tips to Help You Get Active offers tips to help readers become
more physically active, overcome barriers to activity, and stay
motivated (available online at
Walking…A Step in the Right Direction explains how to start
a walking program, presents a sample program, and shows
stretches for warming up and cooling down (available online at
18 | Active at Any Size
Additional Resources
2008 Physical Activity Guidelines for Americans
U.S. Department of Health and Human Services (HHS)
U.S. Department of Agriculture (USDA)
Dietary Guidelines for Americans, 2010
National Institute on Aging, National Institutes of Health
National Diabetes Education Program
National Kidney Disease Education Program
Inclusion of resources is for information only and does not imply
endorsement by NIDDK or WIN.
Active at Any Size | 19
Why should I participate in clinical trials?
Clinical trials are research studies involving people. Clinical trials
look at safe and effective new ways to prevent, detect, or treat
disease. Researchers also use clinical trials to look at other aspects
of care, such as improving the quality of life for people with chronic
illnesses. To learn more about clinical trials, why they matter, and
how to participate, visit the NIH Clinical Research Trials and You
website at For information
about current studies, visit
Weight-control Information Network
1 WIN Way
Bethesda, MD 20892–3665
Phone: 202–828–1025
Toll-free number: 1–877–946–4627
Fax: 202–828–1028
Email: [email protected]
Find us on Facebook:
The Weight-control Information Network (WIN) is a national information
service of the National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK), part of the National Institutes of Health (NIH).
WIN provides the general public, health professionals, and the media
with science-based, up-to-date, culturally relevant materials and
tips. Topics include how to consume healthy foods and beverages,
barriers to physical activity, portion control, and eating and physical
activity myths. Publications produced by WIN are carefully reviewed
by both NIDDK scientists and outside experts. This brochure was also
reviewed by Steven Blair, P.E.D., Department of Exercise Science,
Arnold School of Public Health, University of South Carolina.
This publication is not copyrighted. You are encouraged to download
the publication, make copies and distribute widely. This brochure is also
available at
Photography in this brochure was provided on behalf of the Yale Rudd
Center for Food Policy & Obesity.
20 | Active at Any Size
Emotions You have taken a very important step towards improving your health. This life changing surgery can have emotional as well as physical results. Healing from surgery is difficult. You experience pain, are limited in your activities, lack endurance and become easily fatigued. You are changing one of the most basic behaviors of all, eating. You are unlearning things, some of which you have done your whole life. Your feelings about yourself are changing, as perhaps are feelings others have about you. It is normal to have many different emotions as these changes happen. You may feel frustrated and angry as well as happy and proud. Each person is unique and will have a different emotional experience. As you recover 
Be aware of your emotions 
Acknowledge negative feelings 
If possible, talk with family and friends when you are emotionally vulnerable 
Set realistic expectations for yourself and others Feelings of loneliness, isolation, and withdrawal are signs that may lead to depressions. Talk with your family doctor or social worker if you feel that depression or anxiety is interfering with your ability to cope. Behavioral Health Service counselors are also available. Call toll free 1‐
888‐287‐2680 for more information. There are a variety of treatments available to help. See the Behavioral Health Services brochure found in the back pocket of this booklet for more information. 91 If you have Sleep Apnea Don’t just stop using CPAP/APAP/BiPAP Procedure for post Bariatric Surgery APAP/CPAP/BiPAP withdrawal 1. The patient in conjunction with the surgical support team will establish a goal weight. 2. The first APAP download will be at 50% of Goal.* A. If the 90th percentile APAP pressures on download is 6 cwp or less, a follow‐up test will be ordered to determine if OSA has resolved. B. If download 90th percentile pressure exceed 6 cwp the patient will continue with APAP use. 3. The second APAP download, if needed, will be at goal weight* A. If the 90th percentile APAP pressures on download is 6 cwp or less, a follow‐up test will be ordered to determine if OSA has resolved. B. If download 90th percentile pressure exceed 6 cwp the patient may still need to continue with APAP. The download will be forwarded to the sleep physician. He/She will determine if a follow‐up test is appropriate. Note: All Bariatric patients will be set up with an APAP with smart card or chip. This machine will adjust the pressures as weight is lost. * If the patient was started on CPAP and not APAP, an order for a 5 day autoset will be submitted to replace the download. 92 Hair Loss Yes it can happen, though not all patients will experience hair loss. This is thought to be due to the very low calorie diet, as it happens to those on very low calorie diets that have not had bariatric surgery. Hair loss is temporary. As your calories increase, the hair loss will lessen and stop over time. For prevention:  Eat adequate protein daily  Take supplements as prescribed  Take Biotin 3000mcg‐5000mcg daily (aka 3mg‐5mg)  Avoid coloring and perming your hair  Can use products like Nioxin that help to prevent hair loss o Found at hair salons and specialized beauty product stores Excess Skin This too can happen. The amount of excess skin after weight loss will depend on multiple factors, to include how much weight you loss, genetics and muscle tone. It will be important to keep the skin folds clean to prevent infection. If infections do occur, you should see your primary care physician for evaluation and treatment and to ensure that these are documented in your medical record. If you are interested in plastic surgery to remove excess skin, it’s important to know that the only procedures that have a chance of being covered are the abdominal pannus (panniculectomy) or breasts and that coverage is much like bariatric surgery, in that it must be medically necessary. Surgeries for cosmetic reasons are rarely covered. Some insurance contracts cover surgical procedures to remove excess skin when specific criteria have been met. These criteria are different for varying insurance contracts. You can discuss possible surgery with your primary physician who can place an authorization request for you. These requests are then reviewed by the specific health plan to determine whether you meet the criteria for coverage of the requested procedure. The most important thing you can do is to receive proper care for any skin infections and have them documented in your medical record. There are also garments that can be purchased that will hold skin in place, if plastic surgery is not something that you are interested in or your referral is denied. 93 94 Bariatric Resources Books & Cookbooks 
The Success Habits of Weight Loss Patients (Colleen Cook) Never Going Back (Al Roker) Weight Loss Surgery for Dummies Weight Loss Surgery Cookbook for Dummies Before and After: Eating Well After Weight Loss Surgery The Everything Weight Loss Surgery Cookbook The Good Life Weight Loss Surgery Cookbook The Emotional First Aid Kit: A Practical Guide to Life After Bariatric Surgery (Cynthia Alexander, PsyD) Bounderies: When to Say Yes, How to Say No, to Take Control of Your Life (Dr. Henry Cloud & Dr. John Townsend) The Seven Habits of Highly Effective People: Powerful Lessons in Person Change (Stephen Covey) Small Bites: Daily Inspiration for Weight Loss Surgery Patients (Katie Jay MSW & J. Persing) Obesity Surgery: Stories of Altered Lives (Marta Meana, PhD & Lindsey Ricciardi, PhD) Anatomy of a Food Addiction (Anne Katherine) Magazines 
Weight Loss Surgery Lifestyles Health Cooking Light Fitness Women’s Health Men’s Health Eating Well Online 
 (National Association for Weight Loss Surgery) Obesity Action Coalition 95 Cont… 
Weight Circles Thinner Times Bariatric Support Center Facebook (see our newsletter for Group Health patients Facebook page) American Bariatric Support Group Pinterest – Weight Loss Surgery Recipes Online Journaling Resources 
 Calorie‐ 96 Weight Loss Surgery Poem ☼__________________________________________________☼ Do you have cookies in your car? Are those chips not very far way? Is that soda in your glass? Was Weight Loss Surgery your choice to do? Or did someone force you to do it? If surgery was what you chose, Why are you still doing all of those things? Success begins with the wise choices that you make. Don’t let noncompliance be your mistake. The surgery you had was to assist you in changing. Your compliance is for success long term. So think before you decide to cheat. Remember the goals you want to meet. For surgery is not something you were forced to do. It was what you wanted for a healthier you. ☼__________________________________________________☼ 97 98 Glossary A Ambulation: Walking Analgestics: Medicine that relieve pain Anastomosis: A connection between tubular structures Anesthesia: Medicines used during surgery or other painful procedures to block the ability to feel pain Antibiotics: Medicine used to fight infections caused by bacteria Anticoagulation Medicine: Medines used to delay blood clot formation. Sometimes referred to as ‘blood thinners’ Arthritis: Inflammation of a joint usually accompanied by pain and frequently, changes in structure B Bariatric Surgery: An operation for control or treatment of obesity Blood Clot: Collection of blood proteins and cells that forms a mess to slow or block the flow of blood Blood Pressure: The amount of force pushing against the walls of blood vessels as blood flows through them Blenderized: See Pureed C Cardiac: Pertaining to the heart Cardiologist: Physician specializing in treatment of heart disease D Diabetes: A disorder of carbohydrate metabolism characterized by increased blood glucose levels resulting from inadequate production or utilization of insulin Digestive Enzymes: Chemical substances that act on food causing it to break down to simpler compounds for use by the body Dumping Syndrome: A condition characterized by sweating and weakness after eating. Exact cause is unknown, but rapid emptying into the small intestine is associated with the symptoms 99 E Electrocardiogram (EKG): A record of the electrical activity of the heart Endoscopically: A procedure by which a tube and a means for visualization are passed through a natural body opening or incision to allow for inspection or manipulation Embolism: A blockage of a blood vessel by an air bubble, blood clot or other foreign body Electrolytes: Ions or elements in the body, including potassium, calcium, and magnesium that are essential to life G Gallbladder: Sac attached to the liver for storage of excess bile Gallstones: Lump of solid matter formed in the gallbladder Gastroenterologist: Physician specializing in treatment of stomach, intestines and related structures such as esophagus, liver, gallbladder and pancreas Gastrografin Study: Xray of the stomach and surrounding structures Graze: Continued sampling of small amounts of food H Hernia: Protrusion of an organ or tissue through an opening in its surrounding walls, especially the abdomen Hypertension: High blood pressure I Incentive Spirometer: A device used to induce deep breathing Informed Consent: Agreement to undertake a course of action based on disclosure of complete information Intravenous Line: A small plastic tube inserted with a needle into a vein. The needle is removed but the flexible tube remains in place and is attached by other tubing to a bag of fluids. The IV is used to give fluids, medications and any blood products, as needed IV: See Intravenous Line J Jejunum: The second section of the small intestine beginning about 8 to 11 inches from the stomach and extending about 8 feet. The products of digested food are absorbed through the surface lining the intestine 100 L Laparoscopic Procedure: A technique which allows the surgeon to perform an operation through small incisions and the use of an instrument by which to visualize the are of interest inside the body Liver Enzymes: See Digestive enzymes M Marginal Ulcer: See Ulcer Malaborption: Disordered or inadequate absorption of nutrients from the small intestine N Nasal Cannula A soft tube which directs oxygen to the nares of the nose Nasogastric Tube: Soft plastic tube passed through the nose and throat into the stomach NG Tube: See Nasogastric Tube O Open Procedure: Operative technique which provides full, unobstructed visualization and manipulation of the areas of interest and surrounding tissues Oxygen Saturation: Amount of oxygen in the blood available for use by the body P Pneumonia: Inflammation of the lungs Postoperative: Events or activities occurring after a surgery or procedure Pre‐Operative: Events or activities occurring before a surgery or procedure Pulmonary: Pertaining to the lungs Pulmonologist: A physician specializing in diseases of the lungs Pulse Oximeter: A device used to measure the amount of oxygen circulating in the blood Pureed: To process and strain to make smooth R Reflux: A return or backward flow Roux‐en‐Y Gastric Bypass: A type of operation performed to treat obesity by dividing the stomach to reduce its size while maintaining absorption activities of the small intestine 101 S Saline Lock: Site of IV that is disconnected from the tubing and bag and capped where a small plastic tube enters the skin. Allows for continued access to the vein for the intermittent administration of fluids, medications, or blood products without continuous infusion Satiety: Sensation of being full especially of food Sleep Apnea: Periods of not breathing occurring during sleep Sleeve Gastrectomy: A type of operation performed to treat obesity by removing a portion of the stomach to reduce its size while maintaining absorption activities of the small intestine Stricture: A narrowing or constricture of the opening of a tube, duct or hollow organ T Transfusion: Transfer of blood or blood products U Ulcer: An open sore on the skin or any surface of the body Ultrasound: The use of high frequency sound waves to outline the shape of various tissues and organs in the body V Vital Signs: The indicators of the life processes such as temperature, heart rate, breathing rate and blood pressure 102 Document Your Measurements Weight Jan Feb March April May June July August Sept Oct Nov Dec Waist Chest Thigh Arm Wrist Ankle Calf Neck Hips Shoe Size Dress Size Pant Size 103