Download Bariatric Surgery Program at Sunrise Hospital Sleeve Gastrectomy (VSG) Everything. For Your Everything.

Bariatric Surgery Program
at Sunrise Hospital
Sleeve Gastrectomy (VSG)
Everything. For Your Everything.
Table of Contents Nutritional Guidelines for Vertical Sleeve Gastrectomy……………………. 2 How to Prepare for Surgery …………………………………………………. 3 Potential Dietary Issues Following Weight Loss Surgery…………………… 4 Protein: A Necessary Part of Your Diet……………………………………… 8 Protein Supplements ………………………………………………………… 9 Caffeine……………………………………………………………………… 10 Required Vitamin and Mineral Supplements……………………………….. 11 Diet Stages and Recipes…………………………………………………… 14 Foods That May be Difficult to Tolerate after Weight Loss Surgery………. 28 Signs & Symptoms of Dehydration…………………………………………. 29 Instructions for Liquid Diet before Surgery…………………………………. 30 Additional Resources……………………………………………………….. 31 1 Nutritional Guidelines for Vertical Sleeve Gastrectomy Purpose: This diet is designed to restrict caloric intake to produce desired weight loss, to help develop appropriate eating habits, to keep you safe immediately after surgery, and maintain your nutritional and overall health. Main Focus: 1. Drink enough fluids to keep your body hydrated. 2. Eat adequate protein. 3. Take required vitamin and mineral supplements to meet Recommended Daily Allowances. Diet Principles: 1. Drink 6­8 cups of fluid each day. a. Sip one cup of liquid over an hour b. Do not drink during meals, and do not resume drinking fluids until 30 minutes after meals c. Sip allowed beverages slowly d. Do not use a straw 2. High calorie foods, beverages, and snacks are omitted. 3. Take vitamins and minerals for life. Refer to the required vitamin and mineral supplements section of this booklet. 4. Eat very slowly; allow 20‐30 minutes for a meal. 5. Chew food thoroughly, at least 20‐30 times to the consistency of toothpaste before swallowing. 6. Stop eating as soon as you are full. Indications of fullness are: a. A feeling of pressure in the center just below your rib cage b. A feeling of nausea c. A pain in your shoulder area or upper chest. Contact your doctor if the above symptoms persist or worsen. 7. Eat protein first at each meal. As you heal and your diet advances, you may only need to eat 3 meals and 1‐2 high protein snacks each day. 8. Limit caffeine & coffee intake. Caffeine may cause dehydration and gastric reflux. Caffeine free beverages are preferred. 9. Avoid carbonated beverages. Carbonation may cause abdominal discomfort, avoid completely early post‐op, and avoid on a daily basis thereafter. 10. Avoid alcohol. Alcohol is full of excess calories and may cause ulcers if consumed in excess. 2 How to Prepare for Surgery Start preparing for surgery today! Accomplishing just a few of the following suggested changes will make it easier to transition to new eating patterns after surgery. 1. Start taking a multivitamin plus iron and calcium plus vitamin D supplements before surgery. This will help you prepare for taking vitamins after surgery and improve your nutritional health. 2. Practice eating your meals without drinking fluids. 3. Take small bites and chew very well. Use small plates and utensils and practice eating from these. 4. Reduce your caffeine intake, but do so slowly to avoid harsh withdrawal symptoms. 5. Reduce or give up carbonated beverages. Try to get down to only one carbonated beverage per day before starting the preoperative diet. Once starting the preoperative diet, you are no longer allowed to have carbonated beverages. 6. Carry a beverage container with you at all times. This will help you get in the habit of drinking fluid throughout the day. Do not chug fluids. Practice taking small, frequent sips. 7. Identify your trigger foods. Trigger foods are different for everyone. These are foods you turn to when you have cravings, are stressed, bored, etc. Once identified, think of ways to help you handle your triggers better after surgery. 8. Eat more vegetables, fruits, and whole grains to improve your overall health for surgery. Aim to have 1‐2 cups of fruit, 2‐3 cups of vegetables, and 3 servings of whole grains each day. 9. Practice eating 3 meals each day. Planning your meals ahead of time is the easiest way to help you change habits. Identify ways to help you avoid skipping meals or grazing between meals. 10. Keep a food record to help you identify ways to improve your current diet and prepare for after surgery changes. Research show people who write down what they eat and drink lose more weight! After surgery, a food record will help you keep track of how much protein and fluid you are consuming each day. 11. Go shopping. Purchase products you will need for the first couple of weeks after surgery. 3 Potential Problems Following Weight Loss Surgery and Suggested Dietary Modifications Nausea and Vomiting One of the main causes of nausea and vomiting after surgery is not following the nutrition guidelines. If nausea and vomiting occur after eating a new food, wait several days before trying that food again It may be necessary to return to liquids or pureed foods temporarily Eating/drinking too fast may cause nausea or vomiting Eating/drinking too much may cause nausea or vomiting Insufficient chewing may cause nausea or vomiting Avoid cold beverages and those with caffeine or carbonation If nausea and vomiting persists, call your surgeon Pain in shoulder or upper chest area (occurs when you eat too much or eat something hard to digest) Stop eating if pain occurs during eating and try to eat later after pain has resolved If pain persists, call your surgeon Dehydration (see page titled “Signs & Symptoms of Dehydration for more information) Dehydration can occur with inadequate fluid intake, persistent nausea, vomiting or diarrhea. At least 6‐8 cups of fluid a day are recommended Avoid caffeine Lactose Intolerance/Diarrhea Lactose intolerance is the inability to digest significant amounts of lactose, the major sugar found in milk. Lactose intolerance is caused by a shortage of the enzyme lactase, which is produced by the cells that line the small intestine. Common symptoms of lactose intolerance, which range from mild to severe, include nausea, cramps, bloating, gas, and diarrhea. Symptoms begin about 30 minutes to 2 hours after eating or drinking foods containing lactose. The severity of symptoms depends on many factors, including the amount of lactose a person can tolerate, age, ethnicity, and digestion rate. Most adults do not have to avoid lactose completely, but people differ in the amounts and types of foods they can handle. For example, one person may have symptoms after drinking a small glass of milk, while another can drink one glass but not two. Others may be able to manage aged cheeses, such as cheddar and Swiss, but not other dairy products. People can also tolerate more lactose by having smaller amounts of it at one time. The level of dietary control needed with lactose intolerance depends on how much lactose a person’s body can handle. Use Lactase‐treated milk and lactase enzyme tablets Try low fat Lactaid®, Dairy Ease®, or soy milk 4 Constipation After surgery, given the drastic change in your eating habits, your bowel habits will change. Be prepared that you will not likely have a bowel movement every day given the reduced intake of food. After surgery it is common to have a bowel movement every two to three days. Ensure you are getting adequate fluid (minimum of 64 ounces per day) between meals Increase your fiber intake as your diet progressions allows (fruits, vegetables & whole grains are the best sources of dietary fiber) Getting adequate exercise often helps You may need to add a stool softener or fiber supplement, speak with your dietitian or surgeon about available products If these suggestions do not resolve the problem, you can consider taking a fiber supplement or flaxseed meal. Fiber Supplements Benefiber® (may be purchased at pharmacies) FiberSure® (may be purchased at grocery stores) LiquaFiber™ (may be ordered online at www.globalhp.com) These products can be added to food or liquid without changing taste or consistency. Flaxseed Flaxseed is a good source of heart‐healthy omega‐3 fatty acids and an excellent source of both insoluble & soluble fiber. Adding 1‐2 tablespoons daily to your diet may help with bowel regularity. If you are interested in adding flaxseed to your diet, start slowly with 1‐2 tsp daily and be sure to buy flaxseed meal (already ground flaxseed) instead of the whole seeds. It will need to be stored in the freezer to prevent the fat from going rancid. Flaxseed meal may be sprinkled over yogurt, added to cereal, or added to any other food/beverage you consume. Diarrhea Limit high fiber, greasy foods, milk and milk products Avoid very hot or cold foods Eat smaller meals Sip fluids between meals If diarrhea persists, call your surgeon Bloating Limit liquids to 2 oz at one time Sip slowly 5 Gastroesophageal Reflux Disease (GERD) Patients may experience GERD symptoms following sleeve gastrectomy. GERD occurs when gastric contents reflux (backward motion) in to the esophagus. It is recommended that a trial of limiting or eliminating the following foods may reduce the symptoms of GERD: Carbonated beverages Chocolate Alcohol Caffeinated beverages (regular tea, coffee, colas, energy drinks) Pepper High‐fat foods, including: o 2% milk, whole milk, cream, high‐fat cheeses, high‐fat yogurt, chocolate milk, cocoa o Fried meats, bacon, sausage, pepperoni, salami, bologna, frankfurters/hot dogs o Other fried foods (doughnuts, French toast, French fries, deep‐fried vegetables) o Nuts and nut butters o Pastries and other high‐fat desserts o More than 8 teaspoons of oil, butter, shortening per day o Any fruits or vegetables that cause symptoms (these will vary from person to person) Avoid drinking from a straw Avoid overeating Taste/Sensory Changes This may occur during the first few months after surgery but will resolve over time Some foods may taste too sweet or have a metallic taste Strong smells from cooking may affect you, try to avoid the kitchen while someone else is cooking Blockage of the Stoma (opening of the stomach) The stoma may be temporarily blocked if foods with large particle size are eaten without thorough chewing If symptoms of pain, nausea, and vomiting persist, contact your surgeon Do not progress to solid foods until your surgeon tells you to Rupture of the staple line after surgery Rupture of the staple line is unlikely; however, avoid eating an excessive quantity of food at one time 6 Stretching of the stomach pouch Avoiding large portions of food at one time can reduce the risk of stretching the stomach pouch The risk can be decreased by gradually increasing the texture of foods in the early post‐operative weeks Follow the recommendations for advancing your diet to prevent risk of stretching Avoid carbonated beverages Weight gain or no further weight loss You might be eating high calorie foods or beverages Keep a record of all foods, beverages and snacks eaten to determine the exact reason for this Measure portions sizes Avoid prolonged use of nutritional supplements such as Ensure, Boost, etc. Use only low calorie beverages in addition to fat free milk Increase physical activity 7 Protein – A Necessary Part of Your Diet Protein is the nutrient responsible for maintenance of all of the tissues in your body. This includes bone, muscle, organs and even hair and skin. In addition, protein helps the body function properly and is essential for healing. The average woman needs 50‐60 grams of protein a day and the average man needs 60‐70 grams of protein a day to stay healthy. After weight loss surgery, your minimum protein intake is 60 grams a day. Tips to help you maintain adequate protein intake: Your best sources of protein are: lean beef, poultry, fish, milk, dairy products and eggs. Make sure you use low‐fat dairy products, lean cuts of meat, white or dark meat of poultry without the skin, eggs or egg substitutes. When preparing your protein foods avoid frying. This adds extra fat and may cause you discomfort. Bake, broil, poach, or grill your foods instead. Also, choose low‐fat or fat‐free products, as much as possible. As soon as your doctor allows, begin to drink fat free milk throughout the day (if milk makes you feel bloated or nauseated, you may want to switch to low fat lactose free milk, such as Lactaid®, or soy milk). It is important to start your meal with the protein portion and finish as much of it as you can. During the pureed and soft phases: Try strained low‐fat cream soups like cream of chicken (many condensed soups can be made with fat free milk to reduce the fat). Use low‐fat cottage cheese, ricotta, and light or non‐fat yogurt at meals. Begin pureeing low‐fat cuts of meat, poultry, or fish or use baby food meats. Eat scrambled eggs or egg substitutes. As your diet advances further, continue to: Eat the high protein foods first Drink fat free milk throughout the day If you have trouble tolerating milk or other protein sources, you may want to use commercial protein powder as recommended by your dietitian. These items can be found in pharmacies, nutrition stores, and supermarkets 8 Protein Supplements The following are a few examples of protein supplements available on the market. These products should be used as a meal replacement. Rule of thumb: Protein supplements should contain less than 200 calories, less than 20 g of carbohydrates and at least 15 g of protein per serving. The main protein ingredient is whey protein, soy protein, or albumen protein. Protein should be the first ingredient. If the product is pre‐made (AKA “ready to drink”) the first ingredient will be water, but the second should be one of those three proteins. Also, check with your dietitian or surgeon before using any other products that are not listed on this page. Some products contain large amounts of other substances (i.e. caffeine, hidden sugars, herbs) or they may interact with medications. Disclosures: The product references following do not necessarily constitute endorsement by Sunrise Hospital & Medical Center. Manufacturer Product Name Portion Size Calories Protein(grams) Nestle “No Sugar Added: Carnation 1 packet + 1 cup 150 13 ®
Instant Breakfast with 1 fat free milk or 1% cup fat free or 1% milk or milk or Lactaid® ®
Lactaid GNC Pro Performance® 100% 1 scoop 130 20 Whey protein NEXT Proteins Designer Whey™ Protein 1 scoop 90 18 Powder Slim Fast “Low Carb Diet” or “High 11 oz 180 20 Protein” Slim Fast® 190 15 Natures Best Isopure Zero Carb 20 oz 160 40 ®
MET­Rx Protein Plus Powder 1 scoop 70 15 Resource Optisource™ High Protein 8 oz 200 24 Drink EAS Advant Edge® 11 oz 100 15 Syntrax Nectar Fuzzy Navel, 1 scoop 90 23 Innovation Lemonade, Apple, etc Novartis Glucose Control Boost 8 oz 190 16 Atkins Advantage 11 oz 170 20 Non‐fat powdered milk 2 Tbsp 50 6 **Be sure to read the food labels on all products. The protein and calorie amount may vary with different flavors. 9 Caffeine – A Little Can Be Too Much Caffeine is a stimulant and is naturally found in more than 60 plants, including cocoa, tea, and coffee. Caffeine is also added to soft drinks and is often a component of many over‐the‐counter medications and dietary supplements including certain protein powders and drinks. Caffeine temporarily speeds up the body’s heart rate, boosts energy and is often used to “fight fatigue”. Caffeine acts as a diuretic, which means loss of fluids. As a result, caffeine can leave you feeling thirsty if used as your main source of fluid intake. The recommended intake of caffeine is defined as 300 milligrams, or no more than three 5 ounce cups of coffee per day. However, it is best to AVOID caffeine after surgery. For every 8 oz of a caffeinated beverage you drink, you would have to consume an additional 8 oz of a non‐caffeinated beverage. If you continue to drink caffeine after surgery, it will be very difficult for you to meet your fluid goals. If your diet contains a large amount of caffeine, you should decrease your intake gradually to prepare for surgery. This will help to avoid headaches caused by caffeine withdrawal. 10 Required Vitamin and Mineral Supplements after Vertical Sleeve Gastrectomy You will not be able to meet certain vitamin and mineral needs without supplementation. Vitamin and mineral deficiencies have been observed in patients after weight loss surgery. Iron, vitamin B12, calcium, and vitamin D are most affected after sleeve gastrectomy. It is very important that you take multivitamins every day of your life and that you are monitoring your vitamin status by keeping your follow‐up visits with the Surgical Weight Loss Clinic. It is recommended you take only chewable or liquid vitamins for one month after surgery. **DO NOT purchase Centrum Silver or Viactiv chewable vitamins – these contain inadequate amounts of necessary nutrients for patients after surgery. Required vitamin & mineral supplementation includes: Mandatory Dosage/Day Multi­Vitamin and Mineral 2 Vitamin B12 500 mcg Calcium Citrate with Vitamin D 1200‐2000 mg As Directed by Physician Iron 27‐28 mg Vitamin C 500 mg Zinc 10‐20 mg Stool Softener As directed Mandatory 1. Multi‐vitamin and Mineral Dosage: 2 daily *Type: Please refer to pg. 13 for a list of multi‐vitamins/minerals that contain the minimum of nutrients required after surgery Function: Multi‐vitamins will help ensure that you are getting enough of all the micronutrients that you need. Interactions: Do not take with calcium supplement or with foods that contain calcium. 11 2. Vitamin B12 Dosage: 500 micrograms tablet or sublingual daily or 1000 micrograms monthly of injectable B12 Type: Any sublingual (dissolves under tongue), tablet, or monthly injection (prescribed by your surgeon) Function: Helps with blood cell and nerve function, digestion and absorption of food, and protein synthesis. Deficiency may cause certain types of anemia. Interactions: None 3. Calcium citrate with Vitamin D Dosage: 1200‐1500 mg daily. Calcium is best absorbed in doses of 500‐600 mg at a time. Take with meals. Type: Tums® initially, once tolerating regular diet switch to Citracal®+D or any equivalent brand with calcium citrate. The citrate form of calcium is better absorbed since it doesn’t require the acid from your stomach to be absorbed. Function: Maintains bone strength; also helps heart pump correctly and repairs soft tissue. Interactions: Caffeinated products, spinach, and whole grain products may decrease absorption. Take at least 1‐2 hours before or after taking iron, since calcium will decrease iron absorption. As Directed by Physician 4. Iron Dosage: 27‐28 mg of elemental iron daily. Take with vitamin C. Type: Any tablet of ferrous sulfate, gluconate, or fumarate that is equivalent to 27‐28 mg of elemental iron. Prenatal vitamins may already have enough iron in each tablet. Read the label first to see if additional supplementation is required. Function: Vital to the formation of red blood cells that provide oxygen to the entire body. Interactions: Take 1‐2 hours before or after taking calcium. Do not take with milk, cheese, eggs, whole‐grain breads and cereals. May cause diarrhea or constipation. 5. Vitamin C Dosage: 500 mg daily. Take with iron. Type: Any capsule, chewable tablet or liquid form. Function: Plays a role in body’s calcium levels and bone formation. Promotes wound healing and reduced changes of infection. Enhances iron absorption. Interactions: Antacids may decrease absorption. Take Vitamin C at a different time if using Antacids. 12 The following list is not inclusive, but provides the names of some brands that do contain the minimum level of nutrients required after gastric bypass. You can review them with your physician or dietitian. RDA for males RDA for females Tablets Centrum Centrum Performance CVS Naturalized Spectravite Tablet, With Lutein and Lycopene CVS Daily Multiple Plus Minerals A thru Z Advantage One‐A‐Day Maximum Equate MVI for Adults Complete MVI Rite Aid Central‐Vite Rite Aid Central‐Vite Multivitamin/Mineral, Tablets Super Aytinal for Active Adults Walgreens Premium Formula A thru Z Advantage, Multivitamin/Multimineral Supplement with Herbs Tablets Walgreens Windmill Maximum Formula Daily Vitamin Chewable Centrum Adult Chewable Centrum Kids Chewable CVS Chewable Spectravite Flintstones Chewable Chewable, aspartame­free (with fructose, sorbitol, sucrose, manitol, or xylitol) GNC MultiBite Complete Kangavites Complete Liquid Centrum Liquid Powder ONE A DAY Energy Advantage 2O Multivitamin/Multimineral Supplement Drink Mix (mix w/water)
Serving (Tablet) Vit K (mcg) Biotin (mcg) Zinc (mg) Thiamin (mg) B12 (mcg) Folic Fe Acid (mg) (mcg) 400 8 400 18 500 18 400 18 400 18 ‐‐‐‐‐‐‐‐‐ ‐‐‐‐‐‐‐‐‐ 1 1 1 120 90 25 25 25 30 30 30 50 30 11 8 11 11 15 1.2 1.1 1.5 4.5 1.5 2.4 2.4 6 18 6 1 1 1 1 1 1 25 25 25 25 25 25 30 40 30 30 30 30 15 15 15 11 15 15 1.5 4.5 1.5 1.5 1.5 1.5 6 18 6 6 6 6 400 400 400 500 400 400 18 18 18 18 18 18 1 1 25 25 40 50 15 11 5 4.5 12 218 400 400 25 18 1 25 30 15 1.5 6 400 18 1 1 1 1 25 10 10 0 30 45 45 40 15 15 15 15 1.5 1.5 1.5 1.5 6 6 6 6 400 400 400 400 18 18 18 18 1 1 1 Tbsp (15 mL) 1 packet 0 0 0 50 50 300 1.5 1.5 3 2.5 0.75 1.5 5 3 6 200 100 0 6 2.5 9 30 450 8 4.2 23 600 8 13 STAGE I CLEAR LIQUIDS (1­2 days) 1. After surgery, you will not eat any food or drink any liquids until approved by the surgeon. 2. Once approved, you will receive water, sugar‐free gelatin (no red while in hospital)*, broth, and decaffeinated** tea. You will only be able to drink 1 oz every hour. If you tolerate 1 oz of liquid each hour, you may advance to 2 oz of liquid every hour. If you experience nausea, decrease amount to 1 oz every hour. a. No carbonation b. No sugar c. No calories d. No caffeine e. No alcohol 3. Once at home, you may drink as tolerated. You SHOULD NOT continue to drink just 2 ounces an hour. Listen to your body, stop when you feel full. Aim for a total of 64 ounces of fluid daily. 4. Remember to drink liquids SLOWLY. DO NOT use a straw***. 5. There may be large quantities of liquids brought to you on your tray. You do NOT have to finish everything. When you feel full STOP! 6. It is not unusual to experience nausea and/or vomiting during the first few days following surgery. Make sure that you drink slowly. If nausea or vomiting persists contact your nurse. *If “red foods” are consumed after surgery and you vomit, it may be mistaken for blood. “Red foods” include foods on the clear liquid diet such as sugar‐free gelatin, sugar‐free popsicles, or any “red” sugar‐free beverages. **Caffeine should be avoided after surgery because it is a diuretic. This will cause you to lose fluids and make it difficult for you to keep yourself hydrated. ***If you drink from a straw after surgery you will cause air to enter into your new pouch. This will create a full feeling and you will have less room for liquids needed to keep hydrated as well as nutritious foods when you advance to those stages. 14 STAGE II FULL LIQUID DIET 1. Upon discharge from the hospital you will start on the full liquid diet (typically begins on post‐op day 3). 2. You will stay on the full liquids for 10‐14 days, unless directed otherwise by the Surgeon and Registered Dietitian. 3. To prevent nausea and vomiting, DRINK LIQUIDS SLOWLY. At each meal, sip ¼ cup (2 oz), or more if tolerated of a liquid protein source over 30 minutes. You do NOT have to finish everything. When you feel full STOP! 4. Drink at least 6‐8 cups of water or low calorie drinks between high protein beverages. Remember to avoid carbonation, caffeine, and citrus. 5. Take your prescribed multi‐vitamin/mineral supplements and calcium as instructed. (Refer to page 11, titled “Required Vitamin and Mineral Supplements after Vertical Sleeve Gastrectomy” for a list of all mandatory supplements) 6. Make sure you keep track of the kind and amount of high protein beverages you drink. Remember, you need a minimum of 60 grams of protein each day. The following are examples of protein sources that should be included on the Full Liquid Diet: 1 cup Fat free or 1% milk= 8 grams protein 1 cup Soy milk or low fat lactose‐free milk (Lactaid®, or Diary Ease®)= 8 grams protein No‐sugar added breakfast drink made with fat free or 1% milk (Carnation Instant Breakfast®)= 12 grams protein 1 cup of strained low fat cream soup made with milk (no tomato, no mushroom or corn pieces)= 8 grams protein Commercial supplements as suggested by the surgeon or RD (refer to list on page 9, titled “Protein Supplements”) *To help boost protein intake add non­fat powdered milk to the above list of liquids. (1 Tbsp=3 grams of protein, 25 calories) 15 STAGE II – Full Liquid Diet SAMPLE MEAL PLAN Below is a sample meal plan that you may use while on the Full Liquid Diet. This meal plan provides 60 grams of protein and 6‐8 cups of fluid. Portions may vary with EACH INDIVIDUAL. Make meals last 30 minutes. Time Amount Food 8:00 ¼ cup Breakfast drink with fat free milk 3 3 Tbsp Non fat powdered milk 9 Liquid between meal 1 cup Water or low calorie beverage 10:00 ¼ cup Creamy peanut butter shake 5 Liquid between meal 1 cup Fat free milk 8 12:00 ¼ cup Breakfast drink with fat free milk 3 3 Tbsp Non fat powdered milk 9 Liquid between meal 1 cup Water or low calorie beverage 2:00 ¼ cup Creamy peanut butter shake 5 Liquid between meal 1 cup Fat free milk 8 4:00 ¼ cup Yogurt smoothie 6 Liquid between meal 1 cup Water or low calorie beverage 6:00 ¼ cup Yogurt smoothie 6 Liquid between meal 1‐2 cups Water or low calorie beverage Total Protein Protein (grams) 62 The “Liquid between meal” should be sipped slowly between meal times. If you feel full STOP, you do not have to finish everything! If you do not tolerate milk, try lactose free milk (Lactaid®) or soy milk instead. Recipes for the “Yogurt Smoothie” and “Creamy Peanut Butter Shake” are on the following page. You may choose from the other recipes and make substitutions. If you find additional recipes, check with your dietitian first to make sure they meet the diet guidelines. 16 RECIPES FOR FULL LIQUID DIET Creamy Peanut Butter Shake 2 Tbsp CREAMY peanut butter ¼ cup powdered milk/powdered soy protein 1 package of sugar substitute 2 ice cubes ½ soft banana ½ cup water Place all ingredients in a blender and blend until smooth. Makes about 1 cup. Yields: 20 grams of protein per recipe 5 grams per ¼ of recipe Yogurt Smoothie 1 container (6 oz) of light or non‐fat yogurt (any flavor) ½ cup fat free milk, soy milk, or lactose‐free milk ¼ cup powdered milk ½ banana or ½ cup canned “lite” peaches Place off ingredients in a blender and blend until smooth. Makes about 1 cup. Yields: 24 grams of protein per recipe 6 grams per ¼ of recipe Mexican Chocolate Shake 1 can Chocolate “Low Carb” Slim Fast® 1 scoop Designer Whey® vanilla or chocolate protein powder Dash of cinnamon ½ tsp vanilla 3 ice cubes Place all ingredients in a blender and blend until smooth Yields: 38 grams of protein 17 RECIPES FOR FULL LIQUID DIET Tropical Shake 1 packet of Vanilla “No Sugar Added” Carnation Instant Breakfast® 1 cup of fat free milk, soy milk, or lactose‐free milk 1 scoop vanilla Designer Whey® protein powder ½ banana ¼ tsp coconut extract 3 ice cubes Place all ingredients in a blender and blend until smooth. Yields: 30.5 grams of protein Higher Protein Strawberry Shake 1 packet of Strawberry “No Sugar Added” Carnation Instant Breakfast® 1 cup of fat free milk, soy milk, or lactose‐free milk 1 scoop vanilla Designer Whey® protein powder 3 ice cubes Place all ingredients in a blender and blend until smooth. Yields: 30.5 grams of protein Cream of Chicken or Mushroom Soup 1 can of cream of chicken or mushroom soup 1 cup of fat free milk, soy milk, or lactose‐free milk Heat soup, stirring frequently until it just comes to a boil. Strain soup and discard chicken pieces and mushrooms. Add 2 tbsp of non fat powdered milk to EACH ½ cup serving and mix until blended. Enjoy with a twist of fresh ground pepper. Yields: 10 grams protein per ½ cup serving 18 STAGE III PUREE DIET 1. After 10‐14 days on the Full Liquid diet, you will be able to SLOWLY add foods of a thicker consistency. All food for the next 7 days will be BLENDED to a APPLESAUCE consistency. 2. You can continue to include foods on the full liquid diet throughout this stage. 3. It is very important to CHEW foods thoroughly to avoid blockage or nausea. Try 1‐2 Tbsp of food at a time to see if tolerated. Each meal should consist of only 2‐4 Tbsp (1/8 – ¼ cup of food). 4. Remember to always eat PROTEIN FIRST at each meal. You need a minimum of 60 grams of protein each day. 5. Keep yourself hydrated! Drink 6‐8 cups of water and low calorie beverages between meals. Fat free or 1% milk can be included as part of your total fluid intake. 6. Continue to keep track of the kind and amount of protein you eat every day. The following are examples of foods from each food group that should be included on the Puree (Blended) Diet. The meat and milk group include food choices that are “complete” proteins. “Complete” proteins contain all the essential amino acids your body needs. Food choices from the starch, fruit, and vegetable groups are not “complete” proteins and should only be used with foods from the milk and meat group. Meat Group (7 grams protein per serving) 2 Tbsp (1 ounce) cook pureed lean meats (chicken, fish, turkey are best tolerated) ¼ cup (2 ounces) baby food meats ¼ cup fat free or 1% cottage cheese (mash it with a fork to a smooth consistency) ¼ cup low fat ricotta cheese ¼ cup egg substitutes Milk Group (8 grams protein per serving) 1 cup fat free or 1% milk ¾ cup light or non‐fat yogurt (no fruit pieces) 1 cup sugar free pudding made with fat free or 1% milk 1 cup strained low fat cream soup made with milk (no tomato, no mushroom or corn pieces) Starch Group (3 grams of protein per serving) ½ cup cream of wheat/rice/baby oatmeal ½ cup mashed potatoes, sweet potatoes, winter squash 1 cup broth based soup 19 Fruit Group (0 grams protein per serving) ½ cup pureed peaches, apricots, pears, melon, banana (no skins or seeds) ½ cup unsweetened applesauce ½ cup baby food fruits ½ cup diluted unsweetened fruit juice (limit to 1 serving a day) Vegetable Group (2 grams protein per serving) ½ cup pureed carrots, green beans (no skins or seeds) ½ cup baby food vegetables Important Tips: 1. You may need to add fat free milk, clear broths, or fat free gravies to the above foods and use a blender to make the foods a APPLESAUCE consistency. 2. Add non‐fat powdered milk or acceptable protein powders to your foods to boost protein amount. 3. Try one new food at a time. If you feel nauseated or experience gas or bloating after eating, then you are not ready for this food. Wait a few days before trying this food again. 4. Portions may need to be adjusted depending on your individual tolerance. Listen to your body. Stop when you feel full. 20 STAGE III ­ PUREE DIET SAMPLE MEAL PLAN Below is a sample meal plan that you may use while on the Puree (Blended) Diet. This meal plan provides 60 grams of protein and 6‐8 cups of fluids. Portions may vary with EACH INDIVIDUAL. Make meals last 30 minutes. Time Amount 8:00 ¼ cup Pureed 1% milkfat cottage cheese 7 2 Tbsp Non fat powdered milk 6 Liquid between meal 1 cup Water or low calorie beverage 10:00 ¼ cup Light or non fat yogurt 2 2 Tbsp Non fat powdered milk 6 Liquid between meal 1 cup Fat free milk 8 12:00 ¼ cup Strained cream of mushroom soup made with fat fee milk 2 2 Tbsp Non fat powdered milk 6 Liquid between meal 1 cup Water or low calorie beverage 2:00 ¼ cup Sugar free vanilla pudding with fat free milk 2 Liquid between meal 1 cup Fat free milk 8 4:00 ¼ cup Baby food chicken and gravy 7 Liquid between meal 1 cup Water or low calorie beverage 6:00 ¼ cup Light or non fat yogurt 2 2 Tbsp Non fat powdered milk 6 Water or low calorie beverage Liquid between meal 1‐2 cups Total Protein Food Protein (grams) 62 21 STAGE IV SOFT DIET 1. After following the Puree Diet for 7 days, you will no longer have to blend your foods. You can slowly add foods that are soft in consistency. Food textures should include: moist, minced, diced, ground, pureed. If you can’t chew to “mush” in your mouth… don’t swallow. 2. You will remain on the Soft Diet for a minimum of 14 days. Remember to try one new food at a time. 3. For better portion control use smaller plates and baby spoons and forks. Stop eating when you feel full. 4. Keep yourself hydrated! Drink 6‐8 cups of water and low calorie beverages between your meals. Don’t drink with your meals. Don’t drink 30 minutes before and 30 minutes after meals. 5. Continue to take your supplements as prescribed. 6. Continue to keep track of the kind and amount of protein you eat every day. Remember, your goal is a minimum of 60 grams of protein each day. The following are examples of foods from each food group that can be included on the Soft Diet. Meat Group (7 grams protein per serving) 2 Tbsp (1 ounce) cooked lean meats: fish, ground turkey, lean ground beef (moist meats are usually tolerated best, beef is usually least tolerated) 2 Tbsp (1 ounce) water packed tuna or chicken ¼ cup egg substitute or 1 egg scrambled ¼ cup fat free or 1% cottage cheese 1 oz (1 slice) low fat mild cheese 1 Tbsp CREAMY peanut butter – reduced fat ¼ cup tofu (3.5 grams of protein) 1 oz lean meatballs ½ cup chili Milk Group (8 grams protein per serving) 1 cup fat free or 1% milk ¾ cup light or non‐fat yogurt (no fruit pieces) 1 cup sugar free pudding made with fat free or 1% milk 1 cup low fat cream soup made with milk (no tomato, no mushroom or corn pieces) Starch Group (3 grams protein per serving) 1 slice of bread (toasted) 4‐6 crackers ½ cup cooked cream of wheat/rice/oatmeal ½ cup mashed potatoes, sweet potatoes, winter squash 1 cup broth based soup 22 Fruit Group (0 grams protein per serving) ½ cup canned peaches or pears (in own juices or water packed) ½ soft banana ½ cup unsweetened, diluted fruit juice (limit to 1 serving a day) Vegetable Group (2 grams protein per serving) ½ cup soft cooked carrots or green beans (no skins or seeds) Important Tips: 1. All foods should be cooked without added fats. Bake, grill, broil, or poach meats. You may season meats with herbs and spices instead of fats. 2. Moist meats are tolerated better at this phase. Add chicken or beef broths, fat free gravies and low fat cream soups to moisten meats. Finely dice meats and chew well. 3. Add 1‐2 Tbsp of a new food at a time, if you feel nauseated or bloating after eating then you are not ready for this food. Wait a few days before trying this food again. Everyone progresses differently. Listen to your body. 23 STAGE IV SOFT DIET SAMPLE MEAL PLAN Below is a sample meal plan that you may use while on the Soft Diet. This meal plan provides 60 grams of protein and 6‐8 cups of fluid. Portions may vary with EACH INDIVIDUAL. Make meals last 30 minutes. Time Amount Food 8:00 ¼ cup Scrambled egg substitute ¼ cup Canned “lite” peaches Liquid between meal 1 cup Water or low calorie beverage 10:00 ¼ cup Light or non fat yogurt 2 2 Tbsp Non fat powdered milk 6 Liquid between meal 1 cup Fat free milk 8 12:00 ¼ cup Can of water packed tuna (2 oz) 14 ¼ cup Soft cooked green beans Liquid between meal 1 cup Water of low calorie beverage 2:00 ¼ cup Sugar free vanilla pudding with fat free milk 2 Liquid between meal 1 cup Fat free milk 8 4:00 ¼ cup Baked salmon 14 ¼ cup Mashed potatoes Liquid between meal 1 cup Water or low calorie beverage 6:00 ¼ cup Light or non fat yogurt 2 ¼ cup Canned “lite” peaches Liquid between meal 1 cup Water or low calorie beverage Total Protein Protein (grams) 7 63 24 STAGE V MAINTENANCE DIET 1. After at least 14 days on the Soft Diet, if ready, you may begin the maintenance diet. You may be ready for this phase approximately 5 weeks after surgery, or possibly not until up to 4 months after surgery. Everybody progresses differently. 2. This is the last stage of the diet progression. Continue to add new foods in slowly. Raw fruits and vegetables can be added in as tolerated. You may want to avoid the skin and membranes on fruit. Citrus fruits can be added back into diet as tolerated. 3. Follow a low fat diet and avoid simple sugars for life. Your protein goal remains at a minimum of 60 grams each day. For successful weight loss, caloric intake may range between 800‐1200 calories each day. Ask your registered dietitian how many calories are appropriate for you. 4. Continue to eat 5‐6 small meals each day. As your pouch expands, 3 small meals and 1‐2 high protein snacks may be more appropriate. 5. Continue to take your prescribed supplements for life. 6. Keep yourself hydrated! Always include 6‐8 cups of water and low calorie beverages daily. 7. Continue to track your daily intake and activities. Include calories, protein, fluids, supplements, and exercise. The following are examples of foods from each food group that are included on the maintenance diet. Meat Group (7 grams protein per serving) ¼ cup egg substitutes, 2 egg whites ¼ cup fat free or 1% cottage cheese 1 ounce cooked lean meats (chicken, turkey, pork, fish, beef) 2 Tbsp peanut butter – reduced fat 1 ounce lean luncheon meats 1 ounce low‐fat cheese ½ cup cooked beans, peas, lentils Milk Group (8 grams protein per serving) 1 cup fat free or 1% milk ¾ cup non sugar added/low fat “lite” yogurt 1 cup sugar free pudding made with fat free or 1% milk 1 cup low fat cream soup made with milk 25 Starch Group (3 grams protein per serving) 1 slice of bread (may be tolerated better toasted) 4‐6 crackers ½ cup cooked cream of wheat/rice/oatmeal ¾ cup unsweetened dry cereal ½ cup potatoes, winter squash, corn, or peas ½ cup rice, pasta – whole wheat 1 cup broth based soup Fruit Group (0 grams protein per serving) ½ cup canned “lite” fruit ½ banana or small fresh fruit (avoid skins and membranes) ½ cup unsweetened, diluted fruit juice (limit to 1 serving a day) Vegetable Group (2 grams protein per serving) ½ cup cooked non‐starch vegetables 1 cup raw non‐starchy vegetables Fat Group 1 tsp margarine or oil 2 tsp diet margarine 1 tsp mayonnaise 1 tbsp low fat mayonnaise or salad dressing 26 STAGE V MAINTENANCE DIET SAMPLE MEAL PLAN Below is a sample meal plan that you may use while on the maintenance diet. This meal plan provides 60 grams of protein and 6‐8 cups of fluid. Portions may vary with EACH INDIVIDUAL. Make meals last at least 20 minutes but not more than 30 minutes. Time Amount Food Protein (grams) 8:00 ½ cup Low fat cottage cheese ½ cup Canned “lite” pineapple Liquid between meal 1 cup Water or low calorie beverage Liquid between meal 1 cup Fat free milk 8 12:00 ¼ cup Can of water packed tuna (2oz) 14 14 with 1 tsp lite mayo 1 slice Wheat bread (toasted) ¼ cup Soft cooked green beans Liquid between meal 1 cup Water or low calorie beverage 3:00 ½ cup Sugar free vanilla pudding with fat free milk 4 Liquid between meal 1 cup Fat free milk 8 6:00 ¼ cup Baked Chicken 14 ¼ cup Mashed Potatoes ¼ cup Soft cooked carrots Liquid between meal 1 cup Water or low calorie beverage Liquid between meal 3 cups Water or low calorie beverage Total Protein 62 27 Foods That May be Difficult to Tolerate After Weight Loss Surgery Meat & Meat Substitutes Steak Hamburger Pork Chops Fried or fatty meat, poultry or fish Starches Bran, bran cereals Granola Popcorn Whole‐grain or white bread (non‐toasted) Whole‐grain cereals Soups with vegetable or noodles Bread Rice Pasta Vegetables Fibrous vegetables (dried beans, peas, celery, corn, cabbage) Raw vegetables Mushrooms Fruits Dried fruits Coconut Orange & grapefruit membranes Skins (peel all fruit) Miscellaneous Carbonated beverages Highly seasoned and spice food Nuts Pickles Seeds Sweets Candy Desserts Jam/jelly Sweetened fruit juice Sweetened beverages Other sweets 28 Signs & Symptoms of Dehydration On average, an adult’s body weight is 55‐75% water. Water serves many important functions in the body, including waste elimination, nutrient transportation and maintenance of both blood pressure and body temperature. Adequate hydration following weight loss surgery is critical. Rapid weight loss along with a protein‐rich diet causes the kidneys to work harder to eliminate waste. Drinking plenty of water helps the body flush out these waste products and prevents dehydration. Symptoms of mild dehydration: Dry mouth, lips and or tongue Thirst Fatigue Headache Dry skin Constipation Irritability Nausea Urine that is both dark yellow in color and produced in very small amounts Symptoms of severe dehydration: Dizziness Flushed and clammy skin Elevated temperature If any of these symptoms occur, immediately increase your fluid intake. This may mean replacing food with liquids until hydration is restored. If symptoms persist longer than 24 hours or become more severe, call your physician. If not corrected early, dehydration can become a serious health emergency requiring medical treatment. Any non‐carbonated, sugar‐free beverage can help meet your daily fluid needs but to help your body function at its best, ideally at least half of your daily fluid should come from water. Listed below are some ways to prevent dehydration: Do not rely on thirst to tell yourself to take a drink. If you are thirsty you are already mildly dehydrated Have a water bottle or its equivalent with you at all times. Take small frequent sips. Aim to drink six ounces per hour. Drink water before, during, and after exercise. Limit caffeine intake because caffeine acts as a diuretic. 29 Instructions for Liquid Diet Before Surgery Your surgeon has determined you need to follow a high‐protein, liquid diet 14 days prior to your surgery date. Compliance to this diet is mandatory and necessary. Research has shown a liquid diet lowers your surgical risk. The diet also assists with preoperative weight loss. The diet consists of liquid protein supplements and sugar‐free, non‐carbonated beverages. This diet is liquid only. No food is allowed. The Diet Basics: Protein Drinks Women: drink approximately 65 grams (800‐900 calories) of liquid protein supplements daily. Men: drink approximately 80 grams (1000‐1100 calories) of liquid protein supplements daily. You will need to drink multiple protein supplements each day. Use the supplement facts label to help you determine how many grams of protein are in the supplements. Refer to the list within this packet for suggested protein supplements (pg. 9). Do not use Boost®, Ensure®, Glucerna®, Special K®, and most SlimFast® products as these products lack protein and are often too high in carbohydrates. Refer to the list within this packet for recipes for full liquid diet (pg. 17­18). Use low­fat milk (skim, 1% or light soy milk) or water for mixing Drink a minimum of 64 ounces of fluid daily. Keep a beverage container with you at all times and practice taking small, frequent sips. Fluids need to be non‐carbonated, low calorie, and sugar‐free. Appropriate fluids include: Low‐fat milk Tea/Coffee (Can use sugar substitutes, such as Splenda®, Equal®, or Sweet n’Low®; no creamer) Sugar Free Kool‐Aid® Crystal Light® Flavored waters (sugar free/non carbonated i.e. Fruit2O®) Clear broth or bouillon (chicken, beef, or vegetable) Sugar‐free gelatin Sugar‐free popsicles Sugar‐free sports drinks (i.e. Propel® and PowerAde Zero®) **If you have diabetes and are taking oral medications and/or insulin you will want to discuss this with your doctor that manages your diabetes. You may also choose to use products that are NOT “low carbohydrate” versions. Make sure to monitor your blood sugars more closely as this is a very drastic change in your diet. Call your doctor if you are experiencing high or low blood sugars. Disclosures: The above references to brands of products does not necessarily
constitute endorsement by Sunrise Hospital & Medical Center.
30 Additional Resources Protein Content of Commonly Consumed Foods 31 Food/Beverage Meat, Fish, Poultry Lean ground sirloin Roast Corned beef Pork chop Spare rib Red snapper Shrimp, boiled Tuna, in water Salmon Perch Flounder Lobster Haddock Baked ham Chicken, dark Chicken, white Turkey Peanut butter TVP (texturized vegetable protein) Boca Burger Starches Mashed Potatoes Fat free refried beans Baked potato, no skin Barley Baked beans Kidney beans Soups Broth Low‐fat creamed soup Chicken noodle soup Bean, pea, or lentil soup Minestrone soup Milk, Cheese, Yogurt Cottage cheese Skim mozzarella Fat free American cheese Fat free cheddar, shredded Skim milk Nonfat dry milk Yogurt, light Egg, large size Egg white Egg substitute Tofu Soynuts Serving Size Protein Calories 3 oz 3 oz 3 oz 3 1/2 oz 6 pieces 1 cup 3 oz 1/2 cup 3 oz 3 oz 3 oz 1 cup 3 oz 3 oz 3 1/2 oz 3 1/2 oz 3 oz 2 Tbsp 1/4 cup dry 1 patty 21 gm 21 gm 21 gm 21 gm 15 gm 21 gm 21 gm 22 gm 20 gm 22 gm 21 gm 19 gm 16 gm 26 gm 25 gm 28 gm 25 gm 8 gm 11 gm 10 gm 230 200 215 150 200 100 85 90 125 100 100 85 95 130 175 160 120 190 59 70 1/2 cup 1/2 cup 1 small potato 1 cup 1/2 cup 1/2 cup 2 gm 9 gm 3 gm 3 gm 8 gm 7 gm 100 135 130 200 160 110 1/2 cup 1 cup 1 cup 1 cup 1 cup 1 gm 6‐9 gm 4 gm 7 gm 5 gm 25 90 35 60 60 1/2 cup 1 oz 1 slice 1/4 cup 1 cup/8 oz 1 Tbsp 1 cup 1 egg 1 egg white ¼ cup ¼ cup 1 oz 14 gm 6 gm 7 gm 9 gm 8 gm 1 gm 8 gm 7 gm 3 gm 7 gm 5 gm 12 gm 80 80 35 35 80 5 90 65 20 50 95 120 32 Shopping List Listed below are the items you will need to purchase for the first three weeks after surgery. Plan ahead, and go shopping early. As your diet progresses, you can continue to have the foods from the previous stages. The items listed below each stage are new “allowed” foods. Weeks 1‐2 (Full Liquid Diet) Skim or 1% milk Protein drinks (see recipes for full liquid diet) Non‐carbonated, sugar‐free flavored waters (Propel®, Dasani®, Aquafina®, Fruit2O®) Sugar‐free Kool‐Aid® Crystal Light Sugar‐free Popsicles® Sugar‐free gelatin Artificial sweetener of choice Fat free broth or bouillon Weeks 2‐3 (Puree Diet) Lean meats (chicken, fish, turkey) Baby food meats Cottage cheese Low fat ricotta cheese Light or non‐fat yogurt (no fruit pieces) Sugar free pudding Low fat cream soups (no tomato, no mushroom, or corn pieces) Cream of wheat, instant oatmeal Potatoes, sweet potatoes, winter squash Canned peaches or pears (in own juices or water packed) Banana Unsweetened applesauce Baby food fruits 100% fruit juice (NO CITRUS) Canned carrots, green beans (no skins or seeds) Baby food vegetables Week 4 (Soft Diet) Deli meat (chicken/turkey) Lean meats (fish, ground turkey, lean ground beef) Canned tuna, salmon or chicken (packed in water) Eggs/Egg substitute Cheese (less than 5 grams of fat per serving) Peanut Butter (creamy) Tofu/soy products Bread Crackers (3 grams of fat or less per serving
33 Exercise & Daily Food Diary Date: Meal Amount Calories Carbohydrates (g) Sodium (mg) Comments Breakfast Snack Lunch Snack Dinner Snack Water Exercise: 34 Weight Management App Reviews Sarah Krieger, MPH, RD, LDN, reviews the top‐rated free iPhone apps for weight management. Calorie Counter Tracks food, exercise, weight and all the nutrients listed on a Nutrition Facts label. Includes daily inspirational articles, healthy recipes and an easy‐to‐understand help section. RD Rating: 4 stars Calorie Counter & Diet Tracker by MyFitness Pal Tracks a combination of fitness goals and nutrition analysis features to help you lose weight. RD Rating: 4.5 stars Calorie Counter by MyNetDiary Allows user to personalize a calorie limit for weight loss, gain or maintenance. RD Rating: 3 stars Calorie Counter: Diets & Activities Features a classic food diary that tracks calories, water, fitness and the time each food item is consumed and an option to create your own diet and physical activity plan and an Integrated Body Tracker. RD Rating: 4 stars Calorie Tracker by Livestrong.com Food and fitness diary designed to help you achieve your diet and nutrition goals, whether you want to lose, maintain or gain weight. RD Rating: 4 stars Daily Burn Keep track of calories consumed and track workouts to see how much energy is burned. RD rating: 2 stars Lose it! Keeps track of foods you eat with this detailed food database; primarily for people wanting to lose weight. RD Rating: 3 stars Sparkpeople Food and Fitness Tracker Fitness and food tracker for people looking to lose a half‐pound to 2 pounds per week or to maintain weight. RD Rating: 4 stars Weight Watchers Mobile Follows the Weight Watchers plan step by step, using interactive tools, finding local meetings and creating shopping lists. RD Rating: 2 stars 35 CONTINUING EDUCATION http://www.obesityhelp.com ObesityHelp, Inc. Making the Journey Together http://www.smallscar.com The Johns Hopkins Obesity surgery Center, Michael Schweitzer, M.D., F.A.C.S http://www.asbs.org/html/about/patients.html American Society for Bariatric Surgery: for patients http://www.obesityaction.org/home/index/php Obesity action Coalition http://www.obesity.org/ The American Obesity Association http://www.nlm.nih.gov/medlineplus/weightlosssurgery.html Medline Plus: Weight Loss Surgery http://www.bariatricsurgeryfyi.com Bariatric Surgery FYI http://www.nhlbi.nig.gov/guidelines/obesity/ob_home.htm National Institutes of Health (NIH) Obesity Guidelines http://www.eatright.org The American Dietetic Association: Your link to nutrition and health 36