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Bariatric Surgery Educational Booklet

The University of Texas Medical Branch (UTMB Health) is in-network for most major insurance plans.

Important Reminders • Preoperative diet begins two weeks before surgery • Postoperative diet begins after surgery and continues for life

It’s Time for the New You We are a partner in your weight loss journey. Our multidisciplinary team of surgeons, advanced practice providers, psychologists, nurses, dietitians, and physical therapists are here to help support you in achieving and maintaining your weight loss goals. After bariatric surgery, losing weight and keeping it off requires permanent eating and behavior changes. Bariatric surgery is only one part of your longer-term treatment, and the recommended post-surgery diet changes will be followed for the rest of your life.

There are several dietary stages outlined in this booklet. Most importantly, listen to your body. After surgery, your stomach pouch will hold only a few tablespoons of food at a time. When eating, find a state of comfortable satisfaction — not fullness. Eating past comfortable satisfaction can cause nausea and vomiting, and slowly stretch the pouch. Eat mindfully by starting when you feel slightly hungry and stopping when you feel satisfied. If you do not tolerate a food well, do not get discouraged. Wait a week or two and try again. Following these instructions will give you the greatest chance of achieving and maintaining your physical health

Ask your care team for information about our support group. We recommend downloading the Baritastic app to your phone/tablet. This No. 1-rated app for bariatric surgery patients includes: • Recipe recommendations for each stage of your journey • Exercise planning • Tracking of: • Water intake • Protein intake • Food intake • Weight changes

Table of Contents Bariatric Office Information Contact Information................................................................................................................................ 2 When to Call........................................................................................................................................... 3 Surgical Procedures............................................................................................................................... 4 Incisionless Procedures......................................................................................................................... 8 Nutrition Pre-Surgery Checklist...........................................................................................................................11 Medications...........................................................................................................................................11 Vitamins and Supplements...................................................................................................................12 Protein Supplements.............................................................................................................................13 Dietary Stage: Before Surgery...............................................................................................................14 Dietary Stage 1......................................................................................................................................15 Dietary Stage 2......................................................................................................................................16 Dietary Stage 3A...................................................................................................................................17 Dietary Stage 3B...................................................................................................................................18 Dietary Stage 4......................................................................................................................................19 Dietary Stage 5..................................................................................................................................... 20 Exercises...............................................................................................................................................21 Moving Forward What to Avoid........................................................................................................................................27 Troubleshooting & Common Complaints............................................................................................. 28 Preventing Weight Regain.....................................................................................................................31 Your Health and Future......................................................................................................................... 32

Bariatric Surgery Team Contact Information

Clinic UTMB Health League City Campus 2240 Gulf Freeway South, Suite 2.402E League City, TX 77573 Phone: 832-505-1800 Fax: 832-426-3045

Dietitian Bariatric Dietitian Services BariatricDietitians.com PsyMed Health, Assessment and Counseling Phone: (214) 348-5557 www.psymedhealth.com

Physical/Occupational Therapy UTMB Physical & Occupational Therapy UTMBhealth.com/services/rehab

Behavioral Health UTMB Behavioral & Mental Health Services https://UTMB.us/8nq Advantage Point Behavioral & Mental Health Services https://advantagepointbehavioral.com PsyMed Health Phone: (214) 348-5557 https://psymedhealth.com

When to Call You are meeting your goals if you are: • • • • •

Drinking 64 or more ounces of clear liquids per day Walking at least every hour while awake Meeting protein requirements Losing 2-5 pounds a week Advancing through the diet stages

Contact the clinic if you have: • • • • • • • • •

Pain that can’t be tolerated with your prescribed medications Not been tolerating your diet, or are unable to advance your diet to the next stage Not been able to consistently reach your daily liquid or protein goals Nausea or vomiting that is not relieved with prescribed medications Dehydration symptoms: headache, dizziness, urinating less, dark urine, or fatigue Incision sites that are draining, red, warm to the touch, or have a foul odor A temperature greater than 100°F Constipation after troubleshooting interventions (see page 28) Any questions or concerns

Please go to the emergency room or call 911 if you experience any of the following: • • • •

Vomiting that is bright red or looks like coffee grounds Chest pain Shortness of breath Severe abdominal pain

Surgical Procedures There are several different types of bariatric surgical procedures. Your care team will help you determine which is best for you, your body, and your health goals.

Sleeve Gastrectomy The laparoscopic sleeve gastrectomy, often called the “sleeve,” is performed by removing approximately 80% of the stomach. The remaining stomach is about the size and shape of a banana. The Procedure • •

The stomach is freed from organs around it. Surgical staplers are used to remove 80% of the stomach, making it much smaller.

How It Works The new stomach holds less food and liquid, helping reduce the amount of food (and calories) that is consumed. By removing the portion of the stomach that produces most of the “hunger hormone,” the surgery influences metabolism. It decreases hunger, increases fullness, and helps the body reach and maintain a healthy weight, as well as supports blood sugar control. The simple nature of the operation makes it very safe without the potential complications from surgery on the small intestine. Advantages • • • • •

Technically simple and shorter surgery Can be performed in certain patients with high-risk medical conditions May be performed as the first step for patients with severe obesity May be used as a bridge to gastric bypass or SADI-S procedures Effective weight loss and improvement of obesity-related conditions

Disadvantages • • •

Irreversible procedure May worsen or cause a new onset of reflux and heartburn Less impact on metabolism compared to bypass procedures

Roux-en-Y Gastric Bypass (RYGB) The Roux-en-Y gastric bypass, often called “gastric bypass,” has now been performed for more than 50 years and the laparoscopic approach has been refined since 1993. It is one of the most common operations and is very effective in treating obesity and obesity related diseases. The name is a French term meaning “in the form of a Y”. The Procedure •

First, the stomach is divided into a smaller top portion (pouch), which is about the size of an egg. The larger part of the stomach is bypassed and no longer stores or digests food.

•

The small intestine is also divided and connected to the new stomach pouch to allow food to pass. The small bowel segment that empties the bypassed or larger stomach is connected to the small bowel approximately 3-4 feet downstream, resulting in a bowel connection resembling the shape of the letter Y.

•

Eventually, the stomach acids and digestive enzymes from the bypassed stomach and first portion of the small intestine will mix with food that is eaten.

How It Works The gastric bypass works in several ways. As with many bariatric procedures, the newly created stomach pouch is smaller and holds less food, which means fewer calories are ingested. Additionally, food does not come into contact with the first portion of the small bowel, resulting in decreased absorption. Most importantly, the modification of the food course through the gastrointestinal tract has a profound effect in decreasing hunger, increasing fullness, and allowing the body to reach and maintain a healthy weight. The impact on hormones and metabolic health often results in improvement of adult-onset diabetes even before any weight loss occurs. The operation also helps patients with reflux (heartburn) and symptoms often improve quickly. Along with making appropriate food choices, patients must avoid tobacco products and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen. Advantages • • •

Reliable and long-lasting weight loss Effective for remission of obesity-associated conditions Refined and standardized technique

Disadvantages • • • • •

Technically more complex when compared to sleeve gastrectomy or gastric band More vitamin and mineral deficiencies than sleeve gastrectomy or gastric banding There is a risk for small bowel complications and obstruction There is a risk of developing ulcers, especially with NSAID or tobacco use May cause “dumping syndrome”, a feeling of sickness after eating or drinking, especially sweets

Surgical Procedures Biliopancreatic Diversion With Duodenal Switch (BPD-DS) Biliopancreatic diversion with duodenal switch (BPD-DS) begins with creation of a tube-shaped stomach pouch, like the sleeve gastrectomy. Unlike the gastric bypass however, it bypasses a much larger portion of the small intestine. The Procedure •

Following creation of the sleeve-like stomach, the first portion of the small intestine is separated from the stomach.

•

A part of the small intestine is then brought up and connected to the outlet of the newly created stomach, so that when the patient eats, the food goes through the sleeve pouch and and into the lower part of the small intestine, bypassing most of it.

How It Works The smaller stomach, shaped like a banana, allows patients to eat less food. The food stream bypasses roughly 75% of the small intestine, more than any other commonly performed bariatric procedure. This results in a significant decrease in the absorption of calories and nutrients. Patients must take vitamins and mineral supplements after surgery. Even more than gastric bypass and sleeve gastrectomy, the BPD-DS affects intestinal hormones in ways that reduce hunger, increase fullness, and improve blood sugar control. The BPD-DS is considered to be the most effective approved metabolic operation for the treatment of type 2 diabetes. Advantages • • •

Among the best results for improving obesity Affects bowel hormones to cause less hunger and more fullness after eating It is the most effective procedure for treatment of Type 2 diabetes

Disadvantages • • • • •

Has slightly higher complication rates than other procedures Highest malabsorption and greater possibility of vitamins and micronutrient deficiencies Reflux and heartburn can develop or get worse Risk of looser and more frequent bowel movements More complex surgery requiring more operative time

Single Anastomosis Duodeno-Ilial Bypass With Sleeve Gastrectomy (SADI-S) Single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) is the most recent procedure to be endorsed by the American Society for Metabolic and Bariatric Surgery. While similar to BPD-DS, the SADI-S is simpler and takes less time to perform as there is only one surgical bowel connection. The Procedure •

The operation begins the same way as the sleeve gastrectomy, by creating a smaller, tube-shaped stomach.

•

The first part of the small intestine is divided just after the stomach.

•

A loop of intestine is measured several feet from its end and is then connected to the stomach. This is the only intestinal connection performed in this procedure.

How It Works When the patient eats, food goes through the pouch and directly into the lower portion of the small intestine. The food then mixes with digestive juices from the first part of the small intestine, allowing enough absorption of vitamins and minerals to maintain healthy nutrition levels. This surgery offers good weight loss along with reduced hunger, increased fullness, better blood sugar control, and improvement in diabetes Advantages • • •

Highly effective for long-term weight loss and remission of Type 2 diabetes Simpler and faster to perform (one intestinal connection) than gastric bypass or BPD-DS Excellent option for a patient who already had a sleeve gastrectomy and is seeking further weight loss

Disadvantages • • • •

Reduced absorption of vitamins and minerals compared to sleeve gastrectomy or gastric band Newer operation with only short-term outcome data Potential to worsen or develop new-onset reflux Risk of looser and more frequent bowel movements

Incisionless Procedures Endoscopic Sleeve Gastroplasty (ESG) Endoscopic sleeve gastroplasty (ESG) is a minimally invasive weight loss procedure that reshapes the stomach from the inside without external incisions. A physician uses a flexible endoscope and specialized suturing device to fold and stitch the stomach, reducing its capacity by about 70-80%. How It Works Because a stitched, smaller stomach holds less food and liquid, it helps patients naturally eat fewer calories, feeling full sooner and developing healthier eating habits. This supports weight loss and improves blood sugar. This minimally invasive and straightforward procedure is considered very safe and avoids the risks associated with more extensive surgery. Advantages • • • • • • • •

No incisions or scarring Same-day procedure for many patients Most patients return to daily activities within two to three days Can be performed in certain patients with high-risk medical conditions May be performed as a first step for patients with obesity Suitable for patients with obesity and a BMI between 30 and 50 kg/m2 Effective weight loss and improvement of obesity-related conditions Retightening can be performed if sutures break or sleeve stretches

Disadvantages • •

May worsen or cause new-onset reflux and heart burn Less impact on metabolism, compared to more invasive bariatric surgeries

Intragastric Balloon The Orbera™ Intragastric Balloon System is a nonsurgical, reversible weight loss procedure performed with an endoscope, without any incisions. An endoscope is a thin, flexible tube with a light and camera on the tip that allows doctors to see inside the body. This balloon system supports weight loss while helping patients develop lasting healthy habits. The process involves three main steps: 1. Perform an endoscopy 2. Place the balloon into the stomach 3. Fill the balloon with sterile saline How It Works: The intragastric balloon works by reducing stomach capacity and slowing the rate at which the stomach empties. This encourages smaller portion sizes and supports weight loss when combined with a healthy lifestyle and behavior changes. After six months, the balloon is removed, and patients are encouraged to maintain their nutritious diet and active habits. Because the procedure is reversible, minimally invasive, and simple, it’s considered safe and allows for future weight loss treatments if needed. Advantages: • • • • •

No incisions or scars Tolerated by most patients Reversible procedure, allowing for future, more invasive treatment options Jump start for a healthier path Ideal for patients with obesity and a BMI between 30 and 40 kg/m2

Disadvantages: • •

Maximum placement period is six months Less impact on long-term weight loss and metabolism compared to more invasive bariatric procedures

Incisionless Procedures Transoral Outlet Reduction Endoscopy (TORe) Transoral outlet reduction (TORe), sometimes called gastric outlet revision, helps patients who have had a Roux-en-Y gastric bypass and are struggling with weight regain or are no longer feeling full as quickly as before. The process involves three main steps: •

An endoscopy is performed to view the inside of the stomach

•

A specialized suturing device is used to place stitches inside the stomach, reducing the size of the gastric pouch and outlet

•

The endoscope is removed, leaving the sutures in place to maintain the reduced stomach size

How It Works: The gastric pouch and the opening to the small intestine are made smaller, which limits the amount of food and liquid a person can eat. This helps patients feel full sooner and reduces hunger. As a result, weight regain after gastric bypass is minimized. Because the procedure is minimally invasive, it carries fewer risks than a traditional surgical revision while still supporting similar overall weight loss. Advantages: • • • • • •

No incisions are needed, so there are no scars Most patients can go home on the same day and resume normal activities within a few days Can be safely performed in some patients with certain high-risk medical conditions Offered as a revision option for patients who have had a Roux-en-Y gastric bypass Potential candidates typically have a BMI between 30 and 50 kg/m² Helps reduce weight regain after gastric bypass surgery

Disadvantages: •

Less impact on metabolism and total body weight loss, compared to more invasive bariatric surgeries

Pre-Surgery Checklist You will need to complete the following specialist visits before your procedure is approved: ☐ Clinic visits (number dependent on your preparation for surgery and insurance requirements) ☐ 2 to 5 nutrition visits ☐ Behavioral health evaluation ☐ Physical therapy evaluation ☐ Sleep apnea screen and additional testing (sleep study, titration study) ☐ Liver ultrasound ☐ Upper GI (special X-ray of esophagus and stomach while drinking oral contrast) ☐ EGD (upper endoscopy) ☐ EKG (electrocardiogram to check your heart) ☐ Labs ☐ Additional required surgery clearances as needed based on your health conditions

Notes and scheduled procedures:

Medications Discuss any medication changes with your prescribing physician well before your surgery is scheduled. Initially, all oral medications must be taken one at a time and broken in half, crushed, or opened if any larger than a baby aspirin. Some extended release or behavioral health medications cannot be crushed, so please discuss with your prescribing physician. They may need to prescribe a liquid or other alternative medication. Pregnancy: Women should not become pregnant for 18 months post-surgery. Use two forms of birth control during this time unless you have an implantable form of birth control. Please contact us with questions. If you take medications for diabetes: • Follow all recommendations from your endocrinologist and/or primary care physician. • Monitor your blood glucose at home using a glucometer (glucometer must be available prior to surgery). If you take medications for hypertension: • Follow all recommendations from your cardiologist and/or primary care physician. • Monitor your blood pressure at home at least two times a day (in the morning and evening).

Notes and medication plans:

Vitamins and Supplements Discuss medication changes with your prescribing physician well before your scheduled surgery date. Vitamin Plan Begin your vitamin plan two weeks after surgery (Stage 3B)

Vitamin

Dose Instructions

Directions

Multivitamin- mineral supplement

Choose a “bariatric specific” formula with: • 45-60 mg iron • 400-1000 mcg folic acid • 12 mg thiamine • Zinc & selenium • 350-1000 mcg vitamin B12 • 3000-6000 international units vitamin D3

Progress to tablets/capsules as tolerated. Avoid incomplete children’s vitamins. No gummies.

Calcium citrate

1200-1500 mg per day (total) 1800 mg per day total (BPD-DS)

Progress to tablets/capsules as tolerated. Split into 500-600 mg doses, space evenly throughout the day, and take with food.

Iron deficiency is a common concern after bariatric surgery. To increase iron absorption: • • • •

Take iron supplements with meals containing meat, poultry, or fish Eat vitamin C-rich foods alongside iron-rich foods Cook with a cast iron skillet Avoid taking iron supplements or eating high-iron foods at the same time as: • Antacids • Calcium (take calcium more than two hours before or after iron) • Foods that block iron absorption (tea, coffee, whole grains, nuts, milk/dairy, prunes, red grapes, soy-based foods, or cooked dried beans)

Bariatric-friendly vitamin websites: • • • • • •

https://store.bariatricpal.com https://www.barilife.com https://www.barimelts.com https://www.bariatricfusion.com https://www.bariatricadvantage.com https://patchaid.com

Protein Supplements This list includes some of the commonly available protein supplements on the market. It is not a comprehensive list or a recommendation of products. Many additional options exist. Please discuss with your dietitian if you have any questions about whether a particular product is right for you. General guidelines for protein supplement/meal replacement products: • Serving size: Check carefully, especially for powders • Protein content: 20-30 grams protein per serving • Sugar: Less than 5 grams per serving • Caffeine: Caffeine-free products only Avoid meal replacement drinks such as regular Slim Fast, Boost/Ensure, Glucerna, no-sugar-added Carnation Instant Breakfast, regular sports drinks, juice, or sweet tea. They are high in calories and low in protein. Avoid food sources with more than 5 grams of sugar, sugar alcohols, or total fat per serving.

Protein Powder

Serving Size

Protein

Carbohydrates

Body Fortress® Super Advanced Whey Protein

1 scoop

30 g

7-8 g

EAS® 100% Whey Protein

2 scoops

26 g

GNC Pro Performance®, Unflavored, 100% Whey

1 scoop

25 g

Isopure® Protein Powder Zero Carb

1 scoop

25 g

Pure Protein® Whey Protein

1 scoop

25 g

Syntrax® Nectar® Native Whey Protein Isolate

1 scoop

23 g

UNJURY® 100% Whey Protein Isolate

1 scoop

21 g

Vega® Sport Premium Protein (plant based)

1 scoop

30 g

Ready to Drink

Serving Size

Protein

Carbohydrates

Ensure® Max Protein Shake

11 ounces

30 g

Fair Life® Core Power Elite Protein Shakes

14 ounces

42 g

Isopure® Zero Carb Drinks

16 ounces

32 g

Muscle Milk™ Zero

11 ounces

20 g

5-6 g

Orgain® Plant Based Protein Shake

11 ounces

20 g

Premier Protein® Clear

16.9 ounces

20 g

Premier Protein® Shake

11 ounces

30 g

Pure Protein™ Complete Protein Shake

11 ounces

30 g

Dietary Stage: Before Surgery 2 Weeks Prior to Surgery Start Date: Follow a high-protein liquid diet for two weeks prior to surgery. This diet will assist with weight loss and shrink your liver to make the surgery safer. Meal Plan: Goal: minimum 100 grams of protein per day Select protein powders or shakes with 20-30 grams of protein per serving and less than 5 grams of sugar per serving. •

Every day, drink 4-5 premade protein shakes or Whey protein powder shakes mixed with your choice of: • Skim milk • 1% milk • Unsweetened almond or soy milk • Warm broth • Water or sugar-free, non-carbonated water like Crystal Light

•

Drink at least 64 ounces of clear liquid that is sugar-free, caffeine-free, and not carbonated. Servings should be less than 10-15 calories. • Water should be your biggest source — aim to drink as much as possible • Sugar-free popsicles and gelatin (plain Jell-O only, no fruit pieces) • Sugar-free, non-carbonated waters (Crystal Light, Powerade Zero, Vitamin Water Zero) • Decaf tea and decaf coffee (avoid caffeine because it is dehydrating) • Clear broths (chicken, beef, vegetable) — choose low-sodium options • Avoid juices, as they are high in sugar and sweeteners. You might need to drink more water if you experience:

• Headaches • Urinating less frequently • Dark yellow urine • Fatigue (tiredness) • Nausea/vomiting • Dizziness

• Start a daily fiber supplement such as Benefiber or generic Metamucil. You may also start a stool softener such as Colace as needed. Follow the label for dosing instructions. When in doubt, drink more water. Appropriate hydration is key to the success of this procedure and will help you achieve your long-term health goals.

Dietary Stage 1 Immediately After Surgery Start Date: Follow a clear liquid diet starting the day of surgery, and continuing for an additional three days. Meal Plan: • • • • • • • •

Do not use straws when drinking. Try using an app or timer to remind yourself to drink. Start with 1 ounce per hour for the first six hours. Take small, frequent sips and slowly increase to 1 ounce every 15 minutes. Eventually increase up to 8 ounces maximum per hour. When your diet is delivered in the hospital, do not try to finish everything on your tray. If solid foods are delivered to your room, do not eat them and notify your nurse. No juices or carbonated drinks. Good choices include: • Water • Sugar-free, non-carbonated waters (Crystal Light, Powerade Zero, Vitamin Water Zero) • Clear broths (chicken, beef, vegetable). Choose low-sodium options. • Sugar-free popsicles & gelatin (plain Jell-O only, no fruit pieces) • Decaf tea and decaf coffee (avoid caffeine as it is dehydrating)

You may not feel thirsty, but hydration is critical at this stage. Keep track of your fluid intake to ensure you are staying hydrated. Pain Control After any surgery, some pain is normal. Pain is often part of the healing process and should become manageable with time and appropriate intervention. Pain is easier to manage right after it starts, so discuss options with your care team before your pain becomes severe. Relaxation techniques, warm blankets, cold packs, or changing position may also help. Please discuss any pain history, medications, or concerns with your care team. Slow and steady! Stop if you experience pain, nausea, or fullness. Your care team should provide you with an incentive spirometer to help exercise your lungs after surgery. Using your spirometer regularly will help you recover faster! It is important that you start walking a few hours after surgery. Get up several times throughout the day, and increase your activity daily, either by steps or minutes.

Dietary Stage 2 4 Days After Surgery Start Date: Follow a high-protein liquid diet for days 4–7 after the day of surgery. Meal Plan: Goal: minimum 60 grams of protein per day for women and 80 grams of protein per day for men. Select protein powders or shakes with 20-30 grams protein of per serving and less than 5 grams of sugar per serving, and low-calorie (less than 200 calories per serving). •

Do not use straws when drinking.

•

Drink at least 64 ounces of clear liquid that is sugar-free, caffeine-free, and not carbonated. Each serving should be less than 10-15 calories. • Water should be your biggest source — aim to drink as much as possible • Sugar-free popsicles & gelatin (plain Jell-O only, no fruit pieces) • Sugar-free, non-carbonated waters (Crystal Light, Powerade Zero, Vitamin Water Zero) • Decaf tea and decaf coffee (avoid caffeine because it is dehydrating) • Clear broths (chicken, beef, vegetable) — choose low-sodium options. • Avoid juices, as they are high in sugar and sweeteners.

•

Start with 1 ounce of protein shake per hour, in addition to your clear liquids

•

Work up slowly to 2-3 premade protein shakes per day or protein powder mixed with your choice of: • Skim milk • 1% milk • Unsweetened almond or soy milk • Warm broth • Water or sugar-free, non-carbonated water like Crystal Light

Dehydration can happen quickly at this stage. Drink water often and avoid caffeine or alcohol.

Dietary Stage 3A 7 Days After Surgery Start Date: Follow a high-protein, modified pureed diet for days 7-14 after surgery. Meal Plan: Goal: minimum 60 grams of protein per day for women and 80 grams of protein per day for men. Continue to avoid straws, caffeine, carbonation, juice, sweet drinks, and alcohol. •

Do not drink anything for 30 minutes before and after solid meals.

•

For one to two meals per day, have a “solid meal” (1–2 tablespoons total) such as: • Low-fat cottage cheese or low-fat ricotta cheese • Sugar-free nonfat yogurt (smooth; without chunks of fruit or nuts), or sugar-free Greek yogurt • Sugar-free pudding with added protein powder • Strained, low-fat cream soups • Refined hot cereals low in fiber (such as Cream of Wheat), prepared with extra liquid for a soup-like consistency; add protein powder. Do not eat oatmeal.

•

For the other one to two meals per day, you can have protein shakes and any approved Stage 2 liquids.

•

If any food does not settle well, wait until the next dietary stage to try it again.

•

Drink at least 64 ounces of clear liquid that is sugar-free, caffeine-free, and non-carbonated. Each serving should be less than 10-15 calories. • Water should be your primary source — aim to drink as much as possible • Sugar-free popsicles and gelatin (plain Jell-O only, no fruit pieces) • Sugar-free, non-carbonated waters (Crystal Light, Powerade Zero, Vitamin Water Zero) • Decaf tea and decaf coffee (avoid caffeine because it is dehydrating) • Clear broths (chicken, beef, vegetable) — choose low-sodium options

When in doubt, drink more water. Staying well hydrated is essential to your recovery and will help you achieve your long-term health goals.

Dietary Stage 3B 2 Weeks After Surgery Start Date: Follow a high-protein, pureed diet from day 14 (two weeks) to 4-6 weeks after surgery. You should have 3 meals per day total from here forward. Meal Plan: Goal: minimum 60 grams of protein per day for women and 80 grams of protein per day for men. Continue to avoid straws, caffeine, carbonation, juice, sweet drinks, and alcohol. Start with one new food at a time to identify food intolerances. If a new food does not sit well initially, try again at the next dietary stage. Start your vitamin regimen at this stage. •

Diet (2-4 Tablespoons of food per meal, depending on the density of food) • All Stage 1-3A liquids and foods • Mash or puree the following with any of the following: water, broth, milk, fat-free gravy, light mayonnaise, or plain Greek yogurt. Blend to the consistency of a thick liquid or smooth paste with no solid pieces. Do not eat baby food. • Pureed cooked lean meats, poultry, or fish • Pureed, cooked vegetables and soft beans • Pureed soups (black bean, low-fat cream soup) • Hummus, soft scrambled egg or egg-substitute, avocado, or tofu • Add protein powder to all pureed foods Notes: • Do not drink anything for 30 minutes before and after your solid meals. • Start the meal with protein, followed by vegetables • Eat very slowly & mindfully. Stop when you are satisfied, not full. • Chew your food to liquid consistency (20-30 chews per bite) • In between meals, drink 64 ounces of clear liquid that is sugar-free, caffeine-free, and not carbonated. (Goals and notes for liquids are the same as in stage 3A)

Meal

Food Items

Grams Protein

Calories

Breakfast

1/4 cup Greek yogurt

AM Shake

1/2 cup protein shake

100

1/4 cup cottage cheese, mashed

PM Shake

1/2 cup protein shake

100

Dinner

3 tbsp pureed chicken with fat-free gravy 1 tbsp mashed green beans

PM Shake

1/2 cup protein shake

100

Totals:

71 grams

455 cals

Lunch

Dietary Stage 4 4-6 Weeks After Surgery Start Date: Follow a high-protein, low-fat soft diet from 4-6 weeks after surgery to 6-8 weeks after surgery. Meal Plan: Goal: minimum 60 grams of protein per day for women and 80 grams of protein per day for men. Protein is still the focus of your diet. Continue to avoid straws, caffeine, carbonation, juice, sweet drinks, and alcohol. Add new foods slowly, one at a time to build up tolerance. •

Diet (2-4 tablespoons of food per meal, depending on the density of food) • All Stage 1-3B foods • Tuna, egg, or ham salad made with low-fat or light mayonnaise or plain Greek yogurt • Soft meats including fish, lean ground beef (93% lean or higher), pork, or chicken or turkey that has been baked or slow-cooked • Mashed potatoes without skin • Lean deli meats and sliced low-fat cheeses • Mild chili • Meatloaf • Hard-boiled or poached eggs

•

Continue to drink a minimum of 64 ounces of clear liquid that is sugar-free, caffeine-free, and not carbonated. Servings should be less than 10-15 calories.

•

Foods that are not well-tolerated (avoid these): • Spicy foods • Raw vegetables • Tough cuts of red meat • Grains such as bread, pasta, rice, oatmeal, or tortillas • Acidic foods like tomato sauce • Fresh or dried fruits • Fibrous foods like popcorn, nuts, and seeds • Sweet foods • High-fat foods (fried food, dressings, high-fat sauces)

Make exercise a regular, long-term habit: 30-60 minutes every day if possible. Eat slowly and mindfully. Sit down to eat, and do not snack between meals. Keep daily food records to ensure you are meeting your nutritional goals.

Dietary Stage 5 6 Weeks After Surgery and Throughout Your Life! Start Date: Follow a high-protein, low-fat regular diet from 6-8 weeks after surgery and throughout the rest of your lifetime.

Meal Plan: Goal: minimum 60-80 grams of protein per day for women and 80-100 grams of protein per day for men. Protein is still the focus of your diet. As food portions increase, your need for protein supplements will decrease. Continue to avoid straws, caffeine, carbonation, juice, sweet drinks, and alcohol. Add new foods slowly, one at a time, to build up tolerance. • Slowly increase to¼ cup per meal at 3 months, ½ cup per meal at 6 months, and 1 cup per meal at one year after surgery • All Stage 1-4 liquids and foods • Raw vegetables and fruits (at around two months after surgery) • Continue to drink at least 64 ounces of clear liquid that is sugar-free, caffeine-free, and not carbonated. • Foods that are generally not well-tolerated (tolerance will vary): • Spicy foods • Red meat and overcooked or dried-out poultry • Bread, pasta, rice • Acidic foods like tomato sauce • Fibrous foods like popcorn, nuts, and seeds • Sweet foods • High-fat foods (fried food, dressings, high-fat sauces) Avoid caffeine for the first year, then limit caffeine to less than 100mg per day. Avoid alcohol for the first full year after surgery. Eat slowly and mindfully. Sit down to eat and do not snack between meals. Keep a consistent exercise routine. The Baritastic app is a helpful resource for exercise ideas.

Exercises Exercises When Lying Down Ankle Pumps (Sitting or lying on your back) 1. Point your toes downward and then lift your foot up. 2. The motion is similar to pressing the gas pedal in a car and lifting up. Do sets of repetitions Special instructions:

times a day.

Knee Presses 1. Lie on your back in bed. Press the back of your knee down into the mattress. 2. Tighten the muscles on top of your thigh. 3. Hold for 5 seconds, then relax. Do sets of repetitions Special instructions:

times a day.

Buttock Squeezes (Sitting or lying on your back) 1. Squeeze your buttocks together as tightly as you can. 2. Hold for 5 seconds, then relax. Do sets of repetitions Special instructions:

times a day.

Pillow Squeezes (Sitting or lying on your back) 1. Place a pillow between your knees. 2. Squeeze the pillow with your knees. 3. Hold for 5 seconds, then relax. Do sets of repetitions Special instructions:

times a day.

Exercises Exercises When Lying Down Knee Bends 1. Sit or lie on your back. 2. Slide your foot toward your buttocks, bending your knee and hip. 3. Slowly return to the starting position, straightening the knee completely. 4. Keep your knee pointed toward the ceiling throughout the exercise. Do sets of repetitions Special instructions:

times a day.

Leg Slides 1. Lie on your back with your legs together. 2. Point toes up toward the ceiling and maintain that position. 3. Slide one leg out to the side, keeping your knee straight. 4. Slowly return the leg to its original position. 5. Repeat with the other leg. Do sets of repetitions Special instructions:

times a day.

Half Kicks 1. Put a rolled towel or pillow under your knee. 2. Straighten your knee by raising your foot. 3. Hold for 5 seconds, then lower your foot back down. Do sets of repetitions Special instructions:

times a day.

Leg Lifts 1. Lie on your back. 2. Keeping your knee straight, life your leg slowly. 3. Hold for 5 seconds, then lower your leg back down. Do sets of repetitions Special instructions:

times a day.

Exercises When Sitting

Ankle Pumps 1. Point your toes down and then flex your foot up. 2. It should be similar to pressing the gas pedal in a car and lifting up. Do sets of repetitions Special instructions:

times a day.

Hip Flexion 1. Lift your knee toward the ceiling. 2. Slowly lower your knee back. Do sets of repetitions Special instructions:

times a day.

Exercises Exercises When Sitting

Long Arc Quad 1. Straighten your knee slowly, as if kicking. 2. Slowly return to your starting position. Do sets of repetitions Special instructions:

times a day.

Isometric Hip Adduction 1. Place a pillow between your knees. 2. Squeeze both knees into the pillow. 3. Hold for 5 seconds, then release. Do sets of repetitions Special instructions:

times a day.

Exercises Exercises When Standing

Kick Backs 1. Stand holding onto a counter or the back of a chair with feet shoulder-width apart. 2. Standing on one leg, lift your other leg behind you, keeping your knee straight. 3. Slowly return to the starting position. Do sets of repetitions Special instructions:

times a day.

Mini Squats 1. Stand holding onto a counter or the back of a chair with feet shoulder-width apart. 2. Slowly squat, bending your knees slightly (no more than 45 degrees). Keep your back straight. 3. Slowly return to start position. Do sets of repetitions Special instructions:

times a day.

Side Kicks 1. Stand holding onto a counter or the back of a chair with feet shoulder-width apart. 2. Shift your weight to one leg, lifting the other leg to the side with your knee straight. 3. Slowly return to the starting position. Repeat with the opposite leg. Do sets of repetitions Special instructions:

times a day.

Marching 1. Stand with feet shoulder-width apart. 2. Raise one knee up to hip height, then lower. 3. Repeat with the opposite leg. 4. Continue marching in place. Do sets of repetitions Special instructions:

times a day.

Toe Raises 1. Stand holding onto a counter or the back of a chair with feet shoulder-width apart. 2. Raise your toes up, rocking back on heels. 3. Lower slowly and repeat. Do sets of repetitions Special instructions:

times a day.

Heel Raises 1. Stand holding onto a counter or the back of a chair with feet shoulder-width apart. 2. Raise heels up, rocking on to toes. 3. Lower slowly and repeat. Do sets of repetitions Special instructions:

times a day.

Lunges 1. Stand with your hands on your hips. 2. Step forward with one leg, bending your knee slightly. 3. Keep your opposite heel on the floor. 4. Slowly return to start position. Repeat with the opposite leg. Do sets of repetitions Special instructions:

times a day.

Moving Forward Try to avoid: •

Smoking or nicotine (including e-cigarettes, cigars, nicotine patches or gum, etc.)

•

Weighing yourself every day — celebrate non-scale victories instead, do weekly weigh-ins, and take photos to track your progress.

•

One year after surgery, you can resume: • Drinking caffeine (limit to less than 100 mg per day) • Drinking alcohol in moderation (keep in mind your tolerance may be greatly reduced) • Drinking carbonated beverages • Using straws • Chewing gum

Note: If you had a gastric bypass procedure, avoid NSAIDs (these include aspirin, ibuprofen, Mobic, Aleve, naproxen, etc.) Returning to work, school, and your daily life: Be prepared for the reactions of friends, family, or colleagues. People may notice your weight loss or changed eating habits and may have questions. Think ahead about how you will respond. Tips for a successful transition: •

Prepare lunches in advance, and buy food to keep at work or school: • Sugar-free, fat-free yogurt • Cheese sticks • Baby carrots or canned juice-packed fruits (drained) • Canned protein drinks or protein snack packs • Small cans of tuna, salmon, or chicken

•

Set a timer to regularly remind yourself to: • Drink water • Take your supplements • Take your snack or meal break • Go for walks

•

Gradually increase how often you walk and keep a water bottle with you at all times

You are on a journey to achieve your health and wellness goals, and we are here to help. After surgery, you should have follow-up appointments with your care team: • • • • •

At two weeks after surgery At six weeks after surgery At six months after surgery At one year after surgery After the first year, yearly appointments

Troubleshooting and Common Complaints Immediately After Surgery Headaches or dizziness • • •

Drink water Add salt or broth to your foods Eat meals on a regular schedule

Nausea • • •

Recognize a state of comfortable fullness, and do not eat past that point Drink fluids Try resting or taking a short walk

Vomiting • • • • • • •

Go back to the previous dietary stage until you find foods that you can tolerate — do not stop eating altogether Keep drinking clear liquids if you can Chew all foods thoroughly Take about 30 minutes to eat each meal — sit down and minimize distractions while eating Avoid alcohol, high-fat foods, or sugary foods Do not drink liquids for 30 minutes before or after a meal Make sure all medications and vitamins are crushed, chewable, or liquid

If these suggestions do not work, call the clinic, or if you vomit bright red or dark brown liquid, please go to an Emergency Room Constipation • • • • • • •

Drink water regularly, and try warm liquids in the morning Walk every day Exercise regularly Eat healthy fats like olive oil, avocados, and salmon (refer to diet stages) Try over-the-counter stool softeners (like Colace) or laxatives (like Miralax or Dulcolax) If you have no bowel movements for three days, try 2 tbsp Milk of Magnesia or one Dulcolax suppository If you are more than a month after surgery, you can try fiber supplements like sugar-free Metamucil or Benefiber

Later Postoperative Burping or hiccups • • •

Chew with your mouth closed Avoid straws, carbonated beverages, and chewing gum Eat slowly

Excessive hair loss •

Hair loss can be normal for several months following surgery. This is not permanent and will improve once your weight has stabilized.

•

To minimize hair loss: • Stick to your protein regimen • Drink water • Take your vitamins • Talk to your surgeon about taking biotin, zinc, or essential fatty acid supplements

Diarrhea • • • • • • •

Eat slowly and stop when you reach a state of comfortable satisfaction Do not drink liquids 30 minutes before or after your meal Avoid sugar, fat, alcohol, caffeine, and spicy foods, and do not smoke Continue to eat well-tolerated foods until you feel better, or go back to the last dietary stage Limit sugar-free sweeteners like sorbitol and mannitol Take over-the-counter Imodium as directed If diarrhea continues, contact the clinic to check for a possible bacterial infection

Leg cramps • • • •

Increase fluid and electrolyte intake Follow your diet closely as advised by your surgeon and dietitian, and take your vitamins Get up and move every 30 minutes and elevate your legs if they feel swollen Avoid crossing your legs or wearing anything tight on your legs

Food “getting stuck” • •

Eat slowly and chew thoroughly — cut food into very small pieces and eat smaller portions Avoid dry, tough, or stringy foods

Dumping syndrome Symptoms include nausea, vomiting, sweating, bloating, diarrhea, cramping, lightheadedness, and fast heart rate. This usually occurs after eating high-fat or high-sugar foods and lasts about 30 minutes. Avoid fatty or sugary foods, and those with hidden sugars like honey, corn syrup, molasses, jellies, jams, sweet spreads, barbecue sauce, ketchup, and sweet pickles. Cold or congestion • You can take Sudafed, Zyrtec or Claritin, sugar-free throat lozenges or chloraseptic spray, and Tylenol • Avoid NSAIDS or anything with sugar.

Heartburn/burning feeling in stomach • • • • •

Avoid caffeine, tea, coffee, chocolate, spicy foods, black or red pepper, and alcohol Avoid foods that are too hot or too cold Avoid smoking Avoid aspirin and other NSAIDs (try Tylenol instead) Discuss symptoms and medications you are taking with your surgeon. Your surgeon may prescribe an antacid.

Weight loss stops • • •

Evaluate portion sizes, limit high-calorie foods and beverages Increase physical activity Consult your dietitian and/or exercise team

Plugging or indigestion (the sensation that food has “blocked” an opening) • • • •

Avoid dry, tough, sticky, gummy, spongy, stringy, or fibrous foods Avoid bran, cereal, granola, popcorn, noodles, rice, corn, peas, cabbage, celery, dried beans, dried fruit, coconut, citrus membranes, and fruit or vegetable skins or peels Avoid acidic foods Go back to an earlier dietary stage

Lactose intolerance Some people develop intolerance to some dairy products after weight loss surgery. This may feel like gas, bloating, cramping, and diarrhea. • •

Avoid milk and milk by-products. Replace milk with sugar-free soy milk or lactose-free milk (like Lactaid) Try over-the-counter lactase supplements

Gout • • • • •

Stay hydrated according to your daily fluid schedule to flush waste from your kidneys Avoid alcohol, keep protein intake toward the low end of your goal Avoid high-purine foods like organ meats (liver, kidneys, heart, etc.), game meat, sardines, anchovies, scallops, mussels, and mackerel Limit moderate-purine foods (oatmeal, wheat bran and germ, asparagus, peas, cauliflower, spinach, mushrooms) Note: Colchicine (a medication to treat gout) may cause diarrhea

Kidney stones • • • •

Drink fluid according to your schedule to flush waste from your kidneys Avoid excessive intake of vitamin C (too much vitamin C can contribute to kidney stones) Avoid high-oxalate foods (beets, cocoa, chocolate, prunes, leeks, greens, quinoa, celery, soy, tofu, peanuts, black tea, coffee, soda, wheat bran and germ, spinach, dried beans, sweet potatoes) Discuss treatment with your care team

Bloating or gas • • • • • •

Avoid sugar alcohols and fructose (sorbitol, maltitol, xilitol) and consider the possibility of lactose intolerance. Use probiotics Avoid straws, chewing gum, carbonated beverages, or gulping Limit fat intake Try gas reduction treatment options (Beano, Gas-X strips) Limit soluble fiber (oat brain, Metamucil, barley, beans, dried peas) and foods that may cause gas (vegetables, high-fiber cereals, peanuts and peanut butter, soy milk, soy protein)

Preventing Weight Regain Sustained weight loss is the result of: • • • • • • • •

Regular and consistent healthy food choices Maintaining portion control and eating mindfully Eating breakfast Planning your meals and following your plan (avoid snacking) Regular exercise Drinking plenty of water Keeping food and exercise journals Getting good rest

Bariatric surgery will jump-start your weight loss, but maintenance will require following a high-protein diet and sticking with your plan over the long term. Be aware that it is still possible to overeat — avoid grazing between meals. At first it might seem like the weight “just falls off” but after the first year, additional weight loss will require persisting with your new healthy behaviors. Think of your surgery as a reset button, but over time the weight loss will slow down. You may begin to regain weight, and that can be a difficult emotional time for many patients. Exercising regularly and referring to your new healthy eating plan will help you sustain weight loss as they become established in your routine. Exercise also has wonderful mental health benefits — people who exercise regularly may have more energy, feel more positive, and sleep better than people who do not. Tips for success •

Let others help you: Join support groups and share even the little milestones. You can cheer others on throughout their journey this way, too.

•

Chart your progress: Track the goals and milestones that are achievable and matter to you.

•

Identify your feelings: For many people, eating can be emotional. Maybe you craved certain foods when different emotions came up. By identifying and addressing the underlying feelings, you can work through emotions without relying on food as comfort.

•

Seek out professional support: Many factors contribute to weight changes, and many emotions may come up. A supportive therapist can help you to identify achievable goals and give you the best chance of success as you begin to rediscover your relationship with your body.

•

Learn to relax: Try deep breathing and engaging with music, art, or the outdoors. Identify things that bring you joy — hobbies, time with friends or family — and add them to your routine.

Remember: you made the choice to have this procedure for your future health and well-being. Going to a restaurant with friends might be difficult, so plan ahead and focus on the social experience rather than the food. People around you will eat foods that you may need to avoid. Remind yourself that this is a choice you have made for yourself, but not necessarily a choice that others have made or will make for themselves.

Your Health and Future Bariatric surgery is one step in the direction of your long-term health and wellness. Your care team is here to support you throughout the process. There is more to obesity than diet and exercise — stress, sleep, hormones, chronic pain, underlying medical conditions, medications, and genetics can all play an important role. Obesity also increases the risk of other health problems such as diabetes and fertility issues. Our multidisciplinary team of surgeons, advanced practice providers, psychologists, nurses, dietitians, and physical therapists are available to help support you in achieving and maintaining your weight loss goals. We are here to help you rebuild your relationship with your body and with food. This journey is about more than how you look — those who live a more active lifestyle are less likely to experience sleep apnea, heart disease, diabetes, arthritis, and back pain. Ask your bariatric surgery team for information about our support group meetings.

Scan to ask your clinic team a question through the UTMB MyChart portal or visit utmb.us/8sk.