Nutritional Informatiom

NUTRITION GUIDELINES FOR THE GASTRIC BYPASS

NOTE: Liquid diet two weeks prior to surgery


Pre-Op Liquid Diet Instructions – Start 2 weeks before surgery

Ø You will have 1000 calories per day and at least 50 grams of protein. No more than 35 grams of fat daily.
Ø Your calories will come from protein/meal replacement shakes. You are permitted to have low calorie vegetables in small portions at lunch and dinner time.
Ø We suggest the following protein/meal replacement shakes:

Brand Name Calories/ Serving Protein Drinks per day
Optifast (premade or powder available) 160 calories (may be purchased in our office) 14 g/per serving 6 per day provide 960 calories & 84 g protein
Carnation Instant Breakfast – No sugar added 150 calories (premade box or from 1 packet with skim milk) 12 g/per serving 6 per day provide 900 calories & 72 g protein
Slim Fast Optima (premade or powder) 180 calories (sold @ pharmacies or supermarket) 10 g/per serving 5 per day provide 900 calories & 50 g protein
Ensure (lactose free)
Glucerna (lactose free; diabetic formula) 240 calories (sold @ pharmacies or supermarket) 10 g/per serving 4 per day provide 960 calories & 40 g protein
Shaklee Cinch Shake Mix (kosher) 2 scoops or 1 packet 180 calories (sold health food stores) * with water 16 g/per serving 5 per day provide 900 calories & 80 g protein
Herbalife Formula 1 Shapeworks Nutritional Shake Mix (kosher) 2 scoops 90 calories (sold at health food stores) * mix with 8oz skim milk 9 g/per serving 5 per day provide 990 calories & 85 g protein
Maxi Health Naturemax Protein Powder (kosher) 1 scoop 101 calories (sold at health food stores) * mix with 8oz skim milk 28 g/per serving 5 per day provide 955 calories & 140 g protein



OTHER OPTIONS (to be used for protein supplementation or to help meet protein needs)
Pure Protein by World Wide Challenge (11 oz can) 160 calories (sold at GNC like stores) 35 g/per serving * pre-made and ready to drink
Unjury by Proynthesis Labs – 1 packet 90 calories (www.unjury.com or 800-517-5111) 20 g/per serving 180 calories & 28 g protein if mixed with skim milk
GNC Next Proteins Designer Whey 1 scoop 90 calories 18 g/per serving 180 calories & 26 g protein if mixed with skim milk


Try blending a premade shake with ice in a blender for variety.

More Pre-op Diet Instructions
(Free foods allowed on pre-op diet)


Ø You may also drink sugar free beverages throughout the day. Water, diet caffeine free soda, caffeine free diet ice tea, Crystal Light, diet lemonade, diet Snapple and the like are unlimited. You may chew sugar free gum.
Ø You may have sugar free ices. Limit to 30 calories per day.
Ø Sugar Free Jell-o is OK.
Ø Low salt broth (i.e. Herb Ox) is OK.
Ø Limit caffeinated beverages as they will make it more difficult to stay hydrated. Limit to 2 cups coffee or soda daily. Caffeine free is OK. You may have skim milk in coffee.
Ø If hungry, you are permitted to have vegetables (raw or cooked). Steamed, boiled, grilled or in a soup. Limit 2 cups daily.
Ø Permitted vegetables include lettuce, spinach, cucumber, onion, tomato, broccoli, cauliflower, carrots, mushroom, zucchini, string beans, okra, cabbage, asparagus, Brussels sprouts and peppers.
No corn, peas, potatoes, or beans - too many calories.
· Mustard, salsa, vinegar are permitted in small amounts.
· Limit fat free dressing to 2 tablespoons daily.
· NO added fats, oils, butter, margarine, mayonnaise, etc.

Ø NO ALCOHOLIC BEVERAGES ALLOWED during this time as it also impacts your liver adversely.
Ø Compliance to this pre-op diet is mandatory. Remember, this is to help shrink or "de-fat" your liver. Shrinkage of the liver makes the surgery significantly easier.


Ø Start Juice Plus supplementation. Contact Ilan Pacher for Juice Plus.


Office: (845) 425-5034; E-mail: Ilangil@aol.com


First 10 days After Surgery – Thin Liquid Diet


w For the first 10 days after the surgery you will be on a thin liquid diet. Anything that is thin enough to be sipped through a straw is fine. For example, choose caffeine-free beverages like Wyler’s Light, diet ice tea, Crystal Light, broth, skim milk, sugar free hot chocolate, tomato juice, tomato soup, water, V8 vegetable juice, Vitamin Water, Decaf coffee/tea, ices, Propel. No Jello. Avoid carbonated drinks as they may stretch your new pouch and cause gas. Drinking straws may cause gas too, and should be avoided.
w Include AT LEAST, but not limited to, 2 protein shakes per day. You should opt for a high protein shake Ensure High Protein, Slim Fast High Protein, World Wide Pure Protein, Herbalife, Shaklee or prepare your own. To prepare your own, blend one scoop of a protein powder such as Designer Whey Protein or Unjury into 4 oz. of liquid (preferably milk) with some ice. Carnation Instant Breakfast, ALBA mix, Weight Watcher shake mix can be used as well.
w Limit fluid intake to sips at a time. Sip your fluid slowly all day long. Do not gulp. HINT: Drink fluid as if you were drinking hot tea. This will prevent your pouch from stretching, and prevent nausea/vomiting. It may take 1 hour to drink 8 ounces of fluid.
w Adequate hydration prevents dehydration and constipation. Have a goal of consuming 6-8, eight oz glasses of fluid per day.
w Medications (if large) will be chewed or crushed for the first 3 weeks after surgery. You are advised to take a multivitamin supplement after surgery due to your low caloric and nutrition intake. Take 2 chewable children’s multivitamins (i.e. Flinstones). Or take an adult liquid or chewable multivitamin each day (i.e. Centrum adult multivitamin chewable or liquid, Maxi Health chewable multivitamins (kosher) or Freeda Monocaps multivitamin (kosher and vegetarian) in chewable or liquid form. Start taking a chewable calcium: Tums 400 or (chew 1 with breakfast, 1 with lunch and 1 with dinner). Take calcium 3 times/day,
* YOU WILL COME BACK IN 7-10 DAYS AFTER SURGERY FOR A CHECK UP.



Second 10 days After Surgery – Puree/Soft Diet


w You can begin eating pureed foods after your 10 days of liquids is completed. From this point on you will begin to avoid drinking with meals.
o Remember to stop drinking 30 minutes before your meal and wait 30 minutes after your meal to drink.
w Focus on a balanced healthy diet with an emphasis on protein and nutrient rich foods. Sample food ideas are below.
w To puree food, cut food into small pieces (size of an eraser) and then cook. Drain the fluid and set it aside. Blend the food and liquid (can be juice or broth, too) in a blender/food processor. Blend until applesauce consistency. Strain any lumps or pieces. Usw spices to flavor food. Final consistency should be smooth. Food Group Food Choices
HIGH PROTEIN CHOICES -> Meat, Poultry, Fish, Nuts, Beans and Eggs Chopped up soft poached eggs or scrambled eggs. Blenderized meat or poultry and flaked fish cooked very soft and moist, blenderized tuna salad with no added vegetables. Very soft meatloaf (blended), fork mashed gefilte fish and silken tofu. Non fat refried beans, hummas, creamy peanut butter.
HIGH PROTEIN CHOICES -> Milk, Cheese and Yogurt Low fat or non fat cottage cheese or ricotta cheese, sugar free custards and puddings, non-fat sweetened/sugar free yogurt, sugar free frozen yogurt and sugar free fat free ice cream
Vegetable Any vegetable (except corn) cooked soft and blended or mashed with the back of a fork. Make sure broccoli and cauliflower are cooked very well
Fruit Unsweetened applesauce, pureed canned/jarred peaches and peas in their own juice (not syrup), any fruit pureed with out the skin, mashed ripe banana
Bread, Cereal, Pasta and Rice Hot cereal – unsweetened oatmeal, cream of wheat, grits or mashed potatoes without skin
Fats and Oils Limit all
Miscellaneous Blended soups (no chunks of vegetables or meat) – limit cream soups. Try Healthy Choice, Progresso Lite and Healthy Request, egg drop soup and miso soup
Liquids (Do not drink during meals. Try and drink at least 8 (8 oz) cups of fluid per day No carbonation. Flat diet soda, skim milk or Skim Plus, Crystal Light, nutrasweet Kool-Aid, coffee, tea, all broths, any sugar free beverages, diet Snapple, Gatorade and water!





Bypass Basics

THE POST-OP DIET:
· For the first 10 days after surgery you will be on a liquid diet.
· For the second 10 days after surgery you will be on a pureed diet.
· Meals should include protein first, then fruits and vegetables, and then whole grains. Protein will help preserve lean muscle and help promote wound healing.
· Protein rich foods usually come from animal products (chicken, fish, eggs, cheese, yogurts, etc). Beans, nuts (peanut butter) and tofu and also great sources of protein.
· Avoid concentrated sugars; they can cause the "Dumping Syndrome"
· Limit fats; they can lead to nausea and weight gain
· Eat 3 small nutrient dense meals daily.

IMPORTANT EATING BEHAVIORS:
· Eat slowly - it should take 1/2 hour for each meal!
· Chew slowly and thoroughly - at least 25 times!
· Remember the stomach can only hold a few tablespoons right after surgery. Eventually it can hold abouu 1/2 to 1 cup per meal. (After 6 months a 1/2 sandwich could be a meal. After 1 year a Lean Cuisine sized entrée can be a meal.)
· Stop eating when you feel full – if ignored, vomiting will follow.

PREVENTING FOOD INTOLERANCES
· Introduce new foods one at a time in order to rule out intolerances. If a food is not tolerated, take it out of your diet for a week and reintroduce it one week later.
· If you cannot tolerate dairy, substitute Lactaid for milk. You may need to take Lactase pills with dairy to help digest the lactose.

FLUIDS:
· Drink at least 6-8 cups (8 oz) of fluid per day to prevent dehydration and constipation. You can carry a water bottle around with you.
· Stop drinking liquids 30 minutes before meals and resume 30 minutes after meals.

SUPPLEMENTS:
· Set up a schedule for supplements (refer to supplement form) and medications; remember to take Calcium with meals and separate from Iron supplements.

PHYSICAL ACTIVITY:
· Exercise! This is the key to long term maintenance of weight loss. Walking should be the main exercise for the first 6 weeks. After 6 weeks, more strenuous exercises can be added. After 6 weeks, weight lifting or using weights in your aerobic exercise is encouraged as it helps build muscle.


Dumping Syndrome


The "Dumping Syndrome" occurs when food passes rapidly from the stomach into the small intestine. Dumping can be provoked by: ingestion of concentrated sweets, overeating and consuming liquids with meals. The partially digested food in the small intestine draws water out of the blood vessels from the body into the small intestine, thereby causing the following symptoms: nausea, fullness, cramping, diarrhea, weakness, sweating and a rapid heart rate. The following foods and beverages should be avoided.

Foods to Avoid
Sugar free and artificial sweeteners are ok Ice cream Doughnut Lemonade Candy
Chocolate milk Popsicles Kool-Aid Regular Jell-O
Pudding Cakes Snapple fruit drinks Sugar gum
Sweetened, fruited/frozen yogurt Pies Sugared ice tea Molasses
Dried fruits Cookies Table Sugar Syrups
Sugar coated cereal Regular soft drinks Honey Sherbet/Sorbet


Should this syndrome occur, it usually passes within 15-20 minutes but can last for 4-6 hours. Drink lots of water or take Imodium AD or Pepto Bismol and wait for symptoms to pass.


Diet Progression after Gastric Bypass


This is a general guideline on when to add in various foods. Individual tolerance of certain foods will vary.

Ø Day 1 Post-Op: Nothing by mouth

Ø Day 2 – Day 10 Post-Op: Progress from Clears to No concentrated sweets liquid diet. Try to consume 2 oz of fluid every hour.

Ø Second 10 Days Post-Op: Puree/soft high protein diet (see attached sheet). Try and consume 4-6 oz fluids every hour. Start the habit of eating protein first and avoiding drinking with your meals. Your goal is 60 grams of protein daily.

Ø 3 Weeks Post-Op: Firm tofu, and seafood, thinly sliced deli turkey or ham, boiled dark meat chicken (cut up into small pieces) in broth, crisp toast and crackers, beans and peas, and well cooked pasta. The goal is 75 grams of protein per day. A high protein diet may prevent hair loss.

Ø 2 Months Post-Op: Rice, soft bread, lean ground meat and turkey, duck.

Ø 4 Months Post-Op: Veal, crunchy fruits and vegetables including salads.

Ø 6 Months Post-Op: Beef and pork (choose poultry and fish more often in view of lower fat content).

*** The diet should always be high in protein and low in refined carbohydrates. Protein first, then vegetables, fruits and then preferably whole grains.


Nutritional Supplements


You will require vitamin and mineral supplements for the rest of your life in order to prevent deficiencies. Remember, you are eating much less food, as well as absorbing fewer nutrients, and therefore requires supplemental vitamins, minerals and protein.

First 3 Weeks After Surgery: All pills must be chewed or crushed!

v Chewable Multi-Vitamin (chewable children’s): Flinstones Complete or Centrum Jr. with iron (chew 1 in the AM and 1 in the PM). 2/day.


v Chewable Calcium: Tums 400 or Citracel Creamy Bites 1200mg per day (chew 1 with breakfast, 1 with lunch and 1 with dinner). 3/day.


v Protein Shake: Make protein shake by choosing a protein powder (i.e.: Designer Protein, GNC Challenge 95, Whey Supreme). *1 scoop powder equals about 20 grams of protein and 100 calories. Blend 1 scoop of protein powder with ½ cup mile, ice and 2 tsp. fruit. Premade shakes are also available (i.e.: Isopure – in the clear glass bottle, Ultra Pure Protein) Have 1 shake per day as a meal replacement.


3 Weeks After Surgery: You may start swallowing pills.

v Adult Multi-Vitamin: Centrum with Iron, Geritol Complete, or GNC Ultra Mega (may need to be broken in half) once daily


v Calcium: 1200mg Calcium Citrate (i.e.: Citrical Ultra dense with Vitamin D, www.Vitalady.com brand). You can only absorb 500 mg of calcium at a time. Take throughout the day. Example: take a calcium supplement with each meal and one with a snack. If you are taking thyroid medication, take separately.


v Iron: As prescribed by your doctor. Take on an empty stomach (i.e. first thing in the morning and/or before bed). Take with vitamin C to increase absorption (chewable). Do not take with milk, calcium supplements, coffee, tea or antacids!


v Protein Shake: If unable to consume 60-70 grams of protein/day from diet, then protein supplement may be indicated (protein bar or shake).


(Labs will be followed and other supplements may be prescribed as needed.)


Sample Liquid Diet

(Day 2-Day 10 after surgery)


MORNING IDEAS

1 cup protein shake
1 cup Propel or tea or coffee

AFTERNOON IDEAS

1 cup protein shake

1/2 cup vegetable juice or water
1/2 cup "Cream" of tomato soup (tomato soup with skim milk-no chunks)

EVENING IDEAS

1 cup protein shake

1/2 cup Crystal Light or Wyler’s Light
½ cup broth
1 diet ice pop


REMINDER!


· Try to consume at least 2 high protein shakes (Slim Fast Optima High Protein, Ensure High Protein, Pure Protein, Myoplex Lite, etc.) every day! They will help give you energy and protein. It will help promote would healing and help preserve muscle.
· Shake idea: take 4 oz milk, cruhed ice, and blend with 1 scoop protein powder (i.e. Designer Whey or Isopure) to make a protein smoothie.
· HINT: The first two weeks are the most challenging! It is suggested that you avoid watching TV during this time due to the large number of food commercials. Choose other activities such as reading books, knitting, writing, using the Internet, talking on the telephone, etc., to help keep your mind off of food.






Sample Puree Diet

(Second 10 days after surgery)





BREAKFAST

2 chopped poached eggs
or
3 oz cottage cheese
or
Protein shake




LUNCH

2-3 oz moist tuna (use reduced fat mayo), 1-2 tbsp. pureed peaches
or
2-3 oz silken tofu, 1-2 tablespoons pureed broccoli
or
Protein shake


DINNER

2-3 oz flaky, moist fish, 1-2 tablespoons pureed vegetables
or
2-3 oz blended meatloaf (soft, moist), 1-2 tablespoons pureed cauliflower

** NOTE: You can always replace a meal with a shake




Estimating Your Protein Intake



Your average protein intake for the first 3 weeks after surgery is about 60 grams per day. After 3 weeks it increases to 75 grams.




v Every 1-ounce of protein (meat, poultry, fish, cheese) will have about 7 grams of protein. (i.e. 2 oz of tuna fish has about 14 grams of protein in it).


v An ounce looks like a thin deli slice of turkey or cheese or 1 prepackaged wrapped slice of cheese.


v An ounce looks like the size of a small matchbook or the size of a thumb.


v A cup of milk or yogurt has about 8 grams of protein in it.


v An egg has about 7 grams of protein.


v ½ cup of cottage cheese has 14 grams of protein.


v Read your food labels to help estimate the protein content of other foods.


IMPORTANT REMINDERS!



w Keep in mind that your diet needs to be low fat, low calorie, sugar free and portion controlled for the rest of your life. This is the commitment you must make to achieve maximal weight loss.


w If you experience increased hunger in the first 2 weeks, drink more calorie rich drinks (i.e. protein shakes, milk). Do NOT advance your diet prematurely as you will increase your chances of vomiting. You are on a thin pureed diet to help promote healing.


w If you experience excess gas make sure you are not using drinking straws as it promotes swallowing excessive air. Other possible causes of gas include Lactose Intolerance, high consumption of sugar free foods, excess dietary fiber, and calcium carbonate. Make the appropriate changes if needed. For example, try Dairy Care, lactaid milk or soy milk if you are lactose intolerant. Talk to the MD or RD about products such as GasX, Mylanta or Beano to help reduce gas.


w If you experience constipation, increase fluid, dietary fiber and physical activity as medically feasible. Fiber rich foods include beans, oatmeal, fruits, whoe grain breads and high fiber cereals. Add fiber slowly to your diet to avoid stomach upset. Increase your fluid intake as you increase your fiber intake. Talk to the MD or RD about products such as Philip’s Milk of Magnesia, Colace, or Benefiber to help with constipation.


w It is recommended that you keep a food journal. This will help you keep track of your eating habits. Bring the food journal to your nutrition followup visits to review your progress with the nutritionist.


w It is very common to hit a weight loss plateau (weight loss stops for a period of time). Most people will experience one or more plateaus during their weight loss journey. This is NORMAL!! Your body is becoming more adjusted to consuming fewer calories. At this time review your diet and your eating behaviors. Are you eating protein first? Are you limiting your fats and starches? Are you consuming “soft calorie” foods (i.e. ice cream)? Are you drinking at your meals? Review the original guidelines in this packet and adhere to them. Meet with your nutritionist to review your diet.


Ö


TOP TIPS FOR SUCCESS

Ö Chew food well (until its pureed)
§ Try cutting food into small pieces (the size of a pencil eraser).
§ Liquefy food in mouth before swallowing (chew food 15 times before you swallow).
§ Put your fork down between bites (count to 60 before you take another bite).
§ Try using cocktail forks or baby utensils to help take small bites.


Ö Watch your portion sizes at meals.
§ The less food you put in front of you, the less you will eat.
§ Use saucer plate for meals or buy small Tupperware for portion control.


Ö Stop eating when you feel comfortable satisfied.
§ It takes 20 minutes for your brain to identify that your stomach is full. When you feel a pressure in your upper stomach area, this is your new full feeling. If it is painful, you probably took one too many bites! DO NOT OVEREAT!
§ Eat slowly to recognize this feeling.
§ Keep a timer on your table when eating. Set it for 20 minutes. This visual will be a constant reminder to SLOW DOWN!


Ö Only eat when hungry.


Ö Drink adequate fluids to prevent dehydration.
§ Aim for 48-64 oz (6-8 cups) of fluid a day.
§ Do not drink and eat at the same time. Stop drinking 30 minutes before your meal then wait 30 minutes after a meal to resume drinking.
§ For the first week post-op your stomach is swollen and it may take 30-60 minutes to drink a cup of liquid. Keep sipping all day to help prevent dehydration; it gets easier as the weeks pass. Soon it will only take 5-15 minutes to finish a cup. Beverages must be sipped, no gulping!
§ Try sippy cups or sports top water bottles to slow you down, keep fluids with you all day long and keep sipping.
§ Avoid setting a glass at your place setting. It is too tempting to drink if there is a beverage at your meal.
§ Increase your fluid intake if any of the following signs are present: dark urine, headache, dizziness, confusion, a white coating on the tongue. And call your doctor.


Ö Avoid carbonated beverages and beverages containing sugar.
§ The bubbles may cause irritation and gas.
§ Choose sugar free/calorie free, non carbonated drinks such as: Crystal Light, Fruit 2O, Diet Snapple, Light Minute Mais, etc…
§ Limit caffeinated beverages to no more than 16 oz a day.
§ Caffeine can irritate the lining of the stomach and may increase your risk of developing ulcers after surgery.
§ Wean off carbonated and caffeinated beverages before surgery to help prevent withdrawals.


Ö Avoid alcohol beverages.
§ Alcohol, beer and wine, in excess, can cause weight gain and result in poor nutrition since they are high in calories and low in nutrients. Alcohol may be absorbed more quickly than before due to your small stomach. You may feel the effects of the alcohol after consuming a small amount.


Ö Read food labels.
§ Food choices should be no sugar and low in fat.
§ Foods that are high in sugar and fat may cause diarrhea and abdominal discomfort or cause “Dumping Syndrome”.
§ These poor food choices can slow down the rate of weight loss and may even cause weight gain.
§ Avoid concentrated sugar. (It’s high in calories and leaves you hungry for more!)
§ Keep sugar out of the first 3 ingredients on the food label.
§ The following ingredients are also known as sugar and commonly found on food labels: dextrose, high fructose corn syrup, glucose, sucrose molasses and honey.
§ Artificial sweeteners such as Nutrasweet/Equal, saccharine/Sweet & Low and sucralose/Splenda are acceptable to use.
§ Watch for foods containing sugar alcohol such as sorbitol. Large amount of sugar alcohol found in sugar-free candies, cookies, or ice cream may lead to cramping, abdominal pain, excess gas or diarrhea.


Ö Limit high fat foods.
§ Low fat is 3 grams or less per serving on a food label.


Ö Protein is the most important nutrient you need to consume after surgery.
§ You need at least 60-80 grams of protein a day.
§ Protein should be consumed first at each meal, then vegetables and fruits, then “whole” grains.
§ You may drink a protein supplement if you are not able to consume adequate amounts of protein.
§ Look for drinks made with whey protein isolate (this is absorbed well).
§ Strive for a protein shake with at least 20 grams of protein per serving.
§ Mix with skim or 1% milk for an additional 8 grams of protein per serving.
§ Aim for a product with less than 3 grams of sugar per serving.


Ö Exercise!
§ Aim for at least 30 minutes every day.
§ Exercise helps maintain long term weight loss.
§ The first 6 weeks, walking should be used as the primary exercise.
§ After 6 weeks, try introducing strength exercises.
§ Always speak to your doctor if you have never exercised.