Leads Medical Center
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Nutritional Expectations

After Gastric Bypass you will need to make changes to your eating patterns. The diet after surgery progresses from a liquid diet to a pureed diet to a soft diet and then to a modified regular diet. The diet progression is designed to allow your body to heal. Initially, it will help you meet your protein and liquid requirements, and later, it will assist you in meeting your nutritional needs. It is imperative that you follow the diet’s progression and adhere to this regimen to maximize healing and minimize the risk of unnecessary complications. The size of your stomach pouch is about one ounce or one to two tablespoons. At first your capacity will be somewhat limited, so be patient. You may find that two to three teaspoons of food fill you up. This is expected. You may also find that you are able to eat more of one type of food than another. That is okay, too. Over time, your food pouch will stretch. By six months after surgery, it may stretch to eight ounces or one cup. Long term, the size of your pouch is likely to be eight to twelve ounces or 1 to 1 1/2 cups. This will limit the amount of food you can eat at one time.

One of the changes that patients often comment about is the concept of “wasting food” After surgery your eyes and head still work the same way as they did before. However, because of the new stomach pouch, you will be satisfied with much less. It is critical that you listen to your body’s signals of fullness and not to your eyes that see food left on your plate.

You may also be surprised at how the surgery changes your wants and desires for certain foods. Foods you may have previously loved you may now find you are less interested in.

It is common to see some variation from program to program related to nutrition. Just as there are many food options, there are many options and preferences post-operatively. However, most programs agree that the primary source of nutrition should be protein. 70 to 75% of all calories consumed should be protein based (eggs, fish, meat, etc). Carbohydrates (bread, potatoes, etc.) should make up only 10 to 20%, and fats (butter, cheese, etc.) only 5 to 15% of the calories that you eat. A diet consisting of 600 to 800 calories and 75 grams of protein should be the goal for the first 6 months. Protein drinks can be helpful to fulfill your protein requirements. There are many to chose from. Look for protein drinks that are low calorie and low sugar and that have a good taste.

Avoid foods which contain sugar. Not only will they slow down your weight loss, but they can make you sick! Sugar may cause “dumping syndrome” in patients who have had the gastric bypass procedure. Dumping, in short, is when sugars go directly from your stomach pouch into the small intestine causing heart palpitations, nausea, abdominal pain, and diarrhea. Symptoms may vary among patients. Dumping lasts about 30 minutes to an hour.

To maintain a healthy weight and to prevent weight gain, you must develop and keep healthy eating habits. You will need to be aware of the volume of food that you can tolerate at one time and make healthy food choices to ensure maximum nutrition in minimum volume. A remarkable effect of Bariatric surgery is the progressive change in attitudes towards eating. Patients begin to eat to live – they no longer live to eat. As well, exercise must be part of your daily routine.

Lactose Intolerance

Lactose intolerance is a set of symptoms resulting from the body’s inability to digest the cow milk sugar called lactose. Gastric Bypass Surgery can unmask lactose intolerance, but not cause it. Lactose is commonly found in dairy based foods and beverages, and is digested in the intestines by the enzyme lactase. Lactase breaks down lactose so it can be absorbed in the blood stream. When the body does not produce enough lactase, lactose cannot be digested which may result in lactose intolerance.

Between 30 to 50 million Americans suffer from lactose intolerance. In fact, 75 percent of all adults worldwide do not produce adequate amounts of the lactase enzyme, and therefore may experience some or all the symptoms of lactose intolerance. Depending on the individual, the symptoms may vary, including cramping, diarrhea, bloating, gas and nausea. If you experience these symptoms after eating dairy products, you may be lactose intolerant.

Products that contain large amounts of lactose are cow milk and ice cream; smaller amounts of lactose are found in yogurt, cottage cheese and hard cheese. Prepared foods can also contain lactose, so look on food labels for whey, lactose, non-fat milk solids, buttermilk, malted milk, margarine and sweet or sour cream. Some breads, dry cereal and instant soups contain small amounts of lactose. Although there are supplements that you can take, elimination of dairy is the best approach to solving the problems associated with lactose intolerance. You can still enjoy goat milk products without any worry of having lactose intolerance.

Dumping Syndrome

Under normal physiologic conditions, the stomach and pylorus (the opening of the stomach into the small intestine) control the rate at which the gastric contents leave the stomach. That is, the stomach, pancreas and liver work together to prepare nutrients (or sugar) before they reach the small intestine for absorption. The stomach serves as a reservoir that releases food downstream only at a controlled rate, avoiding sudden large influxes of sugar.

The released food is also mixed with stomach acid, bile, and pancreatic juice to control the chemical makeup of the food that goes downstream and avoid the “dumping syndrome”.

Dumping syndrome is usually divided into early and late phases. The two phases have separate physiologic causes and will be described separately. In practical fact, a patient usually experiences a combination of these events and there is no clear-cut division between them.

Rapid gastric emptying, or early dumping syndrome, happens when the lower end of the small intestine (jejunum) fills too quickly with undigested food from the stomach. After the RNY gastric bypass, patients can develop abdominal bloating, pain, vomiting, and vasomotor symptoms (flushing, sweating, rapid heart rate, lightheadedness). Finally, some patients have diarrhea. Since with the RNY gastric bypass the stomach is not being used (hence the name) and a new, small pouch that directly connects to the small intestine is created, there may be dumping. Early dumping syndrome is due to the now rapid gastric emptying causing bowel distension plus movement of fluid from the blood to the intestine to dilute the intestinal contents. These symptoms usually occur 30 to 60 minutes after eating and are called the early dumping syndrome.

Late dumping has to do with the blood sugar level. The small bowel is very effective in absorbing sugar, so that the rapid absorption of a relatively small amount of sugar can cause the glucose level in the blood to rise rapidly. The pancreas responds to this glucose challenge by increasing the insulin output. Unfortunately, the sugar that started the whole cycle was such a small amount that it does not sustain the increase in blood glucose, which tends to fall back down at about the time the insulin surge really gets going. These factors combine to produce hypoglycemia (low blood sugar) which causes the individual to feel weak, sleepy and profoundly fatigued.

Restricting simple carbohydrates (rice, pasta, potatoes and other sweet-tasting foods), eating more protein and not drinking liquids during a meal can reduce the symptoms of dumping. Further, avoid foods that are very hot or very cold. These can trigger symptoms.

Obviously, surgeons consider dumping syndrome to be a beneficial effect of Gastric Bypass Surgery. It provides quick and reliable negative feedback for intake of the “wrong” foods. In practice, most patients do not experience full-blown symptoms of dumping more that once or twice. Most simply say that they have lost their taste for sweets. Warning: Late dumping is the mechanism by which sugar intake can create low blood sugar, and it is also a way for patients to get into a vicious cycle of eating. If the patient takes in sugar or a food that is closely related to sugar (simple carbohydrates like rice, pasta, potatoes) they will experience some degree of hypoglycemia in the hour or two after eating. The hypoglycemia stimulates appetite, and it’s easy to see where that is going.

Eating Techniques

Your new motto: “slow, small, moist and easy”.
Especially in the first eight weeks after surgery, you need to change your eating habits to avoid pain and vomiting, rupture of staple lines and to aid in weight loss. At this time, the tissue around the staples and sutures in the stomach pouch is very swollen and needs to heal. You also want to prevent obstruction of the area where your stomach pouch connects to your intestines (stoma).

Swallowing food in chunks may block the stoma and prevent foods from passing into the intestine. It is CRITICAL that you eat slowly and chew your food well to lower the risk of getting anything caught in this area.

You may find the following tips helpful:

  • Set aside 30 to 45 minutes to eat each meal.

    Aim to chew your food 30 times with each bite. Ground or soft foods may be necessary if you have dentures. Slow down –we have a lifelong habit of eating too fast. Slow down, enjoy the food and relax.
  • Explain to friends and family why you must eat slowly so they do not urge you to eat faster.
  • Take small bites of food and, for a visual aid, you may want to use a saucer in place of a plate to help with portion control.
  • Pay attention to taste; learn how to savor your food.
  • Eat only at meal times. Between meals snacking or “grazing” on small amounts of food throughout the day will sabotage your weight loss and result in the inability to lose an adequate amount of weight.
  • Never drink liquids when eating solid foods. Liquids should be avoided for a period of 30 minutes before and 30 minutes after eating solid food or meals. Combining liquids and solids may cause nausea, as well as push foods through the stomach pouch faster, enabling you to eat more.
  • Stop eating as soon as you are full (over-eating even one ounce can make you vomit and can lead to stretching your pouch). Listen to your body’s signals, not the food left in your plate.
  • Only eat the best of foods –after all, if you are going to eat so little, shouldn’t you have the best?

Recognizing Fullness

It is often difficult to understand the meaning of new sensations. Indications of fullness may not feel the same as before surgery. Here are some that are not as obvious, but a sure sign that your pouch is nearly full:

  • A feeling of pressure or fullness in the center of your abdomen, just below your rib cage.
  • A feeling of nausea, regurgitation or heartburn.
  • You may have a feeling of satiety several minutes after you are actually full. If your pouch is 30cc (one ounce), you can put 30cc in it, and you will not feel full for about 5 minutes. Try this to help you find out the right portion size:
  • Measure 30cc of water, drink it, and wait for a few minutes. If you feel full with this amount and are comfortable, measure this amount of food before you eat it. This will prevent stretching of the pouch and the misery caused by over-eating.

Foods that may be Difficult to Tolerate

  • Bread products
  • Cow milk products
  • Pasta products
  • Fatty foods and fried foods
  • Candy, chocolate, any sugary foods and beverages
  • Carbonated beverages
  • Bran cereal and other bran products
  • Corn, whole beans, and peas
  • Dried fruits and skins of fresh fruit
  • Coconut

Food Guide for the First Post-operative Week
(Stage I Diet)

During this very early period it is best to limit your intake to liquids. This will give your new stomach pouch time to heal properly. This diet consists of clear, sugar-free fluids and can usually be started by the third day after surgery or as ordered by the surgeon. The liquids should not be carbonated or contain alcohol. Sip your liquids slowly and carefully, stopping whenever you feel full. It is normal to have a reduced appetite in the days following surgery. There is no need to finish everything on the hospital food tray.

Note: Once a patient has advanced to solid foods, they should go back to the stage 1 diet for 24 hours if experiencing excessive nausea, vomiting, or abdominal pain. Call the surgeon if these problems continue for more than 12 hours.

Clear liquids that are well-tolerated:

  • Unsweetened, non-carbonated beverages
  • Clear beef, chicken or turkey broth
  • Strained Miso soup
  • Unsweetened popsicles
  • Unsweetened Jell-O®
  • Decaffeinated beverages
  • Apple, grape or cranberry juice
Note: The first 10 to 14 days you may benefit from diluted fruit juices, however be cautious not to consume too many calories in juices.

Food Guide for Weeks One through Four after Surgery
(Stage II Diet)

At this point, your dietary choices start to expand some what. It is still very important to adhere to the guidelines, as your new pouch is still healing and you are adjusting to a new way of eating. This diet consists of low-sugar foods that are liquid or semi-liquid at body temperature such as hot cereals and low-lactose products. You should limit your intake to liquids, and very soft foods. This diet permits a gradual transition to more solid foods. Again, only eat until you start feeling full. Remain on this diet until your surgeon allows you to advance to the Stage III Diet.

Note: Try adding unflavored protein powder to soups and cereal to increase the nutritional value

Foods that Patients liked after the Fourth Post-operative Week
(Stage III Diet)

This diet includes semi-solid, soft and pureed foods that are easily digested. During the first 6-8 weeks after surgery, the stomach and small intestine are still healing. Limiting a diet to the foods listed in Stage III is necessary to avoid a blockage or other complications. Introduce foods slowly. If you notice a problem, try to identify it and be wary of the speed and amount you ate. Often foods that are not tolerated well at this stage can be added at a later time without any problem. You may experience occasional vomiting after eating, diarrhea, or cramping during the recovery period. Return to the stage 1 diet for 24 hours if these symptoms are severe, and contact your surgeon if they don’t improve within 12 hours. Remember to always chew your food very well, and don’t drink fluids with meals. Sip water and other beverages throughout the day, except at mealtimes.

Gradually, try other sources of protein such as soy products, poultry, fish and seafood, and lastly, meats.

T olerance to foods varies from one individual to the next. Once you are back on a more regular diet, through trial and error, you may find you are able to tolerate some foods better than others. There may be some foods that your digestive system cannot handle well. We advise patients to avoid red meats until their stomach is functioning very well, usually after at least 3 to 4 months. After the gastric bypass, red meats are not well tolerated and can cause vomiting. This is purely a mechanical effect. Steak is much harder to break down so it will be able to fit through the small stomach outlet. If the outlet gets plugged, vomiting will result. Many things can cause discomfort and vomiting. Sometimes the source may be a specific food. Do not avoid a food just because you vomit once after eating it. You may wish to wait a few days, but you should try that food again. T olerance to food may improve over time. Always be sure to chew your food very well, take small bites and eat slowly. Try only a very small amount at first. Cook foods without added fats.

Foods to Avoid
Here is a list of popular foods that are filled with empty calories and that can provoke “dumping syndrome”. The products provide mainly calories with limited nutritional value (protein, fiber, minerals and vitamins). Every bite counts after surgery. Avoid foods which contain sugar. Not only will they slow down your weight loss, but they can make you sick! Sugar may cause “dumping syndrome” in patients who have had the gastric bypass procedure. Dumping, in short, is when sugars go directly from your stomach pouch into the small intestine causing heart palpitations, nausea, abdominal pain, and diarrhea. Filling up on concentrated sweets and other simple carbohydrates can prevent weight loss and good nutrition.

Foods to avoid:

    –Ice cream
    – Pudding
    – Sweetened, fruited or frozen yogurt
    – Dried fruits
    – Candied fruit
    – Canned or frozen fruit in heavy syrup
    – Fruit juice
    – Sugar coated or sweetened cereal
    – Sweet rolls and doughnuts
    – Sports drinks
    – Popsicles
    – Pies
    – Cakes and cookies
    – Jellies
    – Regular soft drinks/Lemonade
    – High fructose corn syrup sweetened beverages
    – Sugared ice tea
    – Non-carbonated fruit drinks
    – Table sugar
    – Honey
    – Candy and chocolate
    – Sweetened gelatin desserts
    – Regular chewing gum
    – Molasses
    – Syrups
    – Sherbet/sorbet
    – Jams
    – Pancakes and waffles with syrup
    – Soup (taken without food)
    – Milkshakes and chocolate milk
    – Sweet pickles or relish
    – Rice, pasta, potatoes

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