Diet after Gastric Bypass | The Hamptons Center for Bariatric Surgery

By Patricia Vonatski, RD in Suffolk County, Long Island

THE SURGERY

The name of the surgery is the Roux-en-Y gastric bypass. It combines gastric (stomach) restriction as well as some malabsorption. Most of the stomach is bypassed, but still makes gastric acid that will help with digestion. A small pouch is made at the top of the stomach using two lines of staples. The small intestine is divided, and the upper limb of the intestine is brought up to the new pouch, so that the foods move from the esophagus into the pouch and then into the intestines. The lower part of the intestine (duodenum) is then reattached to the small intestine. After the surgery the amount of volume the pouch can hold is reduced from about 4 cups to about 1 ounce or 2 tablespoons. Over time the pouch will get bigger.

Although the average weight loss is higher than other restriction operations, poor absorption of iron and calcium can result because the duodenum is bypassed. A lowering of total body iron and predisposition to iron deficiency anemia may occur when a patient experiences chronic blood loss (for example, excessive menstrual flow or bleeding hemorrhoids). Women should be especially concerned about calcium loss, a risk of osteoporosis in women after menopause even with normal digestion.

REQUIRED SUPPLEMENTS

Protein

Protein is perhaps the most important component of your diet after your surgery. Protein is the basic building block for our body. Protein is used to repair and replace damaged tissues. If you do not eat adequate protein, you may experience hair loss, your wounds may not heal and you may lose lean muscle mass.

How will you get enough protein, especially right after surgery? We recommend a protein powder or liquid supplement. These can be purchased at Walmart, health food stores or on the Internet. You will want to get between 15-20 grams of protein with each meal for a total of 60-70 grams per day. As your diet progresses you will be able to reduce your use of protein liquid, as the foods you will eat will contain protein.

Some ideas for protein supplements:

POWDERS- There is a variety of protein powders on the market. These powders are added to your food. They tend to change the taste of the food however.

LIQUIDS-Protein drinks/shakes seem to be better tolerated. Some of the brands that have been tried are as follows:

1. All the Whey protein powder- www.allthewhey.com

2. Pure protein shake-35 grams/can (Body Source-473-3830 or 1-800-854-5019)

3. Nitro-Tech-45 grams of protein (GNC)

4. Isopure dietary supplement- GNC

5. New Whey Liquid Protein (test tube) 25grams in 3.1 ounces

For the first four to six weeks you will be able to get some protein in the foods that you eat (milk, yogurt, sugar free pudding), but you still need the protein supplements.

VITAMINS

Multivitamin

Due to the restrictions of the procedure (small pouch and intestinal changes), you will not be eating enough food to obtain all the vitamins you need. Fortunately, any side effects can be well controlled by taking LIFELONG vitamins. We recommend two multivitamins per day (chewable with iron such as Flintstones complete or any adult chewable) taken separately. If you are a postmenopausal female or a male take one Flintstone complete(one with iron) and one Flintstone with extra calcium(one with no iron).

Vitamin B-12

Careful monitoring of lab work will be important after surgery to determine if you need Vitamin B-12 (either given via injection or sublingually). Intestinal B-12 needs a cofactor (called intrinsic factor) that secreted by the cells lining your stomach. Because bariatric surgery bypasses most of the stomach, intrinsic factor may not be available and the Vitamin B-12 not absorbed. We suggest that you have blood work done at 3,6,9, and 12-month intervals. Vitamin B-12 deficiency will lead to pernicious anemia. Sublingually(under the tongue) take no more than 500ug. Take your B-12 supplement one time per week.

MINERALS

Calcium

One mineral that is difficult to get enough of after the surgery is calcium. At times calcium-rich dairy foods are not well tolerated after surgery. If you are able to tolerate dairy products this will help you in getting the calcium you need. We recommend a chewable calcium supplement with Vitamin D. The Calcium supplement should be made from CALCIUM CITRATE( 1200-1500 mg per day). If you are a postmenopausal woman, speak to the dietitian about your needs

Iron

We do not recommend a separate iron supplement immediately after surgery. We suggested that you have blood work done regularly and monitored by your primary care physician. Everyone’s case is different, and supplementation may be needed.

**Remember these vitamins and minerals are required for you to maintain good health. If you do not take them on a regular basis you are putting yourself at risk for anemia and other deficiencies. **

GENERAL NUTRITION GUIDELINES

Sugar and “Dumping syndrome”

Your new “pouch” is attached to your intestines in such a way that it often will make you sick if you eat or drink food or beverages high in sugar. Digesting sugar causes large volumes of fluid to enter the intestine from the bloodstream to dilute the concentrated sugar molecules. The result for a gastric bypass patient is a rapid reduction in the body’s blood volume and a shock-like reaction. Because normal digestive process has been altered, sugars and carbohydrates now can cause a hyper-insulin response. This reaction to sugar and carbohydrates is called “dumping” and is accompanied by a number of symptoms including:

General weakness Rapid heart rate Ringing in ears

Stomach cramps Diarrhea Nausea

Dumping can last from 30-60 minutes and often can cause you to feel so weak that you will need to lie down until the symptoms subside. In cases of “late” dumping, the cause is complex carbohydrates such as pasta. The symptoms are delayed but can include neurological changes and confusion.

Does this mean, you will never be able to eat something sweet? No, we suggest that you try something sweet with a source of protein. Of course it is not suggested that you eat “sweets” on a regular basis. “Sweets” contain “empty calories”(calories with no nutrition value).

Alcohol Alcohol is problematic for several reasons. It is packed with “empty” calories, which will only contribute to total calorie intake, it dehydrates the body which impacts kidney function and waste removal and lastly because the new pouch empties into the intestine much faster than a normal stomach the effect is quicker and more toxic. We do not recommend alcohol immediately after surgery.

Low Fat Fat may be difficult to tolerate after surgery. You may experience nausea and bloating after a high fat meal. Sometimes the symptoms are similar to those of “dumping syndrome”. Also a high fat food can cause acid reflux or heartburn. NO FRIED FOODS Most importantly high fat foods are high in calories, which could slow down your weight loss rate. You do need some fat in your diet (minimum of 20 grams per day). It is better to choose oils (olive, canola), nuts (when you are allowed to eat them), and avoid saturated fats. Ask your dietitian for further details.

Liquids It can be easy to become dehydrated after gastric bypass surgery because you are only able to sip small amounts of liquid at one time (1-2 ounces at a time). It will be important for you to carry fluid with you throughout your day. The following are guidelines for drinking fluids.

*All fluids should be low calorie and non-carbonated

*Drink fluids between meals NOT with meals

*Stop drinking 15 minutes before you plan to eat a meal and resume drinking one hour after finishing a meal.

*Begin by drinking 4-6 ounces slowly between meals and then increase to 8 ounces five times per day.

*Avoid caffeine-containing beverages, as they are appetite stimulants

*If you would like to drink fruit juice, they must be diluted.

Bowel Habits Because your diet will be very low in fiber for the first few months, you might experience changes in your bowel habits. There is less space in the stomach to hold these bulky foods and less stomach acid to digest them. If you would like to us a fiber supplements speak with your MD and or Registered Dietitian.

TIPS FOR OPTIMAL WEIGHT LOSS

YOU MUST LEARN THE GUIDELINES OF YOUR DIET BEFORE SURGERY IS PERFORMED.

1. Take your time while eating or drinking. Allow plenty of time to eat your meal (20-45 minutes).

2. Stop eating at the FIRST sign of fullness. You may not feel fullness or hunger for the first few weeks after the surgery. Follow the prescribed portions.

3. Sip at least 48-64oz. of calorie free non-carbonated beverages

4. Wait at least one hour between eating and drinking

5. Take small bites and CHEW YOUR FOOD WELL.

6. Avoid concentrated sweets and sugar

7. Take your vitamins and minerals daily

PORTION SIZES AND EATING HABITS

During the first six weeks after surgery, you will only be able to take in tiny amounts because your pouch is swollen and small. Your new pouch over the first one to two months has the capacity to hold about 1-2 ounces (about the size of an egg). It is important to remember that the size of the pouch outlet is only ¼ of an inch wide. Look at your PINKY NAIL- that’s about all the room your food now has to pass through. This is very different than what you had before surgery. You must chew your food until it is liquid otherwise it could get stuck in the outlet causing you to vomit.

Over time the capacity of your pouch will increase to about ¼ cup in the second and third months, then to about ½ a cup in the fourth month and maybe a bit more after that-but never more than one cup.

**If you eat more than you should, you are risking injury to your surgery site, stretching your pouch, physical discomfort such as bloating and vomiting.**

DIET PROGRESSION

IN THE HOSPITAL

Clear liquids- The first stage of the gastric bypass diet is a clear liquid diet. This will be your diet while you are in the hospital. You will start with sips of water and then move to apple, cranberry or grape juice, diet gelatin, clear broth, sugar free water ice and decaffeinated tea. Pro-stat will also be included on your tray. It is good idea to drink out of a medicine cup to help control your portions. A sample meal plan follows:

It will take you a few hours to drink the tray that you receive. Remember only drink about 2 ounces every 15 minutes.

Breakfast	Lunch	Dinner
2 oz. Apple juice 2 oz Chicken broth 3 Tbsp. Diet gelatin 2 Tbsp. Pro-stat	2 oz. Cranberry juice 2 oz. Broth 3 Tbsp. Sugar free water ice 2 Tbsp. Pro-stat	2 oz Grape juice 2 oz Broth 3 Tbsp. Sugar free water ice 2 Tbsp. Pro-stat

FIRST MONTH POST-OPERATIVE (STAGE 1)-Home: Day 1-21

Full liquids- Once you are able to tolerate clear liquids you will progress to a full liquid diet. This will last for three weeks. Foods in this stage should be SMOOTH (no lumps or seeds). You should be able to tolerate thicker foods such as plain or “lite”yogurt, sugar free pudding, or baby food. Your protein supplement is crucial at this point. During this stage you may have a small frequent meals (i.e. 1/4 cup of low fat milk). A guideline and sample meal plan follows: Don’t Forget to take your vitamins

Breakfast	Snack	Lunch	Snack	Dinner	Snack
¼ cup Cream of Wheat	¼ cup milk	¼ cup sugar free strained yogurt	1/4 sugar free yogurt	¼ cup low fat strained soup	1/4 cup sugar free pudding

GUIDELINE FOR STAGE ONE

Category	Choose	Avoid
Beverages	Crystal Light, vegetable juice, skim or low fat milk, diluted unsweetened fruit juice, decaffeinated tea	Soda, fruit drinks, sugar iced tea, alcohol, coffee, tea, and carbonated beverage, whole milk
Soups	Reduced fat cream soup, pureed meat and vegetable soups, broth. All soups must be pureed and lumps strained	All others
Starches	Cooked and blended refined cereals thinned with milk (cream of wheat or rice)	All others. No pasta or rice
Vegetables	Pureed vegetables, vegetable juices	All others
Fruits	Unsweetened applesauce, pureed fruit without seeds or skins, unsweetened baby food fruits	All others
Meat, Protein	Protein shakes (no sugar)	All others
Milk and Milk products	Low fat milk, plain or “Lite” yogurt, Carb control smoothie	Chocolate milk, cheese, fruited yogurt, whole milk
Others	Sugar free gelatin, pudding, custard	All others

GROCERY LIST FOR STAGE ONE

__1% milk

__Plain soymilk

__Plain yogurt

__Yogurt-sugar free (smooth consistency-Columbo raspberry, Dannon key lime pie)

__Sugar-free pudding

__Sugar-free custard

__Liquid protein supplements

__Low fat cream soup(strained)

__Cream of Rice

__Cream of Wheat

__Infant strained fruits and vegetables

__Herbal Tea

__Water

__Crystal Light

__Nonfat dry milk

__Fruit H2O

__Tomato juice/ V-8 juice

__Orange juice (diluted)

__Apple Juice

__Pureed soups such as bean, lentil (thin consistency)

__Dannon Carb control smoothie

SECOND MONTH POST-OPERATIVE (STAGE TWO)-Day 22-35

Pureed/Soft- After three weeks on a full liquid diet, you may eat a pureed or blended diet. At this point you should leave your liquid meals behind, as they will not keep you satisfied as long as solid foods will. Starches such as “doughy” breads, bagel, pasta and rice, chips should be Avoided, as they tend to form a gummy ball in the pouch and cause discomfort. Protein continues to be critical. Protein should be the first food you eat at each meal. A sample meal plan and guidelines follow:

Breakfast	Lunch	Dinner
1/4 cup of Oatmeal ¼ cup plain yogurt Protein supplement	¼ cup Tuna ¼ cup unswt. Applesauce Protein supplement	¼ cup scrambled eggs ¼ cup low fat milk Protein supplement

GUIDELINES

Category	Choose	Avoid
Beverages	Crystal Light, coffee, tea, vegetable juice, skim or 1% milk, diluted fruit juice, water,	Soda, alcohol, fruit drinks, sweetened tea/lemonade, whole milk, milkshake
Soups	Reduced fat cream soup, broths, vegetable soups	Full fat cream soups
Starches	Whole grain toast, pretzels, saltines, mashed potato	White bread, bagels, chips, pasta, rice
Vegetables	Soft cooked vegetables	Raw vegetables, celery, peas, corn
Fruits	Canned fruit (unsweetened), bananas, citrus with membrane removed, diluted fruit juice	All others
Meat, protein	Soft flaky fish, eggs, cheese, cottage cheese, ricotta cheese, hummus, fat free refried beans, smooth peanut butter	Avoid nuts, beef, and pork. Limit chicken, no diced meat
Milk and milk products	Skim or 1% milk, “lite” or plain yogurt, soft cheese, cottage or ricotta cheese	Chocolate milk, condensed milk

GROCERY LIST FOR STAGE TWO

__Non fat or 1% milk

__Plain soymilk

__Reduced calorie smooth yogurt

__Plain yogurt

__Sugar-free pudding

__Sugar-free custard

__Protein supplements

__Low fat cream soup

__Cream of Rice

__Cream of Wheat

__Unflavored oatmeal

__Unsweetened pulp-free juice

__Fresh fruits and vegetables (soft, well cooked)

__Unsweetened applesauce

__ Infant pureed fruits, vegetables, and meats

__Water packed tuna made with mayonnaise

__Minced clams

__Fresh fish (soft and cooked moist)

__Low fat cottage cheese

__Low fat ricotta cheese

__Eggs

__Egg Beaters

__Lowfat mayonnaise

__Herbal Tea

__Water

__Crystal Light

THIRD MONTH POST OPERATIVE (STAGE THREE)

About six weeks after you surgery, you can begin to add solid food to your diet. You must continue to follow a low fat diet and continue to eat SMALL PORTIONS( ½ cup –3/4 cup). Remember to chew your food well

Breakfast	Lunch	Dinner
½ cup cold cereal 2 small slices of banana ¼ cup low fat milk	2 ounces of Turkey salad 4 Saltines ¼ cup of tomato juice	2 ounces of Flounder 2 Tbsp. of Rice ¼ cup of soft carrots

ALWAYS EAT THE PROTEIN IN YOUR MEAL FIRST

Certain food should still be avoided and they are as follows (these foods may obstruct the stomach pouch): AVOID THESE FOODS FOR AT LEAST 6 MONTHS

*Tough meat (brisket, corned beef)

*Stringy vegetables (celery, corn, spinach, asparagus)

*Membranes of oranges and grapefruits

*Skins of various fruits and vegetables (apple,potatoes)

*Coconut

*Seeds and nuts

GROCERY LIST FOR STAGE THREE

_Nonfat milk

__Plain soy milk (low fat)

__Reduced calorie smooth yogurt

__Plain yogurt

__Soy/whey protein powder

__Protein shakes (Pure Protein, Atkins)

__Low fat cream soup

__Sugar free pudding

__Sugar free custard

__Cream of Rice

__Cream of Wheat

__Regular-unflavored oatmeal

__Cold cereal (whole grain, low sugar)

__Fresh fruits and vegetables

__Vegetable juice

__Tuna Fish Salad (no onions or celery)

__Whole Wheat Bread

__Mashed Potato, Sweet Potato

__Pasta

__Rice (brown)

__Minced Clams

__Fish (Flounder)

__Lean Beef (tenderloin)

__Chicken, Turkey (skinless)

__Low fat deli meats

__Legumes

__Cottage cheese

__Low fat ricotta cheese

__Eggs

__Egg Beaters

__Lowfat mayonnaise

__Herbal Tea

__Crystal Light

__Water

__Cheese

Stage II Sample Meal Plan ( two months post-op)

Note that this is a guide. Never force yourself to eat more if you are full.

Meal	Food	Calories	Grams of Protein
Breakfast 8:00am	1 egg of egg substitute scrambled 15 grams of a Protein drink 1/4 slice of Whole wheat toast 1 tsp of Butter/Margarine	80 64 20 45	7 15 1
	Total	209	23

Lunch 12:00pm	2 ounces of Tuna in Water (smooth) 1 tsp of light mayonnaise 2 whole grain crackers 15 grams of a Protein drink	70 35 40 64	14 1 15
	Total	279	30

Dinner 5pm	2 ounce meatball with tomato sauce ¼ cup well cooked vegetables 2 Tbsp mashed sweet potato	200 25 30	14 1 1
	Total	255	16

Snack 8pm	½ cup of plain yogurt 1 tbsp of applesauce 15 grams of a Protein drink	75 20 64	4 15
	Total	159	19
Daily Total		902	88

Stage III Sample Meal Plan (Three months post-op)

Note: This is just a guide. Never force yourself to eat if you are full.

Meal	Food	Calories	Gram of Protein
Breakfast 8:00am	1 egg or egg substitute made with 2 Tbsp. Cottage Cheese ½ slice Whole Wheat toast 1 tsp. Butter/Margarine	75 30 40 45	7 3 1
	Total	190	11

Lunch 1:00pm	2 ounces Sliced turkey 1 Tbsp. Light Mayo ½ slice of Whole Wheat Bread ¼ cup of yogurt (plain)	70 50 40 28	14 1 2
	Total	188	17

Dinner 5pm	3 oz. Salmon broiled with lemon ½ cup of cooked vegetables 2 Tbsp of rice	232 25 40	21 1 1
	Total	297	23

Snack 8pm	1/3 of a peeled apple 2 ounces of low fat cheese	30 150	14
	Total	180	14
	Daily total	855	65

Sample Meals after 3 months

REMEMBER>>>>>>Always eat the protein first, vegetable/fruit second and the starch last. Stop when you are satisfied NOT stuffed.

Breakfast ideas:

1. Scrambled egg or eggbeaters with a 1 slice of low-fat cheese and soft cooked vegetables.

2. ½ cup of oatmeal made with skim milk

3. ½ cup whole grain cereal (Kashi, wheaties) with skim milk

4. 1 slice of whole-wheat toast with 1 slice of low-fat cheese or 2 tsp. Smooth peanut butter or 1-2 Tbsp. Low fat ricotta or cottage cheese.

Lunch ideas:

1. ¼ cup tuna/egg/chicken salad with 3-4 crackers

2. 2-3 oz. chicken or fish with ½ cup mixed greens/cooked vegetables an oil/vinegar

3. 2-3 slices of low fat deli meat rolled up with lettuce

4. ¼ cup shrimp/seafood salad on bed of lettuce with 2 tomato slices and 2 whole wheat crackers

5. ¼ cup of turkey chili with 2-3 whole grain crackers

Dinner ideas:

1. 2-3oz. chicken stewed with tomatoes, onion, and peppers. Served with ¼ cup brown rice.

2. 2-3oz. Broiled fish with ¼ cup steamed broccoli and ¼ cup sweet potato

3. 2 small meatballs with tomato sauce, ¼ cup zucchini, ¼ cup pasta

4. 2-3oz. meatloaf served with ¼ cup green beans

Snack ideas:

1. ½ cup sugar free yogurt with ½ cup sliced strawberries/blueberries

2. ½ protein bar (Atkins, pure protein)

3. 1 ounce of low cheese with 2 apple slices

4. 2 tsp smooth peanut butter and 1/3 banana

5. 3 baby carrots with onion dip made with nonfat sour cream

SCHEDULE FOR SUPPLEMENTS

Day	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Multivitamin (chewable)	1in AM 1 in PM	1in AM 1in PM	1 in AM 1 in PM	1in AM 1in PM	1in AM 1 in PM	1in AM 1in PM	1in AM 1in PM
Vitamin B-12(shot once per month or lozenge once per week)							500ug Lozenge
Calcium Citrate (chewable)	3 chews 1500mg per day	3 chews 1500mg per day	3 chews 1500mg per day	3 chews 1500mg per day	3 chews 1500mg per day	3 chews 1500mg per day	3 chews 1500mg per day
Protein supplement	60-70 grams	60-70 grams	60-70 grams	60-70 grams	60-70 grams	60-70 grams	60-70 grams