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Gastric Bypass Surgery Healthy Eating Guidelines
Weight LossSurgery Service
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Gastric Bypass Surgery
oesophagus
short intestinal roux limb
common channel
duodenum
pylorus
pouch of stomach
anastomosis
bypassed portion of stomach
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Introduction
Gastric bypass surgery has dramatically decreased the size of your stomach to about the size of a golf ball.
It is important to follow these instructions carefully to prevent pain when eating, vomiting or damage to your new stomach.
This operation will enable you to lose weight provided you also work on changes to your lifestyle.
The quality of food you eat is very important to ensure you get the most success from your surgery.
Your diet needs to be well balanced and healthy and you need to be active. This will strongly influence how successful your weight loss is.
Your greatest weight loss will occur in the first 6–8 months following gastric bypass surgery. Most patients will plateau after 12–18 months and after this time additional weight loss will be difficult.
Follow the dietary guidelines in this booklet for each phase of your recovery. It is important to progress the textures of your food carefully to allow time for your body to recover from the surgery and adapt to food again.
You must also follow the ‘golden rules’ in order to attain a weight that is close to your ideal body weight and to maintain the weight you have lost.
‘Golden rules’ for success
• Eat slowly (put your cutlery down between bites to help slow you down)
• Chew food well
• Stop as soon as you feel full (heavy in your chest)
• Do not eat and drink at the same time—have a drink 10–15 minutes before meal times and wait 30 minutes after eating before drinking
• Take small mouthfuls—using smaller cutlery can be helpful
• Avoid distractions at meal times—sit at the table and turn the TV off
• Use a tea plate rather than a dinner plate
• Sit in an upright position when eating and rest afterwards
• Aim to eat 3 small meals per day with small snacks in between if needed
• Eat protein foods first
• Avoid drinks that are high in calories and avoid fizzy/carbonated drinks
• Avoid alcohol
• Avoid foods and fluids containing sugar or high amounts of fat such as pure fruit juice—these can make you sick (dumping syndrome) and slow down your weight loss
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Importance of protein
It is important to ensure adequate protein intake after surgery. Protein is not absorbed as well after a gastric bypass and protein is the nutrient the body uses to make new tissue.
It is important to get enough protein after surgery to help with wound healing and help preserve muscle tissue, so the weight that you lose is mostly fat mass.
To ensure you are getting adequate protein in your diet we recommend you include a protein source in each of your meals and snacks.
It is important to eat the protein source first at meal times. Aim to consume 70–100g of protein each day.
Good sources of protein:
• Meat—including red meat, fish and chicken
• Eggs• Low fat dairy products—including
skimmed milk, low fat low sugar yoghurt, low fat cottage or creamed cheese, fromage frais
• Pulses/legumes and lentils including baked beans
• Tofu or Quorn®
We recommend you include a high protein drink (or shake) 2–3 times a day for the first 6 weeks following surgery—your dietitian will provide you with protein drink recipes.
Supplementation
As gastric bypass surgery changes the digestive process, lifelong nutritional supplements are essential to prevent malnutrition. This is a vital long term element of your treatment.
You will be prescribed a complete multi vitamin and mineral supplement (such as Forceval) which needs to be taken once daily.
You will also be prescribed an additional calcium supplement (such as Calcichew D3 Forte) twice a day and an iron supplement (such as Fersaday) once a day if you are a woman of menstruating age. Your GP will continue prescribing these for you.
Take your vitamin and mineral, and calcium supplement every day for the rest of your life.
Why do I need all these vitamin tablets?
Not only is your dietary intake inadequate in nutrients after bypass surgery, but you also do not absorb all your nutrients as well as you did before.
This is because your stomach is not producing as much acid as it did before surgery. Acid is needed for absorption of many nutrients such as iron and calcium.
Additionally, many of the nutrients you eat are absorbed mostly in the duodenum (top portion of your small intestine).
In bypass surgery, we do not use this portion of our digestion, so the lower portion of your intestine has to absorb the nutrients and it does not do it as efficiently.
Important points about taking vitamins
Space them out over the day for maximum absorption. Many vitamins and minerals will compete for absorption via the same pathway. Taking them at the same time restricts how much of each is absorbed.
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Calcium • Take the 2 tablets separately to
maximise absorption• Take 1–1.5 hours after meals if stomach
upset occurs• Precautions—avoid oxalic acid (rhubarb,
spinach), phytic acid (in bran and whole cereals), and phosphorous (in dairy products) in the meal prior to taking the supplement as these substances may interfere with calcium absorption
• Don’t take with iron as calcium decreases iron absorption
• Action—replaces and maintains calcium which is necessary for the formation of bones and teeth and plays a vital role in cell function, muscle contraction and in the nervous system and plays a role in the prevention of osteoporosis
Iron • Take with fruit juice or water, but not
with milk or antacids as these will affect the iron absorption
• Precautions—avoid taking with foods that may impair oral iron absorption, such as dairy foods, whole grains, tea and coffee
• Do not take at the same time as the calcium supplement.
• If you miss a dose, take it as soon as remembered but don’t take a double dose
• Action—forms part of red blood cells which carry oxygen round the body (iron deficiency may cause hair loss, depression and fatigue)
• Side effects—may turn stools black or green, cause diarrhoea or constipation, or cause infant colic in breastfeeding women
Additional supplement
Additional supplementation may be necessary if routine blood testing reveals deficiencies or if you show symptoms of deficiency. The team will let you know if you need these.
Thiamine (Vitamin B1) • May be needed if you have episodes of
nausea and vomiting that last longer than 2 weeks or if you fail to take your prescribed daily multivitamin and mineral tablets over a period of time.
• Purpose—we have only small stores of thiamine in the body and they can become depleted quickly (after bypass surgery your intake may also be low as you cannot eat much food at any one time)
• Action—thiamine is necessary for the release and utilisation of energy from food and for normal functioning of the nervous system (if you are thiamine deficient, you are at risk of permanent nerve damage, loss of feeling in the hands and feet, coordination problems and memory loss—thiamine deficiency can lead to coma and death)
Vitamin B12• May be needed if you fail to take
your prescribed vitamin and mineral supplements, or if your dietary intake is inadequate
• Action—necessary for blood cell formation, has a role in metabolism of the nervous tissue, essential for normal fat metabolism (deficiencies can result in similar problems with the nervous system and memory as with Thiamine deficiency)
Please contact your dietitian or medical team for further advice if you:
• feel your dietary intake is inadequate• have trouble taking your vitamins• have been vomiting regularly• think you may have signs and symptoms
of deficiency
Even if you think your dietary intake is adequate, you still need to take all of your supplements to prevent nutritional complications later in life.
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Dietary advancement
Below are the dietary advancements you will need to follow after surgery. The dietitian will see you when you are in hospital and advise you when you need to start and finish each phase. Some people may progress at a slightly different rate.
Phase 1
Begin: Day of surgery
End: After gastrograffin swallow performed and no leaks detected
Food type: Nil by mouth (you will have an intravenous drip in your arm and this will provide your fluid requirements)
Phase 2 (initial phase)
Begin: After gastrograffin swallow performed and no leaks detected
Duration: 1 day
Food type: Free fluids
Amount: Sips increasing as tolerated
Fluid goal: 1,000–1,500ml/4–6 cups per day
Phase 3 (free fluid phase)
(You usually go home on this phase)
Begin: Day 2
Duration: 9 days
Food type: Free fluids
Amount: 3–6 servings per day—125–190ml/½–¾ cup maximum per serving
Fluid goal: 1,500ml/6 cups per day
Phase 4 (purée phase)
Begin: Day 10 (~week 3 after surgery)
Duration: 4 weeks
Food type: Purée
Amount: 3–6 servings per day—125–190ml/½–¾ cup maximum per serving
Fluid goal: 1,500–2,000ml/6–8 cups per day
Phase 5 (soft phase)
Begin: Day 38 (~week 6 after surgery)
Duration: 2 weeks
Food type: Soft
Amount: 3 meals + 3 snacks per day— 250ml/1 cup maximum per meal
Fluid goal: 1,500–2,000ml/6–8 cups per day
Phase 6 (regular diet)
Begin: day 53 (~week 8 after surgery)
Duration: ongoing
Food type: solid
Amount: 3 meals + 3 snacks per day— 250ml/1 cup maximum per meal
Fluid goal: 1,500–2,000ml/6–8 cups per day
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Example meal plan for free fluid phaseMeal Suggested menu
Breakfast • High protein drink/shake
Lunch • Soup (no solid bits) or• High protein drink
Supper • Consommé or• Vegetable juice
Snacks (aim for 3 per day)
• Fruit/vegetable juice • Sugar-free jelly• High protein drink
Additional fluids• Water• Fruit/ herbal tea
Start date Finish date
Each meal/drink should not exceed 125–190ml/½–¾ cup per serving and have no solid bits in it.
Aim for 1,500ml/6 cups per day to avoid dehydration—spread your fluids out over the day.
Choose high protein fluids—ask your dietitian for protein drink/shake recipes.
Examples of fluids:• Skimmed milk (good source of
protein)• Milk based drinks (low fat, fat free)• High protein drink/shake*• Water• Diluted fruit juices—no pulp (avoid
orange juice as too acidic)
• Vegetable juices—no pulp• Sugar free squash• Sugar free jelly• Marmite®, Bovril®, consommé,
bouillon• Thin (strained) soup• Herb/fruit teas• Tea and coffee—try to keep to a minimum
as provides almost no nutritional value (use sweeteners not sugar)
Avoid fizzy/carbonated drinks as these will make you feel uncomfortable and can cause bloating. It is important you try to avoid these as much as possible for life.
* We recommend you include a high protein drink/shake 2–3 times a day for the first 6 weeks following surgery.
Free fluid phase10 days (days 1–10) post surgery
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The size of your meals should not exceed 125–190ml/½–¾ cups per serving. Take small mouthfuls, eat slowly and stop as soon as you start to feel full.
Puréed foods should be a similar consistency to baby food or apple sauce. There should be no lumps or stringy pieces—this is most easily achieved by using a food processor or handheld blender.
Put some of the water used to boil the vegetables or consommé in the blender to get the right consistency for puréed meat, fish and poultry. Remove skin, bone and gristle from meat or fish before blending.
L iquidise dishes separately—for example, separate liquidised potatoes from liquidised meats—to keep a better appearance and taste. Liquidise in bulk
and freeze—ice cube holders are useful to portion out dishes. Use herbs and spices to flavour dishes.
Remember to always eat the protein foods first at each meal and drink 1,500–2,000ml/6–8 cups between meals, not with your meals.
Examples of puréed foods: • Low fat yoghurt/low fat fromage frais/
custard• Blended soup• Puréed chicken, white fish or turkey (red
meat is harder to purée)• Puréed legumes or lentils• Puréed potato• Puréed fruit• Soft cereals (Weetabix®, Ready Brek®)
with lots of skimmed milk• Sugar-free puddings
Start date Finish date
Purée phase4 weeks (days 11–38) post surgery
Example meal plan for purée phaseMeal Suggested menu
Breakfast • Weetabix® or Ready Brek® with skimmed milk or• Low fat low sugar yoghurt or fromage frais
Lunch• Blended soup made with milk or• Scrambled egg or• Puréed chicken or fish + puréed potato + puréed vegetables
Supper • Puréed chicken + puréed potato + puréed vegetables
Snacks (2–3 per day)• Low fat and sugar custard or• Puréed fruit or • High protein drink
Fluids (1,500–2,000ml per day)
• Water • Skimmed milk• High protein drink• Diluted fruit juice or diet squash• Tea, coffee (try to keep to a minimum as can
reduce iron absorption if taken with food)
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Example meal plan for soft phaseMeal Suggested menu
Breakfast• Weetabix® or porridge/Ready Brek® with skimmed milk or• Toast + low fat cheese or ham or egg or• Low fat yoghurt or fromage frais
Lunch
• Soup made with skimmed milk/meat/beans/lentils or• Scrambled egg or• Cooked fish/minced chicken or turkey/ground beef/
pulses + risotto/mashed potato/winter squash
Supper
• Shepherd’s pie or• Fish pie or• Fish/minced chicken or turkey/ground beef/low fat mild
cheese + mashed potato/sweet potato/winter squash or • Crackers/toast + ham or low fat cheese
Snacks (aim for 3 per day)
• Custard with puréed apple or• Milk pudding (such as rice or sago) or• Low fat and sugar yoghurt or fromage frais
Fluids
• Water • Skimmed milk• Protein drink• Diluted fruit juice or diet squash• Tea, coffee (sweetener, no sugar)
Start date Finish date
The size of your meals should not exceed 190–250ml/¾–1 cup per serving.
Continue eating the same sort of food you were for the purée phase, but it does not need to be blended—mashing will make it the consistency of toddler food.
It should be still soft, or able to be broken up with a fork. Keep to the same quantities and eat 4–6 times per day.
Cook all meat for longer than you would normally and use moist methods of cooking as this will help to make the meat more tender and easier to chew.
Continue to include protein in every meal and drink between your meals.
Examples of soft foods:• Well cooked/mashed vegetables • Soft minced meat with gravy• Flaky fish • Puréed fruits, moving onto tinned fruit
gradually • Soft cereals such as Weetabix®• Scrambled eg gs/omelet te/eg g
custard (hard boiled eggs are not well tolerated)
• Baked beans (mashed initially)
Soft phase2 weeks (days 39–52) post surgery
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You can start to reintroduce more solid foods into your diet 8 weeks after surgery. It is important to focus on the quality of your diet at this stage to get the most benefit from your weight loss surgery.
Caution foods
There are some foods which are more likely to make you sick if you introduce them to early. It is important to learn about the new restriction your pouch is providing before you progress to the tougher, firmer foods.
The following foods some people find more challenging—we do not recommend you avoid them, but that you do take care when you introduce them back into your diet. If you do have trouble with any foods we recommend you remove them from your diet for 2–3 weeks and then retry them.
Examples of caution foods:• Fibrous foods—string beans, pineapple,
celery, sweet corn, fruit segments, those with pips and seeds
• Foods with a skin—tomatoes, grapes, some fruits
• Over-cooked pasta• Dried fruit• Firmer, chewier meats—steak, pork
or chicken if roasted or barbequed (casseroles, minced meat or pot roasts, which tenderise meat, are easiest to eat)
• Bread—particularly white, soft bread (Weight Watchers® and Nimble brand bread may be better tolerated. Toast is also more manageable)
• Rice• Nuts
Successful patients who have had the gastric bypass have 2 things in common:
1. They follow their dietary recommen-dations closely (see ‘golden rules’ at beginning of booklet)
2. They initiate a regular exercise programme 40–60 minutes 4 times per week
Notes on dietary progression after bypass surgery
It is advisable not to move faster through the dietary progression than is stated above. This is because it takes time for your stomach to heal and to avoid complications after surgery such as staple line leaks.
Some people find it difficult to progress through the phases and may take longer. This is because it takes 2–3 months after surgery for your stomach anatomy to settle into place.
The anastomosis (connection between the new pouch and intestines) changes shape and can get a little narrow. When this happens, you can feel nauseous and suffer from vomiting.
Simply step back a diet phase until the nausea settles and then move up again. If you continue to have nausea and vomiting, even if you have stepped back to the fluid phase, then contact your dietitian or the medical team.
Start date
Regular diet phasefrom week 8 (day 53) post surgery—ongoing
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Side effects
Dumping Syndrome
Dumping syndrome occurs when sugars go directly from your stomach to your small intestine or when undigested contents of your stomach are transported or “dumped” into your small intestine too rapidly.
You may experience the following unpleasant symptoms if you consume food or fluids high in fat, sugar or alcohol:
• Nausea• Rapid heart rate• Sweating• Stomach cramps• Diarrhoea• Sweating• Dizziness• Pallor• Feeling faint• Weakness
What to doAvoid the food that is causing the problem. It can be helpful to keep a food and symptom diary to look for trends.
It can help to stick to 3–6 small meals per day that include some protein, and low glycemic index (GI) carbohydrate (ask your dietitian for examples).
Avoid ‘testing the limits’. Some people like to test different foods that are high in fat or sugar, to see how much they can get away with eating before they get symptoms of dumping syndrome.
This is not advisable as the more your body is exposed to these foods, the sooner your intestines will adapt to absorbing them without getting symptoms, and the less weight you will lose. Also, everyone is individual and what affects one person may not affect the next.
Vomiting
This should not occur. If it does, ask yourself:
• Did I eat too quickly?• Did I eat too much?• Did I chew it well enough?• Did allow enough time between eating
and drinking?• Did I eat the right texture?
If you are still vomiting after you have addressed all of the above consider how soon it is after surgery. If it is within the first 2 months, try returning to a liquid or purée diet and see if symptoms resolve. You may just need to take longer to progress through the phases.
If you experience daily vomiting for over 3 days even on fluids, contact a member of the team for further advice. We may need to admit you for IV hydration, thiamine supplementation and an X-ray to check for any surgical complications.
Hair loss
In the early stages after surgery, weight loss can be very rapid and some people notice that their hair is beginning to thin. However, providing the rate of weight loss slows down and the diet is balanced, hair will return to its normal condition. Ensuring you have an adequate protein intake is essential.
Constipation
To prevent constipation, make sure you drink sufficient fluids (1,500–2,000ml per day), and eat foods high in fibre such as wholegrain cereals, fruit and vegetables. If you continue to get constipated you could take a non-bulking agent such as benefiber, movicol, senna, glycerine suppositories or milk of magnesia. See your doctor or pharmacist for advice, or contact your team at Chelsea and Westminster.
Diarrhoea
Diarrhoea can be a side effect of dumping syndrome (see above). It may also be caused by foods high in fat so consider what you have eaten. If diarrhoea persists let the dietitian know.
Women
Menstrual Cycle IrregularitiesWeight loss can cause changes to your menstrual cycle. This is because body fat produces the female sex hormone
oestrogen. As your body fat levels change, so can your oestrogen levels. Some women find their period becomes heavier or lighter, longer or shorter in duration, or starts and stops.
Oral Contraceptive PillsDuring the first 1–2 years after gastric bypass surgery, the effectiveness of the oral contraceptive pill reduces. For this reason we recommend you use an additional, barrier method of contraception after surgery.
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Dietitian appointments
You will be followed up regularly to monitor your progress and wellbeing. We will monitor your weight loss and discuss any problems or difficulties you may be experiencing and help to prevent any problems becoming complications. We can also request your regular blood tests.
We will expect you to attend appointments every 3 months for the first year, every 6 months the following year and annually thereafter.
If you have any queries or questions regarding the dietary guidelines or have started feeling unwell, please contact us.
Specialist Dietitians in Weight Loss SurgeryT: 020 3315 8161/8178E: [email protected]
Missed appointments
It is your responsibility to stay up-to-date with your clinic appointments with the weight loss surgery team at Chelsea and Westminster Hospital.
It is hospital policy to discharge patients who fail to attend appointments back to their GP for their care.
If you need to change an appointment, think you should have an appointment but have not received one in the mail, or have any other questions regarding appointments, please call the Appointments Office (in the first instance) or the team.
Appointments OfficeT: 020 3315 6666 (new patients)T: 020 3315 5677/5686 (review patients)
Weight Loss Surgery TeamT: 020 3315 8604
Patient support group
We would also encourage you to join our patient support group.
This is held at Chelsea and Westminster Hospital, every third Tuesday of the month from 6–8pm.
Visit www.chelwest.nhs.uk/weightloss and choose ‘Getting Support’ from the sidebar to find out topics, venues and dates of these meetings.
The British Obesity Surgery Patient Association (www.bospa.org) also has a number of support groups within England.
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Weight Loss Surgery Service
369 Fulham RoadLondonSW10 9NH
Main Switchboard020 8746 8000
Websitewww.chelwest.nhs.uk
August 2012