nutrition before and after bariatric surgery

© G21012902W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2021. Document for issue as handout. Unique Identifier: SURG04(21). Review date: April 2023.

Ladywell BuildingDietitians0161 206 1223

Nutrition before and after bariatric surgery

© G21012902W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2021. Document for issue as handout.

Unique Identifier: SURG04(21). Review date: April 2023.

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The liver reducing diet The liver is the largest organ in the body and sits across the upper part of your digestive system (see the diagram below). Following this diet will reduce the size of your liver making the surgery easier and less likely to have complications.

It is recommended that a very restricted diet; one that is low in fat, sugars and starch, be followed for TWO WEEKS prior to surgery.

By following this eating plan the energy supply in your liver is used up, causing it to shrink. You may need to follow this for longer if requested by the surgeon or dietitian, when you meet them in clinic.

This eating plan is only recommended prior to surgery and it is NOT TO BE FOLLOWED AFTER THE OPERATION.

It is possible that you will lose a lot of weight on this diet, but it will mainly be water loss. Please ensure that you have plenty to drink throughout the day; it will not prevent you from losing weight.

If you suffer with kidney disease please speak with your dietitian before commencing this diet. If you have diabetes please see page 7.

Diaphragm

Large Intestine

StomachLiver

You can have any 3 servings from this list per day.

Porridge oats or sugar free muesli

Bread

CrispbreadCrackerOatcake

Breakfast cereal

Pasta or Noodles

Rice

Cous Cous, pearl barley, quinoa

Pitta, Chapatti, WrapBaked or boiled Potato (with skin)

1 Serving is Equal to:Starchy Foods1 heaped tablespoon (uncooked)

1 medium slice OR ½ roll

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3 level tablespoons OR1 wheat / oat biscuit

2 tablespoons cooked1 tablespoon uncooked2 tablespoons cooked1 tablespoon uncooked2 tablespoons cooked1 tablespoon uncooked

½ large OR 1 medium1 small potato ½ large potato 2 egg size potato



3 4



Banana

Milk (semi-skimmed or skimmed)

Please avoid dried fruit and fruit juice as they contain a lot of sugar.

Medium fruit e.g. apple, pear, orange

Diet Yoghurt

Large fruit e.g. melon, pineapple

Soya Milk

Small fruit e.g. plums, Satsuma

Cottage Cheese (low fat)

Berries e.g. strawberries

Low Fat Cheese

Grapes / Cherries

Cream Cheese (low fat)

Tinned/stewed fruit (unsweetened)

1 Serving is Equal to:


Fruit

Dairy Products

1 small

200ml OR 1/3 pint

1 fruit

1 small pot (125-150g)

1 slice

200ml OR 1/3 pint

2 fruits

2 tablespoons

1 large handful

Matchbox sized piece

Approximately 14

1 tablespoon

3 tablespoons



Chicken / Turkey

Butter or Margarine

White fish

Cooking Oil

Beef / pork / lamb

Low fat spread

Oily fish

Mayonnaise, salad cream, oil based dressing

Eggs

Thickened Gravy

Beans, Pulses, Lentils

Lean bacon

Reduced fat / Light Mayonnaise, salad cream, oil based dressing

Cooked meat slices

Unthicken Gravy

Tofu, quorn, soya



Protein Foods

Foods High in Fat

50g (2oz) cooked OR 100g (4oz) raw

1 teaspoon

125g (5oz) cooked

1 teaspoon


2 teaspoons


1 teaspoon

2 medium eggs

1 tablespoon

4 heaped tablespoons cooked

2 grilled rashers (remove visible fat)

2 teaspoons

2 medium slices OR 4 wafer thin slices

4 tablespoons

100g (4oz)



5 6

Alongside this, you can have an unlimited amount of most vegetables and salad so fill yourself up with these.

They should cover over half of your plate. Avoid adding fat when cooking/at the table.

You should avoid the following vegetables for now as they contain too much starch;O BeetrootO ParsnipO PeasO SweetcornO Squash

A typical day might look like this:

Sample meal plan:Breakfast: O 3 tablespoons of low sugar cereal e.g.

porridge OR O�1 slice of toast with a scraping of low

fat spreadMid-morning: 1 Portion of fruit Lunch: O Unlimited non starchy vegetables or

salad O 1 slice of toast with a scraping of low

fat spread O A small portion (2oz or 56g) of lean

meat, fish or cheese Mid-afternoon: 1 Portion of fruit Evening meal: O�Unlimited non starchy vegetables or

salad O�2 egg sized potatoes or 1/2 a jacket

potato O�A small portion (2oz or 56g) of lean meat,

fish, cheese, tofu or quorn based dishSupper: 1 low fat, low sugar yoghurt

Through the day: 1/3 pint milk (for cereal and in cups of tea/coffee)Suitable drinks include: O Tea O Fruit teas O Coffee O Oxo / Marmite / Bovril O Horlicks / Ovaltine (light

options) x1 per dayO Low fat hot chocolate x1

per dayO Water O Sugar free flavoured water O Low sugar cordial O Diet drinks

Tips for success with the liver reducing diet O Use smaller plates, bowls,

knives and forks than you usually do. This will help you to control your portion size

O Aim for half a plate of vegetables or salad at mealtimes; this will fill you without giving you too many calories

O Eat slowly and aim to make your meal last 20 minutes. Chew you food well and put your knife and fork down between mouthfuls

O Include plenty of drinks. This can help to fill you up and reduce your appetite

O You should now be eating less than you did before, so you will want to make the most of it. Eat without distractions and enjoy each bite

O Choose wholemeal cereal, bread, pasta and rice. It will fill you up for longer.



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I am on medication to control my diabetes, will it need to be adjusted?It is likely that you will need change the amount of medication you have whilst following the eating plan. Make sure that you seek advice from your Diabetes Care Team before you start so that you are ready to make the right changes. If you have a blood glucose testing device, check your blood sugars regularly. If you have diabetes but are not on medication, make sure you continue to have starchy foods at every meal as outlined in this plan.

When will I know when to start the diet?You will be given a date for surgery about 4-6 weeks before the operation. Start the eating plan 2 WEEKS before the date of your surgery.

Frequently asked questions

Are there any side effects to following the diet?Most people follow the eating plan very well without any problems. Some people experience headaches or feeling light headed initially, but these symptoms tend to resolve in under a week. You may feel hungrier or possibly lacking in energy. However, these feelings mean you are not giving the body with the energy it needs, which ends up with you losing weight. If you are still concerned you can contact the dietitians for more help.

What if my liver does not reduce in size? In the few cases where the liver has not reduced in size it is usually due to the person not following the eating plan fully. Unfortunately, if this happens the surgery may have to be cancelled. Remember that this does not happen very often if you follow the dietary advice

Diet after surgeryInitially after surgery you will be given 30-60ml (1-2 medicine cups) of water to sip. When the team are happy, you can progress to free fluids. This means you can sip as much water (or no added sugar squash), tea and coffee as you can manage.

Usually, the first day after surgery you are given some clear soup at lunch. Take your time and eat what you can; you are not expected to have it all. If you can tolerate this you can then progress to the recovery diet.

Recovery diet:After your operation you will need to follow a diet which will help you to heal but also result in weight loss. It has three stages lasting for 2-3 weeks depending on the surgery (see table below):

Surgery / Diet

Liquid

Puree

Soft

Band (Weeks)

2

2

2

Sleeve (Weeks)

3

3

3

Bypass (Weeks)

3

3

3

Do not rush through the stages; it will take time for your body to get used to the operation. Everyone is different, so if you think it was too soon for you to progress, go back a step for a couple of days before trying again.

From the day of your operation you have to try and clear your mind of what you were able to eat before - things will be very different from now on. Taste changes are common.

Remember, this is an opportunity to change your relationship with food. Surgery will help you reduce your portion size; you must make the right food choices to lose weight. Surgery will not cause long lasting weight loss on its own; you will have to work with it to achieve that. That starts with the liquid diet.

Surgery will not affect emotional eating. If you are struggling with emotional eating, please contact any of the team who can refer you to a psychologist if necessary.

A checklist of useful items to help with your recovery diet after surgery:( Hand blender / food blender ( Ice cube trays / freeze-able pots ( Small plates and cutlery( Food weighing scales ( Sieve ( Drinking bottle with measurements, to monitor fluid intake



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High protein liquids:

Stage 1Liquid diet (for 3 weeks):Upon discharge you will be allowed a liquid only diet. This means you can have any liquid (unless told otherwise), provided it meets the following 5 rules:

1) It is thin enough to be sucked through a straw

2) You should be able to pass it through a sieve (no ‘lumps’ or ‘bits’)

3) It must be low in fat and sugar

4) Free from alcohol and 5) Not fizzy

It is very important to have enough protein after surgery to help with recovery, keep your immune system strong and prevent hair loss. Try to have a nourishing drink every 2-3 hours with other fluids in between (see following).

Aim to drink a minimum of 2 litres of fluid per day, but monitor your urine colour, aiming for a pale straw colour.

TIPO Aim to include at least

1 pint of milk every dayO�To increase your protein intake

add 4 tablespoons of skimmed milk powder (e.g. Marvel or supermarket own brand) to one pint of milk

O�You can use this enriched milk to make a latte or add some sugar free "avouring to make a milkshake

O If you would prefer to use a proteinpowder, make sure it contains less than 5g/100g of sugar

Semi-skimmed or skimmed milk (preferably with added milk powder)

Low fat/diet yoghurts (no lumps or bits)

Blended and strained high protein soups (including meat, fish, chicken or pulses)

Smoothies made with milk / yoghurt and fruit (no lumps or bits). No more than 100mls per day

If you would prefer to use dairy free alternatives, please speak to your dietitian to ensure they are suitable.

Other liquids:

Liquids to avoid:

Fruit juice (limit to 1 portion per day - small glass of approx. 125mls)

Sugar free squash (or ‘no added sugar’)

Water / flavoured water (still, not sparkling)

Sugar free jelly

Low fat ice cream

Tea / coffee

Horlicks / Ovaltine (light options)

Hot chocolate (light options)

Oxo / Bovril / Marmite

Fizzy, sparkling drinks

Alcohol

High fat liquids

High sugar drinks

Any liquids with bits or lumps

Sample menu for liquid stage:Breakfast: Latte made with 1/3 pint semi-skimmed milk (with added milk powder)

Mid-morning: 1 diet yoghurt (dilute with milk if needed)

Lunch: 200ml home-made chicken and vegetable soup (blended and strained)

Mid-afternoon: Latte made with 200ml semi-skimmed milk (with added milk powder)

Evening meal: 200ml pint tomato and bacon soup (blended and strained)

Supper: 200ml semi-skimmed milk (with added milk powder)

During the day: Drink 1000ml water, 2 cups of tea and 125ml orange juice



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AlcoholWe advise that you should stay away from alcohol completely for the first 6 months after your operation.

After 6 months, if you would like to drink alcohol, then drink small amounts with caution. Remember alcohol is very high in calories and can prevent weight loss.

It is also absorbed by your body more quickly after some operations and you could get drunk a lot faster. Therefore you need to take care and not drive after any alcohol. Go to:

for more details.

www.drinkaware.co.uk

Stage 2Pureed diet:The second stage is designed to reintroduce food in a way that:O Continues the healing process O Helps you to avoid vomiting O Begins to educate your mind

about how your new ‘pouch’ deals with food

Pureed food should be the consistency of baby food or smooth applesauce. It should have no lumps in it. You will only be able to manage very small amounts at each meal (1-2 tablespoons over 20 minutes). If you try to eat much more than this it may make you uncomfortable or sick. As you progress through the pureed stage you may eat a little more than when you started.

To puree foods you will need a food processor or hand held blender. Puree food with extra gravy, milk or sauce and flavour with herbs and (mild) spices.

Each food should be pureed separately rather than together - this way food will look more attractive on the plate and individual foods will be tasted.

Things to remember on the pureed diet:O�Try cooking in bulk and freeze

small portions of pureed meat, fish, vegetables, stews or soup for convenience. Ice cube trays are handy

O�Keep in some baby food as useful standbys

O�Try not to have foods high in fat and/or sugar as they can cause dumping syndrome. See section on dumping syndrome on page 19)

O�If you have problems with a particular food, stop eating it for a few days and then try again

O�Puree any nourishing tinned soups such as lentil or pea and ham or make your own!

Planning your days intakeProtein:Introduce foods high in protein first. High protein foods include meat, chicken, fish, beans, pulses and dairy products.

They are very important for healing and should be taken at each meal and snack. If you find it difficult to eat pureed meat and fish, have more protein from milk or dairy products - but low fat versions.

If you are a vegetarian, go for vegetarian sources of protein including quorn, lentils or pulses.



13 14

Try to include one of these high protein servings at each meal or snack:

O�1/3 pint of milk - skimmed or semi skimmed

O�1 diet/light yoghurt

O�1 fromage frais

O�1oz pureed meat - beef, pork, turkey, chicken, lamb

O�1oz pureed fish (fresh or tinned) - e.g. haddock, cod, tuna, salmon, mackerel, sardines tinned in brine or tomato sauce

O�1oz low fat cream cheese

O�1oz grated low fat cheese, mixed in hot food e.g. mashed potato

O�3 tbsp custard made with semi skimmed milk

O�1-2oz pureed lentils or beans

O�2-3 tbsp pureed casserole

O�2-3 tbsp pureed cottage or fish pie

O�250ml blended meat, chicken or fish based soup

Once you can tolerate some high protein foods at each meal, try introducing some vegetables and fruit. Suitable options include:

O�100mls vegetable juice or fruit juice (unsweetened)

O�1 tbsp pureed vegetable e.g carrots, cauliflower, cabbage, swede, turnip, courgette, broccoli

O�1 tbsp stewed fruit with sweetener if necessary

O�1 tbsp fresh soft (blended) fruit e.g. bananas, strawberries, raspberries

You can also include some starchy foods from this list, if you are not feeling too full:

O�250ml pureed soup of any kindO�2 tbsp fine ground porridge

(e.g. ready brek) made with milk (puree if too lumpy)

O�1/2 weetabix or wheat biscuit (use plenty of milk to make it soggy)

O�1 tbsp pureed potato / sweet potato / plantain

O�1 tbsp pureed pasta and sauceO�1 tbsp (over-cooked) pureed rice

Sample menu for pureed stage:

Meal ideas:

Breakfast: 2 tbsp cooked porridge1 tbsp pureed banana

Mid-morning: 1 diet yoghurt

Lunch: 1 tbsp mashed potato1 tbsp carrots1oz meat / fish

Mid-afternoon: 1/3 pint semi- skimmed milk

Evening meal: 1oz tuna1 tbsp pureed rice1 tbsp puree broccoli

Supper: 1 tbsp tinned peaches1/3 pint semi-skimmed milk

During the day: Drink water and 1/3 pint semi skimmed milk

O�2 tbsp tinned tuna blended with onion, tinned tomato and herbs, served with 1 tbsp sweet potato puree

O�2 tbsp slow cooked chicken pureed in gravy, served with 1 tbsp puree carrot and 1 tbsp smooth mashed potato

Foods to avoid during the pureed stage

EggsDry or tough meatOrdinary bread or toastMost breakfast cerealRaw or salad vegetablesCelery or stringy beansFruit pips, seed, pith and skinsDried fruitBiscuits, crackers, crisp & nutsSweets and chocolatePastry dishes

These foods will not liquidise properly so try not to have them:



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If these foods cause no vomiting, heartburn or indigestion, move onto foods that need a little more chewing such as:O�2oz/50g Casserole or stewO��2 slices tinned meatO��Eggs: omeletteO�Cooked vegetablesO��250ml soup not liquidisedO��2 tbsp rice puddingO��1 tbsp tinned fruit in natural

juice or soft fruit (not pureed)

Stage 3Soft Diet (re-introducing normal textures):The progression from pureed food to a normal diet should take around 3 weeks, starting with foods that are easiest to digest gradually introducing more solid foods.

Remember everyone is different with the foods they can tolerate. It is normal to tolerate a food one day and not the next day. If this happens, leave that particular food and try again at a later stage.

Start by introducing very soft foods such as:

O Soft cooked egg: 1 poached or soft scrambled

O��Cottage cheese: 2oz/50gO��Tender fish in sauce 1oz/25gO��Minced meat/quorn in gravy

1oz/25g

O�1oz/25g tender chicken, turkey, beef, pork, lamb

O��1 slice toasted bread (leave un-toasted bread until the very end)

O��Raw fruit e.g. 1 small peeled apple

O��Small cup of breakfast cereal e.g. bran flakes

O��3 tbsp cooked rice or pastaO��Raw vegetablesO��Salads

You can then introduce foods with a little more texture such as:

Problem foods:Certain foods often cause problems and you may never be able to eat very much of them. We recommend you introduce these foods with caution, paying extra attention to your bite size and chewing. These include:O Soft doughy bread (try toast,

wraps, pitta or crisp bread as alternatives)

O�Pasta and riceO�Tough / dry meat, chicken

and fish (try slow cooking or cooking in a sauce).

You may experience problems with other foods as everyone is different.

Remember the following points:O�Continue to have 3 regular

meals per day with optional snacks if needed.

O�Include some protein at each meal

O�Remember to have a variety of foods in your diet, and keep trying different things

O�Keep working on your eating habits (see page 18)

O�If you find a food difficult to tolerate, leave it and try again after a while. You may be able to manage it eventually.

If you are struggling with recipe ideas during your recovery diet, remember that you can use normal recipe books / recipe websites and just adjust the recipe to the stage of the diet that you are on. If need further help, please discuss with your dietitian.



1817

Things to remember for on-going weight loss

Aim to eat regularly - 3 meals a day

You will be able to eat a larger portion of soft textured food. You should choose challenging textures that require chewing, so that you continue to feel full from small portions

Always include at least a portion of protein at each main meal.

Choose small portions and use small plates

Try not to have high fat high sugar food and drink

Take care with alcohol - it’s high in calories and is easily absorbed. It can also increase your appetite

Work on your eating habits (see page 18)

Example of a menu when you are eating food of normal

consistency:Wake up: Small glass of orange juice with supplements

Breakfast: Small bowl of cereal + 1/3 pint of semi-skimmed milk

Mid-morning: 1 diet yoghurt

Lunch: 2oz tuna with ½ medium jacket potatoSmall salad

Mid-afternoon: Piece of fruit

Evening meal: 2oz cooked meat and vegetables in a sauce3 tbsp cooked rice

During the day: 1/3 pint semi-skimmed milk during the day in drinks

Long term nutritional plan

Good eating habits include:The Rule of 20O 20p coin sized bites of food

(5p if struggling)O 20 chews per bite O 20 seconds rest between bites

(try putting your cutlery down)O Stop eating after 20 minutes

Additional good eating habitsO Stop when you are full (most

important!) - don’t return to food and ‘graze’ or ‘nibble’ on it

O Separate eating and drinking - don’t drink 15 minutes before and 45 minutes after eating

O Sip "uids regularly throughout the day

O Eat regularly, do not go for long periods of the day without eating

It is essential to get into good eating habits after surgery. Good eating habits:O Prevent vomiting and pain O Improve food toleranceO Enhance weight loss O Prevent weight regainO Help you recognise when you are full (prevent overeating)

Eating habits

After surgery you may experience a number of symptoms when you are full, these can include: tightness in chest, pressure, regurgitating, sneezing, hiccups, burping, eyes watering or none of the above, you may just know you are full. Use these as a reminder of when you need to stop eating.

Drinking just before a meal can reduce your food intake, which may mean you are missing out on important nutrition. Drinking with food or too soon after food can make you sick. Make sure that you drink in between meals instead. Get into the habit of sipping instead of gulping fluids because your stomach pouch has reduced a lot in size.

Although these eating habits may relax over time, this may lead to poor food tolerance and weight regain. It is therefore important to continue using them throughout your life.



2019

Dumping syndromeThis is caused when too much fat or sugar enter the gut too quickly. This is more of a feature after gastric bypass, though it does occur sometimes after sleeve gastrectomy.

There are 2 types of dumping syndrome:

Early dumping syndrome Occurs 10-30 minutes after eating. Symptoms include: feeling full quickly, nausea, vomiting, bloating, cramps, diarrhoea, dizziness, feeling tired, and rapid heart rate

Late dumping syndromeOccurs one to four hours after eating. Symptoms include: sweating, shakiness, having a hard time focusing and hunger. Symptoms of late dumping syndrome are from an imbalance in your blood glucose (sugar) levels.

These foods not only cause dumping syndrome, they make it more difficult for you to reach your target weight.

It is important to use the eating habits discussed on the previous page to prevent dumping syndrome from happening.

If you continue to suffer with these symptoms despite following the advice above, please speak to a dietitian or a specialist nurse who can advise you further.

Try not to have:O Foods high in sugar e.g. sweets, chocolates,

biscuits, cakes

O� Foods high in fat e.g. fried food, pies and pastries, takeaway foods, snack foods like peanuts and crisps

O�Drinks high in fat and sugar e.g. milk shakes, full fat milk, ordinary #zzy drinks and squashes

Sugars

Fat

per 100g

5g or less

3g or less

Food labelsWhat is classed as ‘low fat’?What is classed as ‘low sugar’? Food labels can help you choose healthier options, that will increase your weight loss and reduce the chance of having symptoms of dumping syndrome.

Look at ‘per 100g’ on the food label, and use the guide below to identify whether a food is low in fat or sugar. Try to choose foods classed as ‘low’ as often as possible.

Remember, your stomach pouch is very small and can fill up very easily. Vomiting is a sign that you are filling your pouch too much, or too quickly. If you do not change your eating habits, this can result in stretching your pouch, which may cause your weight loss to be less successful.

Usually, vomiting can be avoided by improving your eating habits. This is why working on your eating habits (outlined on page 18) is so important.

But if your nausea or vomiting does not improve even after following the eating habit guidelines for a few days, please contact a member of our team (see section at the end of this leaflet for contact details) or your GP for further advice.

Nausea and vomitingIf you feel sick, or are sick, this may be caused by:O Eating too muchO Eating too fastO Gulping instead of sipping

drinksO Drinking too soon before,

with or after meals



ConstipationDue to the changes in diet and fluid intake it is common to experience constipation. It is important that you do not strain when opening your bowels.

If you are constipated, first ensure that you are having a minimum of 2 litres of fluid every day. Make sure that your intake of fruit and vegetables is as described in this booklet. This should ensure adequate fibre and fluid intake.

If you still remain constipated discuss this with the specialist nurse or your GP for advice. You may require medications to help such as lactulose, fybogel, movicol or senna.

2221

Further information:You will be expected to do your own research to feel happy about the informed choice you are making when having Bariatric Surgery.

Please be aware the Single Anastomosis Gastric Bypass also has 3 other names though are essentially the same procedure; they are Omega loop gastric bypass, mini gastric bypass and one anastomosis gastric bypass.

Once you have met our team we are your support; for any surgical advice please contact the Specialist Nurse and for any Dietetic advice please contact the Dietician.

For any administrative queries please contact your Surgeons secretary, their number will be on the letter sent from your Surgeon after the appointment.

Essential communication regarding further investigations, appointments, pre-operative assessments and date of surgery will come to you in written form in due course.

We politely ask that you be patient to receive this but contact us if concerned. If you have any change of address during this time or contact numbers you must update us.

Useful websites:

Specialist Nurse

British Obesity and Metabolic Surgery Society (BOSS)

Weight Loss Surgery Information and Support (WLSinfo)

Drinkaware – alcohol advice

Weight Loss Resources UK

Dietitian

0161 206 5126

020 7766 9900

01733 345 5920161 206 1223

www.BOMSS.org

www.wlsinfo.org.uk

www.drinkaware.co.uk

www.weightlossresources.co.uk

Be aware that the above numbers have a voicemail attached please leave a message with your name and contact number and we aim to return your call as soon as possible though this may not be the same day. Quit smoking with support

0300 123 1044www.nhs.uk/smokefree

Alternatively download app or speak with your local pharmacy and/or GP.

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nutrition before and after bariatric surgery

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