Diet and Nutrition Forum

But What Will I Be Able To Eat?
You are committed. You have made the decision to have weight loss surgery. You have the date. The surgeon has explained all aspects of your weight loss surgery and post surgical care. You spoke with the dietitian during your pre-evaluation and the nutrition guidelines you received for the first few weeks are posted in your kitchen. You breathe a sigh of relief.  Everything seems in order.  You are focused on your goal:  the weight loss you have always wanted and keeping those pounds off forever.  But the question that remains in your mind is ?What will I be able to eat for the next three months??

Your anatomy is about to be altered and the normal digestive process is going to be disrupted. Before surgery you have many areas that can absorb all your nutrients, but weight loss surgery limits nutrient absorption and/or reduces food intake. Gastric banding (adjustable or vertical) requires that you totally commit to diet changes since it reduces the size of your stomach and slows gastric emptying. The Roux-en-Y gastric bypass (RYGB) not only limits the volume of food you can eat, but also the absorptive capacity of the small intestine.  Nutrient deficiencies following a RYGB are more common. If nutrient deficiencies develop after gastric banding, it is more likely due to inadequate intake and not poor absorption. 

You still need to eat carbohydrates, protein and fat but the emphasis is on protein. A chewable multivitamin as well as a chewable calcium supplement will be needed on a daily basis. Your physician may suggest additional Vitamin B12, folate and iron.

A question often asked is, ?What can I do before my surgery to help me adjust to my new eating habits?? 

• Move!  As long as your physician has told you that you can exercise then do so.  For the beginner, start at 10-15 minutes 3-4 days/week increasing to 20-30 minutes. Just walking at a consistent pace, even if it is not very fast, is beneficial.  For the experienced exerciser, 3-4 days a week of 20-30 minutes of cardiovascular exercise is suggested. The important thing is to just start moving.  Marching in place during television commercials, which provides intermittent activity, can help you accumulate 15-20 minutes of activity in an hour, and it also keeps you away from the refrigerator or pantry.
• Drink!  Consume at least 48-64 oz. (6-8, 8 oz. glasses) of water every day.
• Eliminate regular carbonated beverages from your fluid intake.  They not only add calories but also after surgery the gas in the carbonated beverages can stretch the pouch.
• If you chew gum for fresh breath, consider quitting and replacing the gum with breath strips.  If you accidentally swallow your gum after you have had your surgery, it may block the opening to the small intestine and you could have an unwanted visit to the emergency room. 
• Go strawless! Straws allow excess air to be incorporated into the pouch, which may result in the pouch being stretched.  Try enjoying your liquid without the straw.
• Skip the alcohol.  It provides excess calories and after surgery can contribute to dehydration. 
• Chew your food slowly.  You should be the last to finish your meal instead of the first. 
• Avoid refined sugar, sweets, cookies, candy and high fat and fried foods that contribute additional calories and, after surgery, can also cause dumping.

Dumping? It is an uncomfortable feeling of nausea, cramping, diarrhea, weakness, sweating and a fast heart rate. It can occur when food passes quickly from the stomach into the intestine. This is more prevalent after gastric bypass than with gastric banding. 

Journaling your food intake is also a good idea before and after surgery. Do not just write down what you eat, and how much, but why you are eating and how you feel at the time of your meal or snack. Are you anxious, bored or stressed? Recording those feelings can reveal what comfort foods you seek. Stressful situations, boredom and happy times will still be there after your surgery, so you must learn how to deal with them now. You may want to seek the guidance of a psychologist who will help you develop the psychological skills necessary for a successful weight loss outcome. 

The diet following weight loss surgery is divided into stages of dietary progression. You should be working with your physician and dietitian to determine your appropriate stage. You will consume a liquid to semi-liquid diet that progresses to soft foods and finally a regular, healthy low fat diet. While the food consumed is similar for gastric banding and gastric bypass, the progression for the gastric bypass is slower. No matter which type of surgery you have, one of the most important things to remember is that everyone will advance at his or her own pace. The guidelines for dietary progression are:

• Clear Liquid
• Full Liquid
• Pureed Diet
• Maintenance Phase I
• Maintenance Phase II

Clear liquids are consumed in 30cc (1 ounce or 2 Tablespoons) increments every 15-20 minutes. Fluids are sipped not gulped!  Examples of clear liquids that may be consumed are decaffeinated tea and coffee, clear broth, clear juices such as apple, grape, light cranberry, sugar-free Popsicles and sugar-free gelatin. Remembering to take a sip so frequently can be difficult.  Use a kitchen timer to remind you to drink every 15-20 minutes. If you work daily on a computer, an automated reminder to ?take a sip? can be useful. 

Full liquids are the next dietary progression. You are still consuming one to two tablespoons every 15-20 minutes. Now you have a protein goal of 30 grams a day. You will alternate your full liquids with your clear liquids and consume six cups of liquid over a 12-hour period each day. When starting the full liquid diet you also incorporate low carbohydrate protein powders or shakes as well as milk, yogurt, cream of wheat or rice, farina and grits.  In order to help you meet your protein goal, you may want to try double milk that has 16 grams of protein in approximately 1 cup. It is made by adding 1/3 cup nonfat dry milk powder to one cup of skim milk and is often used when making sugar-free pudding. With the initiation of dairy products, symptoms of lactose intolerance may be a problem. If you were lactose intolerant prior to the surgery, you will probably remain so after surgery.  Some develop it after surgery but usually it is temporary. If the symptoms remain, try using lactose-free or soymilk. Chewable pills or drops that break down the lactose are also available. 

The pureed diet provides more variety in food choices. Pureed foods are the consistency of baby food. You will gradually increase to ¼ cup (2 oz. or 60 cc) and will eat OR drink every 30 minutes. You will never eat and drink at the same time. Your protein goal is 60 grams a day. If you eliminate one source of protein then remember to substitute another good source of protein, such as exchanging a light yogurt for a scrambled egg. Examples of foods that can be introduced in this stage are shown in Table 1. 

Maintenance Phase I consists of soft, low-fat food. It contains 5-6 small meals a day of ½-3/4 cup of food each consumed approximately 3-4 hours apart. You will continue taking a multivitamin and calcium supplement. The daily protein goal is 60 grams for gastric banding and 60-80 grams for gastric bypass. Phase I includes soft foods that are easy to chew or digest. It eliminates foods such as raw fruits and vegetables, chewy breads, fibrous cereals, popcorn, whole beans, nuts and tough meats. Rice and pasta need to be well chewed or avoided. Food should be chewed to the consistency of applesauce. Cooking and mashing the food may help you tolerate the consistency. Continue to sip water between meals, consuming at least 64 ounces a day. You should stop drinking 15-30 minutes before meals and may need to wait up to 30 minutes to one hour after meals. If you drink while you are eating, the pouch will fill with liquid quickly and your food intake will be decreased!  When you do this you sacrifice good nutrition from food and are not allowing yourself to adjust to normal eating. Drinking following a meal results in the pressure of the liquid forcing the food out of the stomach too quickly. Examples of foods that can be introduced in Phase I are smooth peanut butter, frozen low fat convenience foods that are ?carb controlled? and food that can be easily chewed such as tofu, flaky fish, moist chicken without the skin, mashed beans, soft fruit and cooked vegetables.

Phase II is a regular, low fat diet that establishes a permanent guide for new eating habits. It continues to provide 60-80 grams of protein every day. Most will have transitioned to this phase in about three months. You may now add favorite foods from your diet prior to surgery as long as they are low in fat and sugar. Five or six meals a day that are less than or equal to 1 cup per meal are the standard. Usually during this phase, your physician prescribes B12 supplements. 

Other tips that can make dietary progression easier are:

• Try different types of food but introduce them slowly.  Introducing one new food at a time is important.  If you find you do not tolerate that food wait at least a week to reintroduce that food and if it is still not tolerated wait several weeks.
• Keeping a daily food journal can reveal food intolerances as well as emotional triggers that can result in food cravings and overeating.  Try the free food journaling services available on the web or keep a written journal in your desk or bedside. 
• Avoid the cores and skins of fruits and vegetables, as they are hard to digest.
• It is not necessary for your food to be bland.  Introduce seasonings one at a time to establish your tolerances just as if you were introducing a new food.
• Doughy food like bread may be too sticky and not as well tolerated as thin toast without the crust or reduced fat crackers.
• Alcohol adds calories and can be dehydrating so it should be limited or completely avoided.

AND DON?T FORGET ---

• Exercise is essential!  Find something fun. Just as it is in food choices, variety is important.  Varying your exercise routines can keep you interested and motivated.

Whether you are attending or hosting a party it can be a challenge and planning should be a priority.  Incorporating some of the following ideas may reduce some of the stress and make those events more enjoyable.

• Remember to enjoy the people ? TALK!  It is difficult and inconsiderate to do this with your mouth full. 
• Reduce the food table temptation by visiting with others in a different room.
• Carry a glass of water in one hand.  This makes it more difficult to pick up food from a table and keeps you hydrated. 
• It is not always the calorie content of food that makes a party so special!  Food presentation that is attractive on a nicely decorated table also makes the event distinctive.
• Try cutting desserts into several different portion sizes so others and you have a choice.
• Don?t skip meals.  Eat healthy throughout the day.

Someone once said, ?If we don?t put effort in creating what we want, we have to put effort toward coping with what we get.?   These words certainly ring true in losing and maintaining weight loss.  Your bariatric surgery is a major tool in helping you lose your weight but by itself it will not give you the results you desire.  Achieving the optimum weight loss you want and developing the tools for successful weight maintenance requires a life long commitment to a healthier lifestyle.  You can do it!


Janelle Currey, RD, LD, CNSD, is a registered and licensed dietitian and works for Memorial Hermann Hospital in Houston, Texas. Her primary focus is outpatient nutrition counseling for the bariatric surgery program. She has been a registered dietitian since 1992. She believes it is important to practice the healthy lifestyle principles she teaches to others, so she enjoys cooking healthy meals for her family and friends and attends Jazzercise classes.