Bariatric surgery educational booklet

Bariatric

Important Reminders

• Pre-operative diet begins 2 weeks before surgery

• Post-operative diet begins after surgery and continues for life

It’s

Time

for the New You

We are a partner in your weight loss journey.

Our multidisciplinary team of surgeons, advanced practice providers, psychologists, nurses, dietitians, and physical therapists are here to help support you in achieving and maintaining your weight loss goals.

After bariatric surgery, losing weight and keeping it off requires permanent eating and behavior changes. Bariatric surgery is only one part of your longer-term treatment, and the recommended post-surgery diet changes will be followed for the rest of your life.

There are several dietary stages outlined in this booklet. Most importantly, listen to your body. After surgery, your stomach pouch will hold only a few tablespoons of food at a time. When eating, find a state of comfortable satisfaction- not fullness. Eating past comfortable satisfaction can cause nausea, vomiting, and slowly stretch the pouch. Eat mindfully by beginning to eat before you feel over-hungry and stop once you feel satisfied. If you do not tolerate a food well, do not get discouraged. Wait a week or two and try again. Following these instructions will give you the greatest chance of achieving and maintaining your physical health goals.

We recommend downloading the Baritastic App for your phone/ tablet. This is the #1 rated app for bariatric surgery patients, and includes:

• Recipe recommendations for each stage of your journey

• Exercise planning

• Tracking of:

• Water intake

• Protein intake

• Food intake

• Weight changes

Bariatric Surgery Team Contact Information

Clinic:

League City Adult Specialties Clinic

2240 Gulf Freeway South, Suite 2.402E

League City, TX 77573

Phone: 832-505-1800

Fax: 832-426-3045

Dietitian:

Bariatric Dietitian Services

www.BariatricDietitians.com

PsyMed Health, Assessment and Counseling

Phone: (214) 348-5557

www.psymedhealth.com

Physical/Occupational Therapy:

UTMB Physical & Occupational Therapy

www.UTMBhealth.com/services/rehab

Behavioral Health:

UTMB Behavioral & Mental Health Services

https://UTMB.us/8nq

Advantage Point Behavioral & Mental Health Services

https://advantagepointbehavioral.com

PsyMed Health, Assessment and Counseling

Phone: (214) 348-5557

https://psymedhealth.com

When to Call

You are meeting goals if you are:

• Drinking 64 or more ounces of clear liquids/day

• Walking at least every hour while awake

• Meeting protein requirements

• Losing 2-5 lbs every week

• Advancing through the diet stages

Contact the clinic if you have:

• Pain that cannot be tolerated with your prescribed medications

• Not been tolerating your diet, or are unable to advance your diet to the next stage

• Been unable to consistently reach your daily liquid or protein goals

• Nausea or vomiting that is not relieved with prescribed medications

• Dehydration symptoms: headache, dizziness, urinating less, dark urine, or fatigue

• Incision sites that are draining, red, warm to touch, or have foul odor

• Temp greater than 100°F

• Constipation after troubleshooting interventions (page X)

• Any questions or concerns

Please go to the Emergency Room or call 9-1-1 if you experience any of the following:

• Vomiting that is bright red or looks like coffee grounds

• Chest pain

• Shortness of breath

• Severe abdominal pain

Surgical Procedures

There are several different types of bariatric surgical procedures. Your care team will help you determine which is best for you, your body, and your health goals.

Sleeve Gastrectomy

The Laparoscopic Sleeve Gastrectomy, often called the “sleeve”, is performed by removing approximately 80% of the stomach. The remaining stomach is the size and shape of a banana.

The Procedure:

1. The stomach is freed from organs around it.

2. Surgical staplers are used to remove 80% of the stomach, making it much smaller.

How It Works:

The new stomach holds less food and liquid helping reduce the amount of food (and calories) that are consumed. By removing the portion of the stomach that produces most of the “hunger hormone”, the surgery influences metabolism. It decreases hunger, increases fullness, and allows the body to reach and maintain a healthy weight as well as blood sugar control. The simple nature of the operation makes it very safe without the potential complications from surgery on the small intestine.

Advantages:

1. Technically simple and shorter surgery time

2. Can be performed in certain patients with high risk medical conditions

3. May be performed as the first step for patients with severe obesity

4. May be used as a bridge to gastric bypass or SADI-S procedures

5. Effective weight loss and improvement of obesity related conditions

Disadvantages:

1. Non-reversible procedure

2. May worsen or cause new onset reflux and heart burn

3. Less impact on metabolism compared to bypass procedures

Roux-en-Y Gastric Bypass (RYGB)

The Roux-en-Y Gastric Bypass, often called the “gastric bypass”, has now been performed for more than 50 years and the laparoscopic approach has been refined since 1993. It is one of the most common operations and is very effective in treating obesity and obesity related diseases. The name is a French term meaning “in the form of a Y”.

The Procedure:

1. First, the stomach is divided into a smaller top portion (pouch) which is about the size of an egg. The larger part of the stomach is bypassed and no longer stores or digests food.

2. The small intestine is also divided and connected to the new stomach pouch to allow food to pass. The small bowel segment which empties the bypassed or larger stomach is connected into the small bowel approximately 3-4 feet downstream, resulting in a bowel connection resembling the shape of the letter Y.

3. Eventually the stomach acids and digestive enzymes from the bypassed stomach and first portion of the small intestine will mix with food that is eaten.

How It Works:

The gastric bypass works in several ways. Like many bariatric procedures, the newly created stomach pouch is smaller and able to hold less food, which means fewer calories are ingested. Additionally, the food does not come into contact with the first portion of the small bowel and this results in decreased absorption. Most importantly, the modification of the food course through the gastrointestinal tract has a profound effect to decrease hunger, increase fullness, and allow the body to reach and maintain a healthy weight. The impact on hormones and metabolic health often results in improvement of adult-onset diabetes even before any weight loss occurs. The operation also helps patients with reflux (heart burn) and often the symptoms quickly improve. Along with making appropriate food choices, patients must avoid tobacco products and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen.

Advantages:

1. Reliable and long-lasting weight loss

2. Effective for remission of obesity-associated conditions

3. Refined and standardized technique

Disadvantages:

1. Technically more complex when compared to sleeve gastrectomy or gastric band

2. More vitamin and mineral deficiencies than sleeve gastrectomy or gastric banding

3. There is a risk for small bowel complications and obstruction

4. There is a risk of developing ulcers, especially with NSAID or tobacco use

5. May cause “dumping syndrome”, a feeling of sickness after eating or drinking, especially sweets

Surgical Procedures

Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

The Biliopancreatic Diversion with Duodenal Switch, abbreviated BPD-DS, begins with creation of a tube-shaped stomach pouch similar to the sleeve gastrectomy. It resembles the gastric bypass, where more of the small intestine is not used.

The Procedure:

1. Following creation of the sleeve-like stomach, the first portion of the small intestine is separated from the stomach.

2. A part of the small intestine is then brought up and connected to the outlet of the newly created stomach, so that when the patient eats, the food goes through the sleeve pouch and into the latter part of the small intestine.

How It Works:

The smaller stomach, shaped like a banana, allows patients to eat less food. The food stream bypasses roughly 75% of the small intestine, the most of any commonly performed approved procedures. This results in a significant decrease in the absorption of calories and nutrients. Patients must take vitamins and mineral supplements after surgery. Even more than gastric bypass and sleeve gastrectomy, the BPD-DS affects intestinal hormones in a manner that reduces hunger, increases fullness and improves blood sugar control. The BPD-DS is considered to be the most effective approved metabolic operation for the treatment of type 2 diabetes.

Advantages:

1. Among the best results for improving obesity

2. Affects bowel hormones to cause less hunger and more fullness after eating

3. It is the most effective procedure for treatment of type 2 diabetes

Disadvantages:

1. Has slightly higher complication rates than other procedures

2. Highest malabsorption and greater possibility of vitamins and micro-nutrient deficiencies

3. Reflux and heart burn can develop or get worse

4. Risk of looser and more frequent bowel movements

5. More complex surgery requiring more operative time

Single Anastomosis Duodeno-Ilial Bypass with Sleeve Gastrectomy (SADI-S)

The Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy, referred to as the SADI-S is the most recent procedure to be endorsed by the American Society for Metabolic and Bariatric Surgery. While similar to the BPD-DS, the SADI-S is simpler and takes less time to perform as there is only one surgical bowel connection.

The Procedure:

1. The operation starts the same way as the sleeve gastrectomy, making a smaller tube-shaped stomach.

2. The first part of the small intestine is divided just after the stomach.

3. A loop of intestine is measured several feet from its end and is then connected to the stomach. This is the only intestinal connection performed in this procedure.

How It Works:

When the patient eats, food goes through the pouch and directly into the latter portion of the small intestine. The food then mixes with digestive juices from the first part of the small intestine. This allows enough absorption of vitamins and minerals to maintain healthy levels of nutrition. This surgery offers good weight loss along with less hunger, more fullness, blood sugar control and diabetes improvement.

Advantages:

1. Highly effective for long-term weight loss and remission of type 2 diabetes

2. Simpler and faster to perform (one intestinal connection) than gastric bypass or BPD-DS

3. Excellent option for a patient who already had a sleeve gastrectomy and is seeking further weight loss

Disadvantages:

1. Vitamins and minerals are not absorbed as well as in the sleeve gastrectomy or gastric band

2. Newer operation with only short-term outcome data

3. Potential to worsen or develop new-onset reflux

4. Risk of looser and more frequent bowel movements

Pre-Surgery Checklist

You will need to complete the following specialist visits prior to procedure approval:

☐ Clinic visits (number dependent on your preparation for surgery and insurance requirements)

☐ 2 to 5 Nutrition visits

☐ Psychiatric Evaluation

☐ Physical Therapy Evaluation

☐ Sleep Apnea Screen and additional testing (sleep study, titration study)

☐ Liver Ultrasound

☐ Upper GI (special X-ray of esophagus and stomach while drinking with oral contrast)

☐ EGD (Upper endoscopy)

☐ EKG (Electrocardiogram, to check your heart)

☐ Labs

☐ Additional required surgery clearances as needed based on your health conditions

Notes & scheduled procedures:

Medications

Discuss any medication changes with your prescribing physician well before your surgery is scheduled.

Initially, all oral medications must be taken one at a time, and must be broken in half, crushed, or opened if any larger than a baby aspirin. Some extended release or psychiatric medications cannot be crushed, so please discuss with your prescribing physician. They may need to prescribe a liquid or other alternative medication.

Pregnancy: Women should not become pregnant for 18 months post-surgery. Use 2 forms of birth control during this time unless you have an implantable form of birth control. Please contact us with questions.

If you take medications for diabetes:

• Follow all recommendations from your endocrinologist and/or primary care physician

• Monitor your blood glucose at home using a glucometer (glucometer must be available prior to surgery).

If you take medications for hypertension:

• Follow all recommendations from your cardiologist and/or primary care physician

• Monitor your blood pressure at home at least 2 times a day (in the morning and evening)

Notes & medication plans:

Vitamins & Supplements

Discuss medication changes with your prescribing physician well before your surgery is scheduled.

Vitamin Plan (no gummies):

Begin your vitamin plan 2 weeks after surgery (Stage 3B)

Vitamin Dose Instructions Directions

Multivitamin- Mineral Supplement

200% of daily value Choose a “complete” formula with:

• 45-60 mg elemental iron

• 400-1000 mcg folic acid

• 12 mg thiamine

• Zinc & selenium

Vitamin B12

Calcium citrate

Vitamin D3

350-1000 mcg per day (total)

1200-1500 mg per day (total) 1800 mg per day total (BPD/ DS)

3000 International Units per day (total)

Begin with chewable or liquid, progress to tablets/capsules as tolerated. Avoid incomplete children’s vitamins .

Available sublingual, liquid, mouth spray, or nasal gel/spray.

Begin with chewable and progress to tablets/ capsules as tolerated. Split into 500-600 mg doses, space evenly throughout the day and take with food.

Gel capsules, chewable, or liquid form. Often found in combination with calcium.

Iron deficiency is a common concern after bariatric surgery.

To increase iron absorption:

• Take iron supplements at the same time as eating meat, poultry, or fish

• Eat foods that contain vitamin C when you eat foods that contain iron

• Cook with a cast iron skillet

• Avoid taking iron supplements or eating high iron foods at the same time as:

• Antacids

• Calcium (take calcium more than two hours before or after iron)

• Foods that block iron absorption (tea, coffee, whole grains, nuts, milk/dairy, prunes, red grapes, soy-based foods, or cooked dried beans)

Bariatric-friendly vitamin websites:

• https://store.bariatricpal.com

• https://www.bariatricadvantage.com

• https://procarenow.com

• https://celebratevitamins.com

• https://www.barilife.com

• https://patchaid.com

Protein Supplements

This list includes some of the commonly available protein supplements on the market. It is not a comprehensive list or a recommendation of products. Many additional options exist. Please discuss with your dietitian if you have any questions regarding the appropriateness of a particular product.

General guidelines for protein supplement/meal replacement products:

• Check the Serving Size (especially for powders)

• Protein Content: Goal 20 - 30 grams protein per serving

• Sugar: Less than 5 grams per serving

Avoid meal replacement drinks such as regular Slim Fast, Boost/Ensure, Glucerna, no sugar added Carnation Instant Breakfast, regular sport drinks, juice, or sweet tea. They are high in calories and low in protein.

Avoid food sources with >5 grams of sugar, sugar alcohols, or total fat per serving.

Protein Powder

Size

Ready to Drink

Dietary Stage: Before Surgery

2 Weeks Prior to Surgery

Start Date:

Follow a high protein, liquid diet for two weeks prior to surgery. This diet will assist with weight loss and shrink your liver to make the surgery safer.

Meal Plan:

Goal: minimum 100 grams of protein per day

Select protein powders or shakes with 20-30 grams protein per serving and less than 5 grams sugar per serving

• Every day, drink 4-5 premade protein shakes or Whey protein powder shakes mixed with your choice of:

• Skim milk

• 1% milk

• Unsweetened almond or soy milk

• Warm broth

• Water or sugar-free, non-carbonated water like Crystal Light

• Drink 64+ ounces of clear liquid that is sugar-free, calorie-free, and not carbonated. Servings should be less than 10-15 calories.

• Water should be your biggest source. Remember to drink lots!

• Sugar-free popsicles & gelatin

• Sugar-free, non-carbonated waters (Crystal Light, Powerade Zero, Vitamin Water Zero)

• Decaf tea and decaf coffee (avoid caffeine because it is dehydrating)

• Clear broths (chicken, beef, vegetable). Choose low-sodium options.

• Avoid juices, as they are high in sugar and sweeteners.

You might need to drink more water if you experience:

• Headaches

• Urinating less

• Dark yellow urine

• Fatigue (tiredness)

• Nausea/ vomiting

• Dizziness

When in doubt, drink more water. Appropriate hydration is key to the success of this procedure and will help you achieve your long-term health goals.

Dietary Stage 1

Immediately After Surgery

Start Date:

Follow a clear liquid diet starting the day of surgery, and continuing for an additional 3 days.

Meal Plan:

• Do not use straws when drinking.

• Try using an app or timer to remind yourself to drink.

• Start with 1 ounce per hour for the first six hours.

• Take small, frequent sips and slowly increase to 1 ounce every 15 minutes.

• Eventually increase up to 8 ounces maximum every hour.

• When your diet is delivered in the hospital, do not try to finish everything on your tray.

• If solid foods are delivered to your room, do not eat them, and notify your nurse.

• No juices or carbonated drinks. Good choices include:

• Water

• Sugar-free, non-carbonated waters (Crystal Light, Powerade Zero, Vitamin Water Zero)

• Clear broths (chicken, beef, vegetable). Choose low-sodium options.

• Sugar-free popsicles & gelatin

• Decaf tea and decaf coffee (avoid caffeine because it is dehydrating)

You may not feel thirsty, but hydration is critical at this stage. Keep track of your fluid intake to ensure you are meeting you are staying hydrated.

Pain Control

After any surgery, some pain will be normal. Pain is often part of the healing process and should become manageable with time and appropriate intervention. Pain is easier to manage right after it starts, so discuss options with your care team before your pain becomes severe. Add relaxation techniques and warm blankets, cold packs, or try changing position. Please discuss any pain history, medications, or concerns with your care team.

Slow and steady! Stop if you experience pain, nausea, or fullness.

Your care team should provide you with an incentive spirometer to help exercise your lungs after surgery. Using your spirometer regularly will help you recover faster!

It is important that you start walking a few hours after surgery. Get up a few times every hour, and increase every day, either by steps or minutes.

Dietary Stage 2

4 Days After Surgery

Start Date:

Follow a high protein, liquid diet for days 4-7 after the day of surgery.

Meal Plan:

Goal: minimum 60 grams of protein per day for women and 80 grams of protein per day for men. Select protein powders or shakes with 20-30 grams protein per serving and less than 5 grams sugar per serving, low calorie (<200 calories per serving).

• Do not use straws when drinking.

• Drink 64+ ounces of clear liquid that is sugar-free, calorie-free, and not carbonated. Servings should be less than 10-15 calories.

• Water should be your biggest source. Remember to drink lots!

• Sugar-free popsicles & gelatin

• Sugar-free, non-carbonated waters (Crystal Light, Powerade Zero, Vitamin Water Zero)

• Decaf tea and decaf coffee (avoid caffeine because it is dehydrating)

• Clear broths (chicken, beef, vegetable). Choose low-sodium options.

• Avoid juices, as they are high in sugar and sweeteners.

• Start with 1 ounce of protein shake per hour (in addition to your clear liquids)

• Work up slowly to 2-3 premade protein shakes per day or protein powder mixed with your choice of:

• Skim milk

• 1% milk

• Unsweetened almond or soy milk

• Warm broth

• Water or sugar-free, non-carbonated water like Crystal Light

Dehydration can happen quickly at this stage. Drink water often and avoid caffeine or alcohol.

Dietary Stage 3A

7 Days After Surgery

Start Date:

Follow a high protein, pureed diet for days 7-14 after surgery.

Meal Plan:

Goal: minimum 60 grams of protein per day for women and 80 grams of protein per day for men. Continue to avoid straws, caffeine, carbonation, juice, sweet drinks, and alcohol.

• Do not drink anything for 30 minutes before and after your solid meals.

• For 1-2 meals per day, have a “solid meal” that could include a total 1-2 TBSP of:

• Low-fat Cottage cheese, low-fat ricotta cheese

• Sugar-free non-fat yogurt (smooth without chunks of fruit or nuts), sugar-free Greek yogurt

• Sugar-free pudding with added protein powder

• Strained low-fat cream soups

• Refined hot cereals that are low in fiber, such as Cream of Wheat. Make with extra liquid to create a soup-like consistency and add protein powder. No oatmeal.

• For the other 1-2 meals per day, you can have protein shakes and any of the stage 2 liquids.

• If a food does not settle well, wait to try it again until the next dietary stage.

• Drink 64+ ounces of clear liquid that is sugar-free, calorie-free, and not carbonated. Servings should be less than 10-15 calories.

• Water should be your biggest source. Remember to drink lots!

• Sugar-free popsicles & gelatin

• Sugar-free, non-carbonated waters (Crystal Light, Powerade Zero, Vitamin Water Zero)

• Decaf tea and decaf coffee (avoid caffeine because it is dehydrating)

• Clear broths (chicken, beef, vegetable). Choose low-sodium options.

When in doubt, drink more water. Appropriate hydration is key to the success of this procedure and will help you achieve your long-term health goals.

Dietary Stage 3B

2

Weeks After Surgery

Start Date:

Follow a high protein, pureed diet from day 14 (2 weeks) to 4-6 weeks after surgery. You should have 3 meals per day total from here forward.

Meal Plan:

Goal: minimum 60 grams of protein per day for women and 80 grams of protein per day for men. Continue to avoid straws, caffeine, carbonation, juice, sweet drinks, and alcohol. Start with one new food at a time to identify food intolerances. If a new food does not sit well initially, try again at the next dietary stage. Start your vitamin regimen at this stage.

• Diet (2-4 Tablespoons of food per meal, depending on the density of food)

• All stage 1-3A liquids and foods

• Mash or puree the below with any of the following: water, broth, milk, fat-free gravy, fat-free mayo, or plain Greek yogurt. Blend to the consistency of a thick liquid or smooth paste with no solid pieces in the mixture. Do not eat baby food.

• Pureed cooked lean meats, poultry or fish

• Pureed, cooked vegetables and soft beans

• Pureed soups (black bean, low-fat cream soup)

• Hummus, soft scrambled egg or egg-substitute, avocado, or tofu

• Add protein powder to all pureed foods

Notes:

• Do not drink anything for 30 minutes before and after your solid meals.

• Start the meal with protein, followed by vegetables

• Eat very slowly & mindfully. Stop when you are satisfied, not full.

• Chew your food to liquid consistency (20-30 chews per bite)

• In between meals, drink 64+ ounces of clear liquid that is sugar-free, calorie-free, and not carbonated. (Goals and notes for liquids are the same as in stage 3A)

Dietary Stage 4

4-6 Weeks After Surgery

Start Date:

Follow a high protein, low-fat soft diet from 4-6 weeks after surgery until 6-8 weeks after surgery.

Meal Plan:

Goal: minimum 60 grams of protein per day for women and 80 grams of protein per day for men. Protein is still the focus of your diet.

Continue to avoid straws, caffeine, carbonation, juice, sweet drinks, and alcohol. Add new foods slowly, one at a time to build up tolerance.

• Diet (2-4 Tablespoons of food per meal, depending on the density of food)

• All stage 1-3B foods

• Tuna, egg, or ham salad made with low-fat or fat-free mayo or plain Greek yogurt

• Soft meats including fish, lean ground beef (92/8 ratio or higher), pork, or moist poultry

• Mashed potatoes without skin

• Deli meats & sliced low-fat cheeses

• Mild chili

• Meatloaf

• Hard boiled or poached eggs

• As food portions increase, your need for supplement protein shakes will decrease.

• Continue to drink 64+ ounces of clear liquid that is sugar-free, calorie-free, and not carbonated. Servings should be less than 10-15 calories.

• Foods that are not well-tolerated (avoid these):

• Spicy foods

• Raw vegetables

• Tough cuts or red meat

• Whole grains such as bread, pasta, rice, oatmeal, or tortillas

• Acidic foods like tomato sauce

• Fresh or dried fruits

• Fibrous foods like popcorn, nuts, and seeds

• Sweet foods

• High-fat foods (fried food, dressings, high-fat sauces)

Make exercise a regular & long-term habit: 30-60 minutes, every day if possible. Eat slowly & mindfully. Sit down to eat, and do not snack between meals. Keep daily food records to ensure you are meeting your nutritional goals.

Dietary Stage 5

6 Weeks After Surgery and Throughout Your Life!

Start Date:

Follow a high protein, low-fat, regular diet from 6-8 weeks after surgery and throughout the rest of your lifetime.

Meal Plan:

Goal: minimum 60-80 grams of protein per day for women and 70-90 grams of protein per day for men. Protein is still the focus of your diet.

Continue to avoid straws, caffeine, carbonation, juice, sweet drinks, and alcohol.

Add new foods slowly, one at a time to build up tolerance.

• Diet (Slowly increase to 1/4 cup per meal at 3 months, 1/2 cup per meal at 6 months, and 1 cup per meal at 1 year after surgery)

• All stage 1-4 liquids and foods

• Raw vegetables and fruits (at around 2 months after surgery)

• Continue to drink 64+ ounces of clear liquid that is sugar-free, calorie-free, and not carbonated.

• Foods that are generally not well-tolerated (tolerance will vary):

• Spicy foods

• Red meat & dry poultry

• Bread, pasta, rice

• Acidic foods, like tomato sauce

• Fibrous foods like popcorn, nuts, and seeds

• Sweet foods

• High-fat foods (fried food, dressings, high fat sauces)

Avoid caffeine for the first year, then limit caffeine to less than 100mg/ day.

Avoid alcohol for the first full year after surgery.

Eat slowly & mindfully. Sit down to eat, and do not snack between meals.

Keep a consistent exercise routine. Check out the Baritastic app for ideas!

Exercises

Exercises When Laying Down

Ankle Pumps

(Sitting or lying on your back)

1. Point your toes downward and then lift your foot upward.

2. It should be similar to pressing the gas pedal in a car and lifting up.

Do sets of repetitions times a day.

Special instructions:

Knee Presses

1. Lay on your back. Press the back of your knee down into the bed.

2. Tighten the muscles on top of your thigh.

3. Hold for 5 seconds, then relax.

Do sets of repetitions times a day.

Special instructions:

Buttock Squeezes

(Sitting or lying on your back)

1. Squeeze your buttocks together as tightly as you can.

2. Hold for 5 seconds, then relax.

Do sets of repetitions times a day.

Special instructions:

Pillow Squeezes

(Sitting or lying on your back)

1. Place a pillow between your knees.

2. Squeeze the pillow with your knees.

3. Hold for 5 seconds, then relax.

Do sets of repetitions times a day.

Special instructions:

Knee Bends

1. Sit or lie on your back.

2. Slide your foot toward your buttocks, bending your knee and hip.

3. Slowly return to the starting position, straightening the knee completely.

4. Keep your knee pointed toward the ceiling throughout the exercise.

Do sets of repetitions times a day.

Special instructions:

Leg Slides

1. Lay on your back with your legs together.

2. Point toes up toward the ceiling and maintain that position.

3. Slide one leg out to the side, keeping your knee straight.

4. Slowly return the leg back to its original position.

5. Repeat with the other leg.

Do sets of repetitions times a day.

Special instructions:

Half Kicks

1. Put a towel roll or pillow under your knee.

2. Raise your foot off the bed until your knee is straight.

3. Hold for 5 seconds, then lower the foot back down.

Do sets of repetitions times a day.

Special instructions:

Leg Lifts

1. Lie on your back.

2. Keeping your knee straight, life your leg up slowly.

3. Hold for 5 seconds, then lower the leg back down.

Do sets of repetitions times a day.

Special instructions:

Exercises

Exercises When Sitting

Ankle Pumps

1. Point your toes downward and then lift your foot upward.

2. It should be similar to pressing the gas pedal in a car and lifting up.

Do sets of repetitions times a day.

Special instructions:

Hip Flexion

1. Lift your knee up toward the ceiling.

2. Slowly lower back down.

Do sets of repetitions times a day.

Special instructions:

Long Arc Quad

1. Straighten your knee slowly, as if kicking.

2. Slowly return to your starting position.

Do sets of repetitions times a day.

Special instructions:

Isometric Hip Adduction

1. Place pillow between your knees.

2. Squeeze both knees into pillow.

3. Hold for 5 seconds, then release.

Do sets of repetitions times a day.

Special instructions:

Exercises

Exercises When Standing

Kick Backs

1. Stand holding onto a counter or chair with feet shoulder width apart.

2. Standing on one leg, left the other leg behind you, keeping your knee straight.

3. Slowly return to start position.

Do sets of repetitions times a day.

Special instructions:

Mini Squats

1. Stand holding onto a counter or chair with feet shoulder width apart.

2. Slowly squat, bending knees slightly (no more than 45°). Keep back straight.

3. Slowly return to start position.

Do sets of repetitions times a day.

Special instructions:

Side Kicks

1. Stand holding onto a counter or chair with feet shoulder width apart.

2. Shift weight to one leg, lifting the other leg to the side with knee straight.

3. Slowly return to start position. Repeat with opposite leg.

Do sets of repetitions times a day.

Special instructions:

Marching

1. Stand with feet shoulder width apart.

2. Raise one knee up to hip height, then lower.

3. Repeat with opposite leg.

4. Continue marching in place.

Do sets of repetitions times a day.

Special instructions:

Toe Raises

1. Stand holding onto a counter or chair with feet shoulder width apart.

2. Raise toes up, rocking back on heels.

3. Lower slowly and repeat.

Do sets of repetitions times a day.

Special instructions:

Heel Raises

1. Stand holding onto a counter or chair with feet shoulder width apart.

2. Raise heels up, rocking on to toes.

3. Lower slowly and repeat.

Do sets of repetitions times a day.

Special instructions:

Lunges

1. Stand with hands on hips.

2. Step forward with one leg, bending knee slightly.

3. Keep opposite heel on the floor.

4. Slowly return to start position. Repeat with opposite leg.

Do sets of repetitions times a day.

Special instructions:

Moving Forward

Try to avoid:

• Smoking or nicotine (including ecigs, cigars, nicotine patches or gum, etc.)

• Weighing yourself every day. Remember the non-scale victories! Do weekly weigh-ins, and take pictures of your progression.

• One year after surgery, you can resume:

• Drinking caffeine (limit to less than 100mg/day)

• Drinking alcohol in moderation (remember, your tolerance may be greatly lowered!)

• Using straws

• Chewing gum

Note: If you had a gastric bypass procedure, avoid NSAIDS (These include aspirin, ibuprofen, Mobic, Aleve, naproxen, etc.)

Returning to work, school, and your daily life: Be prepared for the reactions of friends, family, or colleagues. People may notice your weight loss or changed eating habits and may have questions. Think ahead about how you will respond.

Tips for a successful transition:

• Prepare lunches in advance, and buy food to keep at work or school:

• Sugar-free, fat-free yogurt

• Cheese sticks

• Packs of carrots or canned juice-packed fruits (drained)

• Canned protein drinks or protein packs

• Small cans of tuna, salmon, or chicken

• Set a timer to regularly remind yourself to:

• Drink water

• Take your supplements

• Take your snack/meal break

• Go for walks

• Build up to walking more often and keep a water bottle handy.

You are on a journey to achieve your health and wellness goals, and we are here to help.

After surgery, you should have appointments with your care team:

• At 2 weeks after surgery

• At 6 weeks after surgery

• At 6 months after surgery

• At 1 year after surgery

• After 1 year, schedule annual appointments for life.

Troubleshooting & Common Complaints

Immediately After Surgery

Headaches or dizziness:

• Drink water

• Add salt or broth to your foods

• Eat meals on a regular schedule

Nausea:

• Recognize a state of comfortable fullness, and do not eat past that point

• Drink fluids

• Try resting or going on a light walk

Vomiting:

• Go back to the previous dietary stage until you find foods that you can tolerate. Do not stop eating altogether

• Keep up with clear liquids if you can

• Chew all foods thoroughly

• Take ~30 minutes to eat each meal. Sit down to eat and choose quiet surroundings.

• Avoid alcohol, high-fat foods, or sugary foods

• Do not drink liquids for 30 minutes before or after a meal

• Make sure all medications and vitamins are crushed, chewable, or liquid

• If these suggestions do not work or if you vomit bright red or dark brown liquid, please go to an Emergency Room

Constipation:

• Drink water regularly, and try warm liquids in the morning

• Walk every day

• Exercise regularly

• Eat friendly fats like olive oil, avocados, and salmon (refer to diet stages)

• Try over the counter stool softeners (like Colace) or laxatives (like Miralax or Dulcolax)

• If you have no bowel movements for 3 days, try 2 TBSP milk of magnesia or 1 Dulcolax suppository

• If you are more than a month after surgery, you can try fiber supplements like sugar-free Metamucil or Benefiber

Troubleshooting & Common Complaints

Later Post-Operative

Burping or hiccups:

• Chew with your mouth closed

• Avoid straws, carbonated beverages, and chewing gum

• Eat slowly

Excessive hair loss:

• Hair loss can be normal for several months following surgery. This is not permanent , and will improve once your weight has stabilized.

• To minimize hair loss:

• Stick to your protein regimen

• Drink water

• Take your vitamins

• Talk to your surgeon about taking biotin, zinc, or essential fatty acid supplements

Diarrhea:

• Eat slowly and stop when you reach a state of comfortable satisfaction

• Do not drink liquids 30 minutes before or after your meal

• Avoid sugar, fat, alcohol, caffeine, and spicy foods. No smoking

• Continue to eat well-tolerated foods until you feel better, or go back to the last food stage

• Limit sugar-free sweeteners like sorbitol and mannitol

• Take over the counter Imodium as directed

• If diarrhea continues, contact the clinic to check for a possible bacterial infection

Leg cramps:

• Increase fluid and electrolyte intake

• Follow your diet closely as advised by your surgeon and dietitian, and take your vitamins

• Increase your activity: move every half hour and put your legs up if they feel swollen

• Avoid crossing your legs or wearing anything tight on your legs

Food “getting stuck”:

• Eat and chew slowly. Cut food into very small pieces and eat smaller portions

• Avoid dry, tough, or stringy foods

Dumping syndrome:

Symptoms include nausea, vomiting, sweating, bloating, diarrhea, cramping, lightheadedness, and fast heart rate. This usually occurs after eating high-fat or high-sugar foods and lasts about 30 minutes.

• Avoid fatty or sugary foods, and those with “hidden” sugars like honey, corn syrup, molasses, jellies, jams, sweet spreads, barbecue sauce, ketchup, and sweet pickles

Heartburn/burning feeling in stomach:

• Avoid caffeine, tea, coffee, chocolate, spicy foods, black/red pepper, and alcohol

• Avoid foods that are too hot or too cold

• Avoid smoking

• Avoid aspirin and other NSAIDs (try Tylenol instead)

• Discuss symptoms and medications your are taking with your surgeon. Your surgeon may prescribe an antacid.

Weight loss stops:

• Evaluate portion sizes, limit high calorie foods and beverages

• Increase physical activity

• Consult your dietitian and/or exercise team

Plugging or indigestion (the sensation that food has “blocked” an opening) :

• Avoid dry, tough, sticky, gummy, spongy, stringy, or fibrous foods

• Avoid bran, cereal, granola, popcorn, noodles, rice, corn, peas, cabbage, celery, dried beans, dried fruit, coconut, citrus membranes, and fruit or vegetable skins/peels

• Avoid acidic foods

• Go back to an earlier diet stage

Lactose intolerance:

Some people develop intolerance to some dairy products after weight loss surgery. This may feel like gas, bloating, cramping, and diarrhea.

• Avoid milk and milk by-products. Replace milk with sugar-free soy milk or lactose-free milk (like Lactaid)

• Try over the counter lactase supplements

Gout:

• Drink fluid according to your schedule to flush waste from your kidneys

• Avoid alcohol, keep protein intake toward the low end of your goal

• Avoid high-purine foods like organ meats (liver, kidneys, heart, etc.), game meat, sardines, anchovies, scallops, mussels, and mackerel

• Limit moderate-purine foods (oatmeal, wheat bran and germ, asparagus, peas, cauliflower, spinach, mushrooms)

• Note: Colchicine (a medication to treat gout) may cause diarrhea

Kidney stones:

• Drink fluid according to your schedule to flush waste from your kidneys

• Avoid excessive intake of vitamin C (too much vitamin C can contribute to kidney stones)

• Avoid high-oxalate foods (beets, cocoa, chocolate, prunes, leeks, greens, quinoa, celery, soy, tofu, peanuts, black tea, coffee, soda, wheat bran and germ, spinach, dried beans, sweet potatoes)

• Discuss treatment with your care team

Bloating or gas:

• Avoid sugar alcohols and fructose (sorbitol, maltitol, xilitol) and consider the possibility of lactose intolerance.

• Use probiotics

• Avoid straws, chewing gum, carbonated beverages, or gulping

• Limit fat intake

• Try gas reduction treatment options (Beano, Gas-X strips)

• Limit soluble fiber (oat brain, Metamucil, barley, beans, dried peas) and foods that may cause gas (vegetables, high-fiber cereals, peanuts & peanut butter, soy milk, soy protein)

Cold or congestion:

• You can take Sudafed, Zyrtec or Claritin, sugar-free throat lozenges or chloraseptic spray, and Tylenol

• Avoid NSAIDS, or anything with sugar.

Preventing Weight Regain

Sustained weight loss is the result of:

• Regular and consistent healthy food choices

• Maintaining portion control & eating mindfully

• Eating breakfast

• Planning your meals and following your plan (avoid snacking)

• Regular exercise

• Drinking plenty of water

• Keeping food and exercise journals

• Getting good rest

Maintaining portion control will help you achieve your health goals. It is possible to overeat. Avoid “grazing”

Bariatric surgery will jump-start your weight loss, but maintenance will require following a high-protein diet and sticking with your plan over the long term. At first it might seem like the weight “just falls off” but after the first year additional weight loss will require persisting with your new healthy behaviors. Think of your surgery as the “reset,” but over time the weight loss will slow down. You may begin to regain weight, and that can be a difficult emotional time for many patients.

Exercising regularly and referring to your new healthy eating plan will help you sustain weight loss as they become established in your routine. Exercise also has fantastic mental health effects- people who exercise regularly may have more energy, feel less depressed, and sleep better than people who do not routinely exercise.

Tips for success:

• Let others help you: join support groups and share even the little milestones. You can cheer others on throughout their journey this way, too!

• Chart your progress: track the goals and milestones that are achievable and matter to you.

• Identify your feelings: for many people, eating can be “emotional.” Maybe you craved certain foods when different emotions came up. By identifying and addressing the underlying feelings, you can talk yourself through emotions without relying on food as comfort.

• Seek out professional support: Many factors contribute to weight changes, and many emotions may come up. A supportive therapist can help you to identify achievable goals and give you the best chance of success as you begin to rediscover your relationship with your body.

• Learn to relax: Try deep breathing and engaging with music, art, or the outdoors. Identify things that bring you joy (hobbies, time with friends or family) and add them to your routine.

Remember: you made the choice to have this procedure for your future health and wellbeing. Going to a restaurant with friends might be difficult, so plan ahead and try to be gracious. People around you will eat foods that you may need to avoid. Remind yourself that this is a choice you have made for yourself, but not necessarily a choice that others have made or will make for themselves.

Your Health and Future

Bariatric surgery is one step in the direction of your long-term health and wellness. Your care team is here to support you throughout the process.

There is more to obesity than diet and exercise.

Stress, sleep, hormones, chronic pain, underlying medical conditions, medications, and genetics can also play an important role.

Obesity also increases the risk of other health problems such as diabetes and fertility issues. Our multidisciplinary team of surgeons, advanced practice providers, psychologists, nurses, dietitians, and physical therapists are available to help support you in achieving and maintaining your weight loss goals.

We’re here to help you rebuild your relationship with your body and with food. This journey is about more than how you look- patients who live a more active lifestyle are less likely to experience sleep apnea, heart disease, diabetes, arthritis, and back pain.

Ask your bariatric surgery team for information about our regular support group meetings.

Scan this QR code to ask your clinic team a question through the UTMB MyChart portal

Department of Surgery