Nutrition and Weight Loss Surgery

1. Nutrition and Weight Loss Surgery Donna Logan, RD, LD donna@tlcsurgery.com Maddie Orsak, MS, RD, LD maddie@tlcsurgery.com

2. Objectives • Preoperative protocol and liquid diet • Cover surgical procedures • Vitamin & mineral requirements Following bariatric surgery • Brief overview of postoperative diet progression • Common intolerances following surgery

3. Nutrition Protocol Before Surgery • Begin immediately • Daily multivitamin • Maintain or lose weight • Avoid the “Last Supper Syndrome” • Liquid Diet • Start 2 weeks prior to surgery

4. PreOp Liquid Diet • Low calorie, low carb meal plan to induce ketosis • If you are diabetic, contact your physician monitoring your diabetes prior to starting the liquid diet. Your physician will need to provide recommendations to adjust your medications as needed. • Benefits – • Reduces size of liver for quicker, safer surgery • Additional weight loss • Familiarity with postoperative diet progression

6. Surgical Procedures • Adjustable Gastric Banding • Sleeve Gastrectomy • RNY Gastric Bypass • Duodenal Switch (DS)

7. Adjustable Gastric Banding (AGB) Why Supplement? • Deficiency pre op • Restriction • Avoid certain foods • maladaptation

8. Vertical Sleeve Gastrectomy (VSG) Why Supplement? • Deficiency pre op • Restriction • Maldigestion • Avoid certain foods

9. Roux-en-Y Gastric Bypass (RYGB) Why Supplement? • Deficiency pre op • Combination • Restriction • Malabsorption • Maldigestion • Avoid certain foods

10. Duodenal Switch (DS) Why Supplement? • Deficiency pre op • Combination • Restriction • Malabsorption • Maldigestion • Avoid certain foods

11. Band Supplementation • Calcium • 1,500 mg/day • Calcium citrate • Chewable with vitamin D • Elemental Iron • 30 mg premenopausal women • Bariatric Multivitamin • 100% Daily Value • 2 a day • Chewable • B12 • Sublingual(350-500 mcg/day) • Nasal spray (500 mcg/week ) • Intramuscular injection (1,000 mcg/month)

12. Bypass/Sleeve Supplementation • Calcium • 1,000 mg/day • Calcium citrate • Chewable with vitamin D • Vitamin D3 • 5,000 IUs daily • Elemental Iron • 30 mg premenopausal women • 18 mg men and post menopausal women • Bariatric Multivitamin • 100-200% Daily Value • 2 a day • Chewable Until diet has progressed to soft foods • B12 • Sublingual(350-500 mcg/day) • Nasal spray (500 mcg/week ) • Intramuscular injection (1,000 mcg/month)

13. Duodenal Switch Supplementation • Calcium • 2,000 mg/day • Calcium citrate • Chewable with vitamin D • Vitamin D3 • 5,000 IUs daily • Elemental Iron • 30 mg premenopausal women • 18 mg men and post menopausal women • Bariatric Multivitamin • 200% Daily Value • 3 a day (per bottle) • Chewable with ADEK • B12 • Sublingual(350-500 mcg/day) • Nasal spray (500 mcg/week ) • Intramuscular injection (1,000 mcg/month)

14. Medications • Discuss with TLC surgeons EVERY medication you are taking – • including over-the-counter and vitamin, mineral, and herbal supplements • You may be told to postpone, discontinue, or change the dosage of the medication • You may be instructed to change the form to liquid or chewable • Do not make medication changes or decisions without consulting the doctor

15. Postoperative Diet Progression • All procedures have the same progression • Clear liquids • Full liquids • Pureed • Soft foods to Maintenance • Difference between procedures is how much time is spent on a stage • Why? • Safety • Avoid leaks • Avoid nausea and/or vomiting • Promote healing

16. Postoperative Diet Progression • The diet progression is gradual. Think about how you might progress with your nine-month old nephew… TAKE BABY STEPS • Try new foods one at a time and gradually replace liquid calories. • If you aren’t progressing through the stages as expected, let us know.

17. Stage 1: Clear Liquids (Day 1-2) • 64 oz a day (48 oz minimum) • Sip 1 oz over 10-15 minutes, then refill • Sugar-Free • Caffeine-Free • Carbonation-Free • Water • Sugar-free flavored water (crystal light) • Decaffeinated tea/coffee • Herbal tea • Sugar-free popsicles • Sugar-free gelatin • Broth and bouillon

18. Stage 2: Full Liquids • Gastric Band: • Days 3-7 • Bypass, Sleeve, DS: • Days 3-14 • Start vitamin and mineral regimen (Day 3) • If your are having difficulty taking all supplements, start with the multivitamin (twice a day) and gradually add in all other supplements. You should be taking everything daily by 2 weeks postop Goal hydration 64 oz/day & adequate protein intake > 60 gms/day

19. Stage 2: Full Liquids • Clear liquids + • Skim milk or light soy milk • Protein shakes • Use those recommended on the preopliquid diet • Bariatric Advantage or Unjury broth flavored powder • Isopure RTD • Vegetable juice (low sodium) • Strained cream soup (look for options low in fat & sugar) • Sugar free pudding Lactose Intolerance – common following sleeve, bypass, and DS. May experience gas, bloating, diarrhea. Switch to lactose free options – light soy milk, low fat Lactaid, Mootopia (HEB)

20. Stage 2: Full Liquids • Sip, sip, sip all day long • Avoid temperature extremes • extra hot or cold can cause discomfort/spasms • If you feel light headed, hungry, or dizzy… you may be dehydrated • Feeling nauseated? • Sip fluids slowly • As your diet progresses, take tiny bites (pencil eraser size), and chew well (apple sauce consistency) • Dab peppermint oil on a handkerchief – smell when nauseated

21. Stage 3: Pureed • Gastric Band: • Days 8 - 21 • Bypass, Sleeve, DS: • Days 15 - 30 All foods previously allowed + food that is the consistency of baby food or applesauce • Baby food • Add broth, skim milk, or water to meats, fruit, and well cooked vegetables and puree/blenderize • Light or plain yogurt • 0% Greek yogurt • 1% cottage cheese • Oatmeal • Fat free refried beans

22. Stage 4: Soft • Gastric Band: • After Day 21 • Bypass, Sleeve, DS: • After Day 30 Foods that you can mash with a fork and chew to the consistency of apple sauce • Ground chicken or turkey breast • Dairy • low fat • Eggs • Beans • Fish • Vegetables • over cooked • Fruit • soft without peel, canned

23. Preventing and Alleviating Possible Food Intolerances and Issues Following Bariatric Surgery Handout • Dumping Syndrome • Reactive Hypoglycemia • Nausea & Vomiting • Diarrhea & Constipation • Excess gas • Pain • Dehydration • Lactose intolerance

24. Preventing and Alleviating Possible Food Intolerances and Issues Following Bariatric Surgery Handout • Alcohol • Avoid for the first year out from surgery or until you have reached goal weight • Short term hair loss Discuss in more detail at First Bite Bring handout to class • Tough meats • Raw fruit and vegetables • Starchy foods

25. Tips for Success • Use small plates and utensils • Avoid eating past the point of fullness • Avoid skipping meals • Avoid drinking 30 minutes before, during, and 30 minutes after meal times • Continue to limit fats and avoid concentrated sweets • Eat your protein first

26. Your success depends on you!

27. Online Course - Documentation • Go to www.tlcsurgery.com • Click on “Patients” • Then click on “Classes” • And finally, click on “Pre-Op Nutrition Class” • Follow the instructions and submit the form IF YOU DO NOT COMPLETE THE FORM, WE WILL NOT HAVE RECORD OF YOUR CLASS ATTENDANCE.