Program for Weight Management

 

BRIGHAM AND WOMEN'S HOSPITAL / FAULKNER HOSPITAL

DIETARY GUIDELINES

FOR

GASTRIC BYPASS^©

 

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AN INTRODUCTION TO THE GASTRIC BYPASS DIET PROGRESSION

This booklet has been designed to help you, your family and your friends learn about the dietary guidelines for gastric bypass.  In order to be successful at losing weight and keeping it off, you must learn how to modify your eating behavior permanently.  The goal of gastric bypass surgery is to help you change your eating habits in order to promote weight loss and weight maintenance.

The surgery is only part of the treatment. Your commitment to a healthy diet is the most vital part of the treatment.  The diet you follow after surgery and for the rest of your life will determine your ability to control your weight.

The gastric bypass diet is different than any other diet you may have followed in the past.  It will progress through a series of five stages; you will eat smaller portion sizes than you are probably used to and you must eat on a regular schedule.  If you overeat, you may become sick to your stomach and/or vomit.  After the surgery, many people feel full after eating small portions of food.  You will start to learn when you feel full over time.

It is important to note that many other diet progressions may be available online or from others who have had the gastric bypass elsewhere. Please keep in mind the diet progression recommended by your dietitian is what we see as the most appropriate diet.

For the first few months, your total food and liquid intake will average of 600-1000 calories per day.  Once you have finished the diet progression, you will consume three to five meals per day.  Your dietitian will design a meal plan for you that is adequate in protein and calories.

It is very important that you keep all of your follow-up appointments with the dietitian and physician.  The people that keep regular appointments have the greatest chance of successful, safe weight loss and maintenance.

PREPARING FOR SURGERY

One of the most important components of gastric bypass surgery is learning new eating habits.  During your visit with the dietitian you will review your past diet, weight history and exercise patterns.  You will be asked to keep a food record to help identify problems that we will work together to solve.

Techniques to help you learn a new way of eating will gradually be introduced.  The dietitian will discuss the diet progression for gastric bypass during your visits.  Feel free to ask any questions you may have.

The surgery will help you to control the number of calories you consume by making it difficult for you to eat large portions of food at one time.  It is still possible for people to overeat and gain weight by eating and/or drinking high calorie foods throughout the day.  This behavior is sometimes referred to as grazing. Try some of these eating tips to stay on track:

BEHAVIORAL TECHNIQUES:

Trying some behavior modification techniques may help you increase your long-term success after the gastric bypass.

Make food less visible in your home

• Store all food out of sight.  Try to keep food off of the counters
• Put your favorite foods in hard to reach places
• When serving meals, keep pots or serving platters on the stove - not on the table
• Store leftovers immediately after meals or immediately throw them in the trash

Modify your food shopping habits

• Avoid grocery shopping on an empty stomach
• Make a shopping list and stick to it. 
• Shop the walls.  Avoid temptation by avoiding the aisles.  Most whole foods are found along the perimeter of the store.
• Buy only the items that are necessary for you and your family
• Avoid buying food items for other people that you may eat.

Slow your eating down

Eating slowly is very important after you have your surgery.  If you eat too quickly, you may vomit.  Start to become aware of eating patterns before surgery and modify the pace of eating. Try some of these tips to help slow yourself down:

1. Allow 30 minutes minimum for mealtimes.  Right after your surgery, you may need up to 60 minutes
2. Take small bites and chew food to a liquid consistency before swallowing
3. Savor each bite.  Pay attention to flavors, textures and consistency
4. Set your utensils down in between bites
5. Make a reminder sign that says EAT SLOWLY to remind you to do so

Portions are important

• Carefully weigh and measure all portions before eating. Start measuring portions prior to surgery to familiarize yourself with what a healthy portion looks like.
• Put all extra food away before eating
• Use small dishes and glasses.  This will make your portions look bigger
• Cook just enough
• Practice leaving something on your plate even before you have surgery.

Make eating an isolated activity

• Choose a spot at home just for eating.  The best bets are the dining room or kitchen table.
• Make a rule to sit whenever you put something in your mouth
• Avoid doing other activities while eating.
• Relax while eating.
• Become aware of hunger and fullness prior to surgery as well as following surgery.

Plan ahead

• Plan what and how much you will be having for lunch or supper
• Many find it helpful to purchase a “cooler” or insulated bag for food transport and help in planning meals.

Try activities that you can do instead of eating

• If you usually eat when you are upset, anxious or depressed, try music, a bath or shower, a walk, yoga, meditation or anther form of relaxation.
• Make a list of 20 things you like to do or would like to try that don’t involve food.  Try them out.
• Practice your new habits on a regular basis.  It may take a while to develop the new habits and feel comfortable doing them

PHYSICAL ACTIVITY

Your weight is a result of the balance between the foods you eat and the amount of calories you body burns in physical activity.  As you lose weight after gastric bypass, you may find it much easier to get around.  Take advantage of this new freedom!  The more active you are, the more quickly you will lose weight. 

Ask your doctor before beginning any strenuous program, particularly in the first three months after surgery.  Try some of these suggestions to increase your physical activity.

1. Walk more.  Walk the dog; go for a walk with a friend, a neighbor or the children.  Walk whenever you can.
2. Take the bus or car less often.
3. If you take public transportation, get off a few stops early
4. Take the stairs instead of the elevators
5. Park your car far away at shopping centers and walk through the parking lot
6. Take a "walking break" at work instead of a coffee break. 
7. Do some yard work, gardening, or household chores that require brisk movement
8. During foul weather, get exercise by walking in the mall
9. Look for easy and fun new ways of exercising with your new body! Before surgery, make a list of fun and exciting classes you might take, such as ballroom dance or water aerobics.
10. Check exercise videos out of the library and make note of some of the simpler toning exercises you could do. Plan a routine based on this.

FREQUENTLY ASKED QUESTIONS:

Should I purchase anything for after the surgery?

Yes!  Measuring cups measuring spoons and a food scale are necessary to determine the exact portion sizes of the food you eat and drink.  You should also purchase and sample a high protein low sugar drink so you have it on hand and are familiar with the taste.

How much weight can I expect to lose?

Your weight loss will depend on how closely you follow the diet after your surgery and the amount of physical activity you do.  The average weight loss ranges between 8-20 pounds the first few months, then a bit slower after that.

What are the side effects of gastric bypass?

Some people may experience nausea, vomiting, constipation and/or food intolerances.  Some individuals report that they can no longer tolerate foods such as red meats, chicken, eggs, rice, pasta and untoasted bread.  Every person is different, and what one person can tolerate, another may not.  A careful food record can help your dietitian or physician sort through the foods that may be problematic.

How will I know when I am full?

As you try new foods after surgery, you may have trouble knowing when you are comfortably full.  Nausea may be your first indication of fullness.  Don’t let this alarm you.  It will take time for your body to adjust to the stomach's smaller size and return to a normal "full" feeling.  You may feel pressure in the center of your stomach or pain in the shoulder area or upper chest when you are full.  Initially you may only be able to tolerate 2-3 teaspoons of food at one time.

What will I eat when I go to a restaurant?

Restaurant eating will be a very different experience for you after the surgery.  Ask the waiter to prepare your food in a low fat manner.  Be prepared to bring much of your meal home in a doggie bag.  Try some of these dining out tips

• Call the restaurant in advance for a preview of the menu.  Don’t be afraid to ask for special orders
• Try ordering one dinner and splitting it with your friend or spouse
• Try ordering two appetizers instead of a full meal
• Ask that your food be broiled or baked with no added butter or fat
• Ask that bread and rolls be removed form the table
• Concentrate on talking and listening to the conversation.
• Be cautious about alcohol – You will feel its effects much sooner
• Remember, the children’s menu is not always the answer for smaller portions.
  Children’s menu foods are often laden with fat calories.

How can I have fun at parties or weddings if I cant eat a lot?

Try to focus on the social aspect of the event.  Position yourself away from the food table and catch up with friends or get on the dance floor.  Scan the buffet in advance and make a plan as to what you will eat. If it is a served meal, call the facility ahead of time and ask what they will be serving. You may allow yourself one or two healthy appetizers and a smaller portion of the meal. Your dietitian will provide you with many tips to make parties and events easier to experience.

If I get upset and want to eat, what will I do?

If you get upset, don’t keep it bottled up inside, try and talk it through with someone.  Try different ways to handle your stress, through exercise, reading or other activities. You may consider a mental health professional if you feel you need additional assistance in dealing with stress.

 

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THE GASTRIC BYPASS SUPPORT GROUP

As a patient considering weight loss surgery, you will meet with many of the experienced health care professionals on our team.  We also recommend that you speak with individuals who have already experienced the surgery.  For this reason we encourage all pre-surgical patients to attend our support group.  No appointment is necessary.

When:              The first and third Tuesday of each month

Time:                6:00-8:00 p.m.

• The first 45 minutes of this group is dedicated to a topic related to gastroplasty and diet.  The remaining time is dedicated to new patient discussion and feedback.

Where:            Carrie Hall Conference Room, Brigham and Women’s Hospital 

• Enter at the 15 Francis Street entrance. Take a right down the main hallway. Carrie Hall is at the end of the corridor

Cost:               FREE to all BWH and Faulkner Hospital surgical candidates

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THE PREOPERATIVE WEIGHT LOSS GROUP

As a patient considering weight loss surgery, you may be asked to participate in a medically supervised weight loss program by your insurance carrier OR your surgeon may recommend that you lose weight before your surgery.   For this reason Brigham and Women’s Hospital has formed a preoperative weight loss program.       

When:             The second, third and fourth Wednesday of each month

Time:              6:30-7:30 p.m.

Where:            Anesthesia Conference Room, Brigham and Women’s Hospital

• Enter at the 75 Francis Street entrance.  Bear to your right down the Brigham and Women’s “ground pike”.  You will see the Connors Center for Women and Newborns elevator on your left.  If you walk past the copper statues, you have gone too far.  Take the elevator down to L-1.  Exit the elevator; you will see a sign pointing to the Anesthesia Conference Room.  The room is located at the end of the hall on the right hand side.

Cost:               FREE to all BWH and Faulkner Hospital surgical candidates

If you have any questions or concerns you would like to discuss about the support group or the medically supervised weight loss program, please do not hesitate to contact us.  You may reach us by calling 617-732-8500 or by emailing us at pwm@partners.org

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       GASTRIC BYPASS DIET PROGRESSION

You are usually in the hospital for 2-5 days following gastric bypass. Your diet will progress through 5 different stages over the course of the next few months. 

Before Surgery: What to Buy

 

• A few bottles of water or sugar-free, non-carbonated, non-caffeinated beverages such as Crystal Light, Fruit₂0, Diet Snapple
• A high protein low sugar drink
• Food scale
• Measuring cups
• Measuring spoons

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Start:                           Day One Postoperatively

• The first day you are able to eat while in the hospital

Duration:                    1 day

Diet Instructions:      Two ounces of non-caloric, non-carbonated, non-caffeinated liquids/hour.

Fluid Goal:                 1-2 oz per hour (a minimum of 28-32 oz is encouraged)

Protein Goal:             None

Important Information:

• Stop sipping as soon as you feel full or if you have any nausea/vomiting
• Use 1-ounce medicine cups to help prevent you from drinking too fast
• Carbonation will cause abdominal distention or discomfort – AVOID CARBONATED BEVERAGES
• Juices should be avoided.  They are too high in sugar and calories & can cause dumping syndrome
• Write down the amount of water you drink on a food record

UNDERSTANDING DUMPING SYNDROME

Dumping syndrome occurs in many gastric bypass patients when sweet foods like juice, soda, sugar sweetened beverages, cakes, cookies and pies are eaten.  The food passes too quickly into the small intestine and causes symptoms such as: nausea or queasiness, a sense of fullness accompanied by discomfort, cramping, diarrhea, general weakness, profuse sweating, vomiting, and heart palpitations (an increase in heart rate).  Most patients experience a combination of these symptoms. Usually the symptoms will subside in about an hour. Most patients find the symptoms are alleviated after they lie down for a while. Dumping syndrome is not dangerous, but it is quite unpleasant.

Some patients “eat through” the dumping syndrome and they are eventually able to tolerate calorie dense foods in smaller quantities. Given this is a lifestyle change, it is important to avoid these calorie dense foods from the beginning and develop healthier alternatives to eating.

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Duration:                    14 Days (postoperative days 2-15)

Diet Instructions:      Five - 8oz servings of a high protein, low sugar beverage

• You may not be able to consume all five servings right away.  This is normal.  Make 5 servings your goal.

Milk Based High Protein, Low Sugar Beverages                  

• Carnation Instant Breakfast – No Sugar Added (blue box) (Stop and Shop, Shaws, Kmart)
• HMR 500, 800, chicken soup (no ice) (www.hmrprogram.com)
• DiabetiTrim (CVS)
• EAS Advant Edge Carb Control (Stop and Shop, Target)
• Worldwide Pure Protein Shake (Trader Joes)
• Atkins Advantage Shake (Walgreens, Walmart, GNC)
• Designer Whey (CVS, Target, Walmart, Walgreens)
• Smartforme shakes/drinks (www.smartforme.com)

Lactose Free High Protein, Low Sugar Beverages

• HMR 70+ (www.hmrprogram.com)
• Glucerna Weight Loss Shake (Stop and Shop, Walgreens)
• Lactaid (drops, chewable tablets or milk)
• Choice DM (CVS, Walgreens)
• Unjury (www.unjury.com)
• Optisource (www.walgreens.com)
• Isopure (Vitamin Shoppe)

Fluid Goal:                At least 56 oz (7 cups) of non-caloric, non-carbonated, non-caffeinated liquid per day. This includes your protein drinks

•  Water
• Sugar free Popsicles
• Sugar free Jell-O
• Fat free/Low fat broth/bullion
• Diet Snapple
• Crystal Light
• Fruit₂0
• Propel
• Try to limit sugar alcohols. When looking at a label, they typically end in “ol”, example:  mannitol, maltitol, sorbitol.  Sugar alcohols can cause gas, abdominal pain and diarrhea

Protein Goal:             60-70 grams/day

Vitamins:                    Separate all vitamins by 4 hours or more

MULTIVITAMINS

• Two chewable multivitamins (children’s or adult) OR Two Tablespoons liquid multivitamin  (Avoid Gummy or Chewy multivitamins)

• Centrum Adult Chewable
• CVS Spectravite Adult Chewable
• Walgreens Adult Chewable
• Nature Made Multi Chewable for Adults (Costco)
• Spring Valley Adult Chewable (Wal-Mart)
• Kirkland Adult Chewable (Costco)
• CVS Spectravite Children’s Chewable
• Centrum Rugrats Complete Chewable
• Walgreens Children’s Chewable
• Wal-Mart Children’s Chewable
• Kirkland Children’s Chewable (Costco)
• Flintstones Complete Children’s Chewable
• GNC Multiples Multibite Plus Minerals & Calcium Multivitamin
• Centrum Liquid

CALCIUM

Important Information

• Sip all liquids slowly over a one-hour period. DO NOT exceed 8 ounces per hour
  • Sip 2 ounces every 15 minutes to stay on track
• Avoid gulping, it introduces air into your system and may cause gas pains.
• Do not force yourself to finish fluids if you feel full
• Some protein drinks contain aspartame sweetener or Sucralose.  Some people cannot tolerate these sweeteners
• Plan ahead and have the protein drinks ready to drink
• Do not drink with meals (consider the protein drink your “meal”)
• Drink fluids 1/2-hour before or 1/2-hour after your meal
• It is VERY important to stay hydrated, sip fluids throughout the day
• Keep an eye on your urine, it should be a light yellow
• Write down the amount of fluid you drink in your food record
• Use a thermos or chill your glasses in the freezer to keep your protein drinks cool while you are drinking them
• Write down all of the fluid you drink on your food record
• AVOID VOMITING!  This may lead to staple line disruption
• If you are lactose intolerant, try Lactaid drops (available at your pharmacy) or Lactaid milk
  • A word on lactose intolerance: 
    •  Lactose intolerance is caused by your body’s inability to breakdown the milk sugar “lactose”.  Lactose intolerance typically causes gas, bloating and/or diarrhea.
    •  Whey Protein Isolate is tolerated by people with lactose intolerance because the lactose is filtered out
    • Lactose is found in many milk based products but some forms can be hidden in labels.  Look for these words in on the food label.  They contain lactose and may cause symptoms if you are lactose intolerant:
      • *Ammonium caseinate
      • *Artificial butter flavor
      • *Butter solids/fat
      • *Calcium caseinate
      • *Casein
      • *Caseinate
      • *Delactosed whey
      • *Demineralised whey
      • *Dried milk
      • *Dry milk solids
      • *Hydrolyzed casein
      • *Hydrolyzed milk protein
      • *Lactalbumin
      • *Lactalbumin phosphate
      • *Lactate
      • *Lactoferrin
      • *Lactoglobulin
      • *Lactose
      • *Magnesium caseinate
      • *Milk derivative
      • *Milk fat
      • *Milk protein
      • *Milk solids
      • *Opta (fat replacement)
      • *Potassium caseinate
      • *Rennet casein
      • *Simplesse
      • *Sodium caseinate
      • *Sour cream solids
      • *Sour milk solids
      • *Whey
      • *Whey protein concentrate

Sample Meal Plan:

• 8 a.m.              8 oz Protein Drink
• 8 a.m               Multivitamin
• 9 a.m.              8 oz Water/Fluid
• 10 a.m.            8 oz Protein Drink
• 12 noon           8 oz Protein Drink
• 12 noon           Calcium Supplement
• 2 p.m.              8 oz Water/Fluid
• 3 p.m.              8 oz Protein Drink
• 4 p.m.              8 oz Water/Fluid
• 4 p.m.              Multivitamin
• 5 p.m.              8 oz Protein Drink
• 8 p.m.              Calcium Supplement
• 8 p.m.              8 oz Water/Fluid

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Diet Instructions:      4 – 2oz  Protein servings, 1 Dairy serving, 3 Fruit/Vegetable/Starch servings, 1 fat serving

Protein – CHOOSE 4 SERVINGS                                                                             

Dairy – CHOOSE 1 SERVING

Fruits/Vegetables/Starch – CHOOSE 3 SERVINGS

Fat – CHOOSE 1 SERVING

Protein Goal:             60-70 grams/day

Vitamins:                    Separate all vitamins by 4 hours or more

MULTIVITAMINS

Two chewable multivitamins (children’s or adult) OR Two Tablespoons liquid multivitamin  (Avoid Gummy or Chewy multivitamins)

• Centrum Adult Chewable
• CVS Spectravite Adult Chewable
• Walgreens Adult Chewable
• Nature Made Multi Chewable for Adults (Costco)
• Spring Valley Adult Chewable (Wal-Mart)
• Kirkland Adult Chewable (Costco)
• CVS Spectravite Children’s Chewable
• Centrum Rugrats Complete Chewable
• Walgreens Children’s Chewable
• Wal-Mart Children’s Chewable
• Kirkland Children’s Chewable (Costco)
• Flintstones Complete Children’s Chewable
• GNC Multiples Multibite Plus Minerals & Calcium Multivitamin
• Centrum Liquid

CALCIUM

•  AVOID VOMITING!  This may lead to staple line disruption
• Increase the protein content of your fruits/vegetables by adding protein powder or dry skim milk powder.  Whey Protein Isolate is an excellent source of protein and well tolerated by people that are lactose intolerant
• It is VERY important to stay hydrated, sip fluids throughout the day
  • Keep an eye on your urine, it should be a light yellow
  • Write down the amount of fluid you drink in your food record
  • Continue drinking 8 oz of fluid per hour between meals
  • For lightheadedness or dizziness, try one cup of bouillon as part of your fluid intake
  • AVOID HIGH CALORIE BEVERAGES such as juice or soda
• DO NOT DRINK WITH MEALS
  • Drink fluids 1/2-hour before or 1/2-hour after your meal
• Do not force yourself to finish fluids if you feel full
• If you are feeling constipated, try adding some milk of magnesia, stool softener or Benefiber to your foods
• The diced protein and smooth foods stage gradually re-introduces solid food to your system
  • It is important for you to eat all of the recommended dietary protein 
  • Your body must get the protein it needs from your diet
• It is important to get on a schedule of eating.  If you are not hungry, take a few bites just to stay on schedule
  • You may need to have more than 5 meals per day in the beginning
  • You may want to consider having one protein shake per day in the beginning of stage 3 to help increase protein intake
• Meat should be tender and moist 
  • Marinated meats, boiled meats and the dark meat of chicken tends to be well tolerated
  • Fibrous meats such as dry turkey, dry chicken breast or hamburger can be difficult to digest
  • Microwaving and grilling dries out meats, making them difficult to tolerate
  • Try adding broth before microwaving to make the meat juicier
  • Some condiments are OK.  Ketchup, light or fat free mayonnaise, mustard, fat free gravy, herbs and spices
• Avoid ground beef, shrimp, scallops or lobster
  • They are very difficult to digest.   Wait until at least 4 months post op to try them
• Do not fry your meats 
  • Frying adds calories and can make foods hard to digest
  • Some people may experience dumping with fatty foods
• Weigh food on a scale after it has been cooked to be sure you are getting adequate protein
  • If you do not own a food scale, cook a piece of protein the size of a deck of cards
• Take VERY small bites of food and chew the food well until it is liquid/paste in your mouth
• Eat slowly, use 10 minutes per ounce as a guideline
• Stop eating if you are full, you can go back to your meal later
• AVOID PICKING OR GRAZING.  This will lead to weight gain
• Avoid very hot or very cold foods, they may cause dumping syndrome
• Continue with your chewable vitamin supplements 
• Do not chew gum or suck on hard candy.  If swallowed it can obstruct your outlet
• If you experience hair loss, be sure you are getting in all of your protein.  Vitamin B12, Zinc, Biotin, Omega 3’s and/or Folic Acid may be necessary. Nioxin shampoo may also be helpful which can be obtained at a local beauty supply store or salon
• Write down all of the food you eat and the fluid you drink on your food record. The food record at this stage is critical to ascertain that you are eating enough protein

Sample Stage 3 Meal Plan

Time	Food	Liquid	Protein (g)
8 a.m.	2 scrambled eggs (protein), 1/2c applesauce (fruit)		12
9 a.m.		8 oz Decaf tea
10 a.m.	1/4c cottage cheese ( ½ protein-split serving)		7
11 a.m.		8 oz water
12 noon	2oz Tuna fish (protein), 4” banana (fruit), 1 tsp lite mayonnaise ( 1/3 fat)		14
1 p.m.		8 oz Crystal Lite
2 p.m.		8 oz Propel
3 p.m.	8 oz yogurt (dairy)		8
5 p.m.		8 oz chicken broth
6 p.m.	2 oz diced chicken (protein), 1/2c mashed potato (starch), 1 tsp light margarine (1/3 fat), 1 tsp fat free gravy (1/3 fat)		14
7 p.m.		8 oz water
8 p.m.	1 oz string cheese (½ protein-split serving)		8
10 p.m.		8oz Decaf tea
Total		56 ounces  (7 cups)	63 grams

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·                     

Stage 4: Reduced Calorie Solids

Start:                           Day 38

Duration:                    4 weeks (postoperative day 38-65)

Diet Instructions:      1000 calorie meal plan

                                    *Serving sizes are listed on a separate page

Fluid goal:                  56 oz of non-caloric, non-carbonated, non-caffeinated liquid (7 cups)

Vitamins:                    Separate all vitamins by 4 hours or more

MULTIVITAMINS

Two chewable multivitamins (children’s or adult) OR Two Tablespoons liquid multivitamin  (Avoid Gummy or Chewy multivitamins)

• Centrum Adult Chewable
• CVS Spectravite Adult Chewable
• Walgreens Adult Chewable
• Nature Made Multi Chewable for Adults (Costco)
• Spring Valley Adult Chewable (Wal-Mart)
• Kirkland Adult Chewable (Costco)
• CVS Spectravite Children’s Chewable
• Centrum Rugrats Complete Chewable
• Walgreens Children’s Chewable
• Wal-Mart Children’s Chewable
• Kirkland Children’s Chewable (Costco)
• Flintstones Complete Children’s Chewable
• GNC Multiples Multibite Plus Minerals & Calcium Multivitamin
• Centrum Liquid

CALCIUM

Chewable Calcium Supplement 1200-1500 mg/day (500 mg/dose max)

• Look for a calcium supplement with Vitamin D, it will help the calcium to be absorbed better

Important Information:

• The Reduced Calorie Solids stage gradually re-introduces solid food to your system
  • It is important for you to eat all of the recommended dietary protein 
  • Your body must get the protein it needs from your diet
  • Start to move away from soft mushy foods and liquid meals. Solid foods will be more filling
• Not everyone will be able to eat all of the recommended foods, especially at first.  Listen to your body and do not overstuff your pouch.
• It is important to get on a schedule of eating.  If you are not hungry, make protein your priority, take a few bites just to stay on schedule
  • As you are able to eat more at meal time, your frequency of eating will be decreased
  • AVOID PICKING OR GRAZING!  This will lead to weight gain
• Meats should be tender and moist 
  • Marinated meats, boiled meats and the dark meat of chicken tends to be well tolerated
  • Fibrous meats such as dry turkey, chicken breast or hamburger can be difficult to digest
  • Microwaving and grilling dries out meats, making them difficult to tolerate
  • Try adding broth before microwaving to make the meat juicier
  • Some condiments are OK.  Ketchup, light or fat free mayonnaise, mustard, fat free gravy
• Avoid ground beef, shrimp, scallops, clams or lobster
  • They are very difficult to digest.   Wait until at least 4 months post op to try them
• Do not fry your meats 
  • Frying adds calories and can make foods hard to digest
  • Some people may experience dumping with fatty foods
• Avoid problematic foods such as:
  • Tough meats such as red meat, hamburger, lobster, scallops, clams and shrimp
  • Membranes of oranges, tangerines and grapefruit - they can obstruct your outlet
  • Cores, skins and seeds of fruits and vegetables
  • Fibrous vegetables such as celery
  • Popcorn and nuts
  • Doughy breads
  • Rice
  • Grapes
  • Peapods
• Start with canned fruits (packed in their own juice) and then advance to fruit with the skin peeled off (watch out for seeds)
• Start with well-cooked vegetables and cook for less time as you progress
• Corn and peas count as starches rather than vegetables
• Bread is better tolerated when toasted
• Weigh food on a scale after it has been cooked to be sure you are getting adequate protein
  • If you do not own a food scale, cook a piece of protein the size of a deck of cards
• Take VERY small bites of food and chew the food well until it is liquid in your mouth
• Eat slowly, use 10 minutes per ounce as a guideline
  • Baby warmer trays or warm plates can be used to keep food warm while you are (slowly) eating your meal
• Stop eating if you are full, you can go back to your meal later
• AVOID VOMITING!  This may lead to staple line disruption
• Avoid ALL spongy starchy foods, breads, cakes, bagels they expand in your stomach and may cause pain or blockage.  They can also be easy to overeat.
• Continue drinking 8 oz of fluid per hour
• DO NOT DRINK WITH MEALS
• Continue with your chewable vitamin supplements 
• Do not chew gum or suck on hard candy.  If swallowed it can obstruct your outlet
• If you experience hair loss, be sure you are getting in all of your protein.  Vitamin B12, Biotin, Zinc, Omega 3’s, Iron or Folic Acid may be necessary. Nioxin shampoo may also be helpful which can be obtained at a local beauty supply store or salon
• Write down all of the food you eat and the fluid you drink on your food record. The food record at this stage is critical to ascertain that you are eating enough protein

Sample Stage 4 Meal Plan

1000 calorie meal plan

• 7 meat/protein servings
• 1 milk serving
• 3 starch serving
• 2 fruit servings
• 2 vegetable servings
• 2 fat servings

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Stage 5: Ongoing

Duration:                    Ongoing

Diet Instructions:      Regular planned meals 1000 or 1200 or 1500 calories

                                               

Food Group                             1000 calories              1200 calories              1500 calories             

Starch                                     3 servings                   4 servings                   5 servings

Meat/Protein (extra lean)     7 servings                   8 servings                   9 servings

Vegetables                            2 servings                   2 servings                   3 servings

Fruit                                         2 servings                   2 servings                   3 servings

Milk (low fat)                           1 serving                     2 servings                   2 servings

Fat                                           2 servings                   3 servings                   4 servings

*See attached sheet for serving sizes

Fluid goal:                  56 oz of non-caloric, non-carbonated, non-caffeinated liquid (7 cups)

Protein Goal:             60-70 grams/day

Vitamins:                    Separate all vitamins by 4 hours or more

MULTIVITAMINS

Two chewable multivitamins (children’s or adult) OR Two Tablespoons liquid multivitamin  (Avoid Gummy or Chewy multivitamins)

 CALCIUM

Chewable Calcium Supplement 1200-1500 mg/day (500 mg/dose max)

• Make protein intake your priority.  Aim for 60-70 grams each day
• You may include most foods into your diet at this stage
• Continue to drink 56 oz of fluids per day (7 cups)
• Move away from soft mushy foods and liquid meals. Solid foods will be more filling
• AVOID PICKING AND GRAZING.  This will lead to weight gain
• AVOID HIGH CALORIE BEVERAGES
• DO NOT DRINK WITH MEALS
• Write down all of the food you eat and the fluid you drink on your food record

Sample Meal Plan 1000 Calories

• 7 meat/protein servings
• 1 milk serving
• 3 starch servings
• 2 fruit servings
• 2 vegetable servings
• 2 fat servings

 

• 8 meat/protein servings
• 2 milk servings
• 4 starch servings
• 2 fruit servings
• 2 vegetable servings
• 3 fat servings

 

• 9 meat/protein servings
• 2 milk servings
• 5 starch servings
• 3 fruit servings
• 3 vegetable servings
• 4 fat servings

EACH ITEM ON THIS LIST = 1 SERVING

15 grams of carbohydrate,

3 grams of protein

80 calories

Whole grain products average about 2 grams of fiber per serving.

Those foods that contain 3 or more grams of fiber per exchange are identified with the fiber symbol Ø.

You can choose your starch servings from any of the items on this list.

CEREALS/GRAINS/PASTA                                   

STARCHY VEGETABLES

• ØCorn                                                                   ½ cup
• ØCorn on cob, 6 in. long                                   1
• ØLima Beans                                                     ½ cup
• ØPeas, green (canned or frozen)                   ½ cup
• ØPlantain                                                             ½ cup
• Potato, baked (3oz)                                            1small       
• Potato, mashed                                                   ½ cup
• ØSquash, winter (acorn, butternut)                 1 cup
•    Yam, sweet potato, plain                                1/3 cup

  BREADS

•    Bagel                                                                 ½ (1 oz.)
•    Bread sticks                                                      2 (2/3 oz)
•      (crisp,4 in. long x 1.2 in. )
•  English muffin                                                   ½
•    Frankfurter or hamburger bun                      ½ (1 oz)
•    Pita, 6 in. across                                            ½
•    Plain roll, small                                               1 (1 oz)
•    Bread, white, wheat, rye, raisin                    1 sl.(1 oz)
•  Tortilla, 6 in. across                                          1

  CRACKERS/SNACKS

•    Animal crackers                                              8
•    Graham crackers                                            3-2.5in sq
•    Matzoh                                                               3/4 oz.
•    Melba toast                                                       5 sl.
•    Oyster crackers                                               24
•    Popcorn (popped, no fat added)                 3 cups
•    Pretzels                                                            3/4 oz.
• ØRye crisp, (2 in. x 3 in.)                                  4
•    Saltine-type crackers                                     6
• ØWhole-wheat crackers                                  2-4sl (3/4 oz.)
  •     no fat added (such as Finn, Kavliâ, Wasa)

  DRIED BEANS/PEAS/LENTILS

(Count as 2 starch plus 1 lean meat)

•  ØBeans and peas (cooked)                         1 cup
  •     (kidney, white, split, blackeye, lentils)          
• ØBroad beans, garbanzo, navy, pinto          2/3 cup  
• ØBaked beans                                                  ¼ cup                          

STARCHY FOODS PREPARED WITH FAT

(Count as 1 starch/bread serving, plus 1 fat serving)

•    Biscuit, 2½ in. across                                1
•    Chow mien noodles                                  ½ cup
•    Corn bread, 2 in. cube                               1 (2 oz.)
•    Cracker, round butter type                         6
•    French fried potatoes,                                10 (1½ oz.)
  •     (2 in. to 3½ in. long)                                      
•   Muffin, plain, small                                       1
•   Pancake, 4 in. across                                 2
•   Stuffing, bread (prepared)                          ¼ cup
•   Taco shell, 6 in. across                               2
•   Waffle, 4½ in. square                                   1
•  ØWhole-wheat crackers                               4-6 (1 oz.)
  •       no fat added (such as Triscuit)
•     Hummus                                                      1/3 cup 

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VERY LEAN AND LEAN MEATS/PROTEIN

       

 EACH ITEM ON THIS LIST = 1 SERVING

VERY LEAN MEAT/PROTEIN AND SUBSTITUTES

0 grams of carbohydrate, 7 grams of protein

0-1 grams of fat, 35 Calories

 

• POULTRY:                                                                                                                                             1 oz.
  • Chicken, turkey, Cornish hen (without skin)           
• FISH:         
  • Fresh or frozen cod, flounder, haddock, halibut, trout, tuna                                             1 oz.
• SHELLFISH:
  • Crab, lobster, scallops, shrimp, clams (fresh or canned in water)                                1 oz.
•  GAME:    
  •  Pheasant (without skin), Venison, buffalo, ostrich                                                            1 oz.
• CHEESE:                     
  • Non fat or low fat cottage cheese                                                                                           1/4 cup
  • Fat free cheese                                                                                                                          1 oz.
• OTHER:                       
  • 95% fat-free luncheon meat (less than 1 gram fa