Gastric sleeve surgery booklet - University of Mississippi Medical

For Urgent Symptoms:

Monday-Friday 8:00am-4:30pm:

Call The Weight Management Program at

601-984-1285

Afterhours, weekends, and holidays:

Call UMMC at 601-984-1000 and ask to page Dr. Ken Vick or the On-Call Surgery

Resident

UMMC Bariatric Information Binder Revised December 16, 2014 1

TABLE OF CONTENTS

WELCOME

M EET O UR T EAM

OVERVIEW

P RE -S URGICAL P ROCESS

O BESITY & B ARIATRIC S URGERY O VERVIEW

T HE GI T RACT

WEIGHT LOSS SURGERY OPTIONS

T YPES OF W EIGHT L OSS O PERATIONS

R OUX -E N -Y G ASTRIC B YPASS

L APAROSCOPIC A DJUSTABLE G ASTRIC B ANDING

V ERTICAL S LEEVE G ASTRECTOMY

S IDE N OTES

PREPARATION STEPS

P ERSONAL P REPARATION

M EDICATION C HANGES

A LCOHOL & T OBACCO

W ORK & D ISABILITY

P ACKING F OR S URGERY

SURGERY DAY

M ORNING O F S URGERY

R EPORTING T O T HE H OSPITAL

S URGERY

P OST -O PERATIVE E XPECTATIONS

D ISCHARGE P LANS

AT HOME

R ECOVERY I NSTRUCTIONS

W OUND C ARE

U RGENT S YMPTOMS

N ORMAL S YMPTOMS

D EHYDRATION

N AUSEA

V OMITING

B OWEL H ABITS

35

39

39

40

41

36

37

38

38


24

24

24

25

26

28

29

29

31

32

34

15

16

18

19

20

21

23

5

8

9

13

6

7

H ERNIA

T HRUSH /Y EAST

A NEMIA

T RANSIENT H AIR L OSS /S KIN C HANGES

S CARS

L ONG -T ERM C OMPLICATIONS

S EXUALITY /B IRTH C ONTROL /P REGNANCY

LONG TERM SUCCESS

F OLLOW UP

E XPECTED W EIGHT L OSS

L IFESTYLE C HANGES

W EIGHT M AINTENANCE

R ECONSTRUCTIVE /P LASTIC S URGERY

F OLLOW -U P

P ERMANENT L IFESTYLE C HANGES

M EDICATIONS

S UPPORT G ROUPS & R ESOURCES

ACTIVITY & EXERCISE

E XERCISE

T IPS F OR G ETTING S TARTED

C OMMON W ORKOUT M ISTAKES

W ALKING

W ATER F ITNESS

P ERSONAL T RAINERS

NUTRITION 67

I NTRODUCTION

B ASIC N UTRITION : N UTRIENTS

B ASIC N UTRITION : F OOD G ROUPS

T IPS : L IMITING F ATS

C HANGES A FTER S URGERY : U SEFUL T OOLS

C HANGES A FTER S URGERY : C OMPLICATIONS

D IET G UIDELINES : C OMPLICATION P REVENTION

P ROTEIN G UIDELINES

V ITAMINS & M INERALS G UIDELINES

D IET S TAGES

S TAGE 1 (C LEAR L IQUIDS )

S TAGE 2 (F ULL L IQUIDS )

S TAGE 3 (P UREED )

S TAGE 4 (S OLID F OODS )

P RE -S URGERY C HECKLIST


78

80

81

82

83

84

86

73

75

76

77

69

70

71

72

57

59

61

62

64

65

65

47

51

52

53

54

56

48

48

50

50

42

42

42

43

43

43

44

PRE-OP & LONG TERM NUTRITIONAL PLANS

P RE -O P N UTRITIONAL P LAN

P RE -O P E XCHANGE L ISTS

L ONG T ERM 1000 C ALORIE N UTRITIONAL P LAN



L ONG T ERM E XCHANGE L ISTS

BEHAVIOR MODIFICATION

B EHAVIOR C HAINS

S UPPORT S YSTEM

G OAL S ETTING

E MOTIONAL C ONSIDERATIONS

C OUNSELING

F AMILY & F RIENDS

B ODY I MAGE

T HE I NTERNET

S TRESS E LIMINATION

MISCELLANEOUS INFORMATION (FORMS, CHARTS, MAPS)

H OTELS N EARBY

S URGICAL C ONSENT

W EIGHT L OSS C HART

UMMC M APS


111

112

113

115

116

88

89

90

92

93

94

95

99

102

104

106

107

108

108

109

110

110

Welcome

We wish to extend to you our deepest congratulations as you embark on a new chapter of your life.

Our hope is that you see this process as a beginning. A beginning to a new, healthier you! We will be there every step of the way and commit to support and encourage you throughout this journey.

We hope that you will be able to see what tomorrow will bring, today as you work toward your healthy life goals.

This binder is full of information to assist you in this journey. Information on what to expect, nutrition, exercise, maps, behavior and long term changes for your long term success.

Our weight management team consists of multiple disciplines. We take pride in our approach to support, encourage, and treat patients with skilled hands, respect, and kindness throughout this journey. Our goal is to help you achieve your goals. Please feel free to contact us with any concerns, questions, or comments. Our skilled personnel are proud to work hand in hand with you on this lifelong journey to a new, healthier you.

We are honored that you chose UMMC’s Weight Management to take part in your process of becoming a healthier you.


~ Meet Our Team ~

Surgeon:

Kenneth Vick, MD, F.A.C.S.

Dr. Vick completed his residency in general surgery at UMMC in 2005. He is a recipient of several awards, including James Powe Award Winner for Laparoscopic Excellence, Outstanding

Laparoendoscopic Resident Surgeon Award, Best Resident in Laparoscopy and Resident of the

Year. His primary research interests are minimally invasive surgery, surgical simulation, surgical education and bariatric surgery. He graduated from the University of Texas in 1996 and from

University of Texas Southwestern Medical School at Dallas in 2000. He completed his education at the University of Mississippi in 2005 where he has been employed since graduation. He is a member of the Association of Surgical Education, James D. Hardy Society, Society of Laparoendoscopic

Surgeons, SAGES, and American College of Surgeons. He has multiple publications in many different journals. He is married to Dr. Laura Vick and enjoys time with his wife and children.

Nurse Practitioner:

Jennifer Godbold, FNP-BC

Nurse Coordinator:

Darla Byrd, BSN RN

Administrator:

Adam Dungey, BSN, MBA

Collaborating Providers:

Dr. John Hall – Research Physician

Dr. Angela Subauste – Research Physician

Dr. John Cross – Internal Medicine Consults

Dr. Molly Clark – Psychology Consults

Jim Miller, NP – Family Medicine Consults

Paul Robertson, RD – Registered Dietitian

University of Mississippi Medical Center's Weight Management Program follows UMMC's commitment to provide people throughout Mississippi with quality, compassionate medical care.

Our comprehensive program includes both surgical and non-surgical weight loss options. Services led by board-certified experts are designed to provide you with the tools you need to not only lose weight, but enjoy long-term weight loss success.


Overview


THE PROCESS PRIOR TO SETTING A SURGERY DATE

Step 1: Consult appointment with your surgeon

Step 2: Insurance Coverage vs. Self-Pay Option

Step 3: Program Required Evaluations

A.

Medicine Evaluation a.

By your primary care provider or by Dr. John Cross and/or Jim Miller, NP in our

Internal Medicine and Family Medicine departments.

B.

Nutrition Evaluation a.

All patients are required to undergo an evaluation by Paul Robertson our Registered

Dietitian.

C.

Psychological Evaluation a.

All patients are required to undergo a psychological evaluation by our psychologist,

Dr. Molly Clark or one of her associates

D.

Lab work or Blood work is required of all Patients

E.

Other testing (may be needed) a.

EKG b.

Sleep Study c.

EGD – Esophagogastroduodenoscopy or “Scope” d.

Other tests as required by your surgeon for other conditions

Step 4: Evaluation by Anesthesia

A.

All surgical patients are required to meet with the Anesthesia Nurse to evaluate for potential problems related to anesthetic.

Step 5: Pre-Op Consent with your Surgeon

A.

Informed Consent

B.

Surgery Date and Time set

Step 6: Surgery and a NEW YOU


OBESITY AND BARIATRIC SURGERY

Overweight and obesity are labels for ranges of weight that are greater than what is generally considered healthy for a given height.

For adults, overweight and obesity ranges are determined by using weight and height to calculate a number called the “Body Mass Index or BMI”. BMI is used because, for most people, it correlates with their amount of body fat. BMI is calculated using the following formula:

BMI:

25-29.9 – Overweight

30-39 – Obese

40 or higher –Morbidly Obese

BMI= [weight in pounds/(height in inches x height in inches)] x 703

BMI is just one indicator of potential health risks associated with being overweight or obese. Other predictors include the individual’s waist circumference (because abdominal fat is a predictor of risk of obesity related diseases), physical inactivity and others.

During the past 20 years, obesity among adults has risen significantly in the United States. The latest data show that one-third of United States adults (35.7%) are obese. This increasing rate raises concerns because of its implication for Americans’ health. Being overweight or obese increases the risk of many diseases and health conditions, including the following:

 High Blood Pressure (Hypertension)

 High cholesterol or triglycerides

 Type 2 Diabetes

 Coronary Heart Disease (heart attack)

 Stroke

 Gallbladder Disease

 Osteoarthritis

 Sleep Apnea and respiratory Problems

 Some cancers (endometrial, breast, and colon)

 And others…




WHO CAN HAVE WEIGHT LOSS SURGERY?

Bariatric surgery is not a quick fix or an easy way out. It is a drastic step, and it includes all the risks of any major abdominal operation. Bariatric surgery is a remedy of last resort, offered only when all else has failed.

In 1991, The National Institute of Health (NIH) held a consensus conference where health care professionals examined all aspects of morbid obesity and set forth criteria for weight loss surgery.

Patients, who meet the following criteria, may qualify for bariatric surgery:

Sustained BMI of 40 kg/m2 or higher, OR Sustained BMI between 35 and 39.9 kg/m2, if they have a significant disease related to their morbid obesity such as: diabetes, hypertension, sleep apnea, or heart disease.

In addition, patients who qualify for morbid obesity surgery should in general (patients need to be evaluated on an individual basis) have:

 History of failed weight loss attempts (some insurance companies may require a specific number of months of medically supervised diet).

 Age at least 21

 Upper weight limit of 400 lbs. (patients who weigh more than 400 lbs. will be evaluated on a case-by-case basis by the Bariatric Team)

 Absence of previous weight loss surgery such as vertical banded gastroplasty (VBG) or other intestinal bypass

 Absence of severe mental health illnesses (patients must be willing to see a mental health professional before and possibly after the operation)

 Knowledge and understanding of surgery risks (including the risk of death) and reasonable weight loss expectations as well as motivation and commitment to diet and life long followup (patients who demonstrate non-compliance with treatment and/or diet are excluded).

Patients who meet the initial weight loss surgery criteria will be evaluated on an individual basis by the surgeon then by the members of our team. Starting the evaluation process does not in any way guarantee the surgery and patients must be found first to be acceptable candidates based upon all the completed evaluations.


THE GASTRO-INTESTINAL TRACT

To better understand how weight loss surgery works, it is important to understand how your gastrointestinal tract functions. As the food you consume moves through the gastrointestinal tract, various digestive juices and enzymes are introduced at specific stages that allow absorption of nutrients. Food material that is not absorbed is then prepared for elimination.

WHAT CAUSES SEVERE OBESITY?

Normal route of food:

Food is swallowed and passed through the esophagus, then gets broken down by the stomach, where digestive juices begin to work in breaking food down. Partially digested food then gets passed down to the small intestines mixing with digestive juices from other organs

(liver/gallbladder/pancreas). This is where fats, calories, vitamins and other nutrients are absorbed. Whatever your body does not absorb passes through the colon and then is removed from your body as waste (stool) through the rectum.

Obesity occurs when a person consumes more calories than he or she burns. What causes this imbalance of "calories in and calories out" differs from person to person. Genetics, eating habits, physical activity, and psychological factors may all play a part in obesity. Some neurological conditions, endocrine problems, and certain medications can cause some weight gain but usually not severe obesity.

Weight GAIN occurs when Calories Consumed is

GREATER THAN Calories Used

Weight LOSS occurs when Calories Consumed is

LESS THAN Calories Used

NO Weight Change occurs when Calories Consumed is

EQUAL TO Calories Used



Weight Loss

Surgery

Operations


TYPES OF WEIGHT LOSS OPERATIONS

The most important step in weight loss surgery is getting all of the information you need about the various surgical options.

If you choose to research weight loss surgery on your own via the Internet or through your local library, be sure that your sources are responsible and recognized experts in the field. Talking to other bariatric surgery patients and attending support group meetings are very helpful. Keep in mind, however, that although information from other patients’ experiences is very useful, most patients will be slanted towards or away from whichever surgery they had, so take it all with a grain of salt. Do your research and remember that the decision to undergo surgery and the type of operation you choose is ultimately your own decision and what works for one patient may not be best for you.

Although the results of weight loss surgery can be drastic, there are potential significant risks and complications. Before making your decision, you should be well informed. This is necessary if you are to give what is called “informed consent” for the surgical procedure. Informed consent is a legal term meaning that a patient agrees that they have received and understood enough information about a procedure’s benefits and risks that allow them to make a decision that is right for them.

Your surgeon will go over the risk of the surgery in much more detail and will require you to sign a detailed consent form before undergoing your procedure.

There are two basic types of weight loss surgery:

 Restrictive procedures that decrease (or restrict) food intake.

 Malabsorptive procedures that alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool.

At the University of Mississippi Medical Center, we offer 3 Procedures:

1.

Roux-en-Y Gastric Bypass (both open and laparoscopic)- Restrictive and Malabsorptive

2.

Laparoscopic Adjustable Band (LAGB)- Restrictive Only

3.

Vertical Sleeve Gastrectomy (Gastric Sleeve) procedure- Restrictive Only


Adjustable Gastric Band Gastric Bypass Vertical Sleeve Gastrectomy

-Reduces the amount of food that can be eaten

-Band wraps around upper portion of stomach, creating a small pouch

-Restricts food intake and amount of calories/ nutrients the body absorbs

-Surgeon creates a small stomach pouch and attaches small intestine to pouch.

Food bypasses portion of small intestine

-Patient feels full sooner and stays full longer

-Normal digestion and absorption

-Smaller stomach pouch causes patient to feel full sooner and eat less

-Bypassing part of the small intestine means the body absorbs fewer calories

-Decreases the size of the stomach, limiting the amount of food eaten at one time

-Thin vertical sleeve is created, the remaining stomach is removed

-Smaller stomach causes patient to feel full sooner and stay full longer

-Normal digestion and absorption

Hospital Stay

24 hours

Hospital Stay

2 to 5 days 2 days

Hospital Stay

Percentage of Weight

Loss

41% (3 years)

Percentage of Weight

Loss

62% (3 years)

Percentage of Weight Loss

66% (3 years)

Weight Loss Expectations Weight Loss Expectations

Slow, gradual (1-2 lbs./week)

Relatively Rapid, 6-9 months then slower weight loss

Weight Loss Expectations

Slow, gradual (1-2 lbs./week)

May take 2-3 years to reach goal

May take 2-3 years to reach goal 12-18 months to reach goal


ROUX-EN-Y GASTRIC BYPASS

Roux-en-Y Gastric Bypass is a combined restrictive and malabsorptive procedure. In this procedure, the stomach is completely divided with staples creating a small (15-30cc) stomach pouch, which would become the reservoir that holds food; the remainder of the stomach (which is not removed) is no longer used. The small bowel is then divided and one end

(called the Roux limb) is brought up and connected to the newly formed pouch. The other end of the divided small bowel is connected to the side of the Roux limb of the intestine creating the “Y” shape giving the technique its name.

ADVANTAGES

Greatly controls food intake leading to rapid weight loss. One year after surgery, weight loss can average 77% of excess body weight. Studies show that up to 96% of certain obesity associated health conditions (back pain, sleep apnea, high blood pressure, diabetes, and depression) were improved or resolved.

Relatively rapid weight loss can be expected over the first 6-9 months, then slower weight loss, may take 12-18 months to reach goal of 62% of excess weight.

The risk of death from this operation is 0.5-1% on average.

RISKS

 Iron deficiency

 Chronic anemia

 Heightened bone calcium loss

 Anastomotic leak (leak at the area of intestine reattachment)

 Fistula

 Metabolic bone disease

 Vitamin B12 deficiency

 Dumping syndrome

 Intestinal irritation and ulcers


LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING (LAGB)

A Laparoscopic Adjustable Gastric Band or LAGB procedure is a purely restrictive surgical procedure in which a band is placed around the upper most part of the stomach. This band divides the stomach into two portions, one small (15cc) and one larger portion. The band has an inner balloon that is connected to a port placed under the skin; by injecting fluid into the balloon (band adjustment), the band is made tighter and patients feel full faster. Food digestion occurs through the normal digestive process.

This operation is almost always performed laparoscopically. Band adjustments are a normal part of follow-up care and are absolutely necessary for adequate weight loss.

ADVANTAGES

LAGB is one of the least invasive surgical techniques used to control obesity. No cutting or stapling is performed on the stomach or any portion of the intestines. The surgery restricts the amount of food that can be consumed at a meal. Food consumed however passes through the digestive tract in the usual order allowing it to be fully absorbed into the body; there is no change in vitamin absorption since no intestinal bypass is performed.

Slow, gradual weight loss (1-2 pounds a week) May take 2-3 years to reach goal with 41% of excess weight lost in 3 years. The risk of death from this operation is about 0.05%

RISKS

 Gastric perforation

 Reservoir leakage or twisting

 Lack of satiety

 Reflux

 Band Erosion

 Nausea and vomiting

 Outlet obstruction

 Pouch dilation

 Band slippage


VERTICAL SLEEVE GASTRECTOMY (GASTRIC SLEEVE)

The Gastric Sleeve is solely a restrictive procedure that results in weight loss due to removing 85% of the stomach mass. The stomach is divided and stapled vertically. The stomach remaining is shaped like a very slim banana measuring about 1-

5 ounces. The excess portion of the stomach is then removed.

The nerves to the stomach remain intact with the idea of preserving the functions of the stomach while drastically reducing the volume. A feeling of fullness results when a small amount of food enters the stomach. After leaving the stomach, the smaller amount of food is digested normally.

ADVANTAGES

The removed section of the stomach is the portion that

“stretches” the most and is responsible for excreting Ghrelin, a hormone that is responsible for appetite and hunger. The remaining portion is least likely to expand over time and creates significant resistance to volumes of food. Not only is appetite reduced, but small amounts of food generate early and lasting fullness. No synthetic material is left in the abdominal cavity except the staples used to divide and seal where the portion is removed. Over time the stomach will create scar tissue that will permanently seal this line.

Slow, gradual weight loss (1-2 pounds a week), may take 2-3 years to reach goad with 66% of excess weight lost in 3 years. The risk of death from this operation is less than 1%.

RISKS

 Tissue separation

 Gastric leakage

 Ulcers







Fistula

Dyspepsia

Esophageal dysmotility


~ ADDITIONAL THINGS YOU SHOULD KNOW ~

THIS IS NOT COSMETIC SURGERY: The weight loss surgical procedures are in no way to be considered as cosmetic surgery. Looking better is only a side effect. The surgery does not involve the removal of adipose tissue (fat) by suction or excision.

LIVING WITH BARIATRIC SURGERY: Bariatric surgery should not be considered until you and your doctor have evaluated all other options. Success of surgical weight loss treatment must begin with realistic goals. The success of bariatric surgery is dependent upon long-term lifestyle changes in diet and exercise.

EATING DIFFERNTLY FOR THE REST OF YOUR LIFE: Remember that this is major, permanent surgery. The changes brought about by surgery are intended to last the rest of your life.

Food is a regular part of our social life. Your pouch will not let you eat a huge meal like everyone else. Going out to restaurants might mean leaving two thirds of your food, or having to bring it home. You will not be allowed to drink soda. You may not have a Margarita or one cookie, without having dumping syndrome. Take some time to imagine what day-to-day life and holidays will be like when your body does not react to food the way it does now.

PREGNANCY: Most women have had successful pregnancies following weight loss surgery.

Women are however advised not to get pregnant for 18-24 months after surgery. Furthermore, contraceptive pills may not be effective during the first few months after surgery, so abstinence (no sex) or a barrier method of birth control (condom or diaphragm) must be practiced during that time.

Discuss other methods of contraception with your GYN provider.



Preparation Steps


STEPS YOU CAN TAKE TO PREPARE FOR BARIATRIC SURGERY

Personal Preparation – Start Exercising. The best time to begin your exercise program is before your surgery. The sooner you start exercising, the easier it will be after you have surgery. Success in bariatric surgery requires choosing the right habits, following appropriate diet, and attending support group meetings. These along with support of the surgical procedure accomplish long-term success.

We want you to start moving more through consistent exercise, but we do not want you to injure yourself. Walking on a daily basis improves your circulation and makes breathing easier during recovery. You will benefit from having a walking routine in place prior to surgery. This will alleviate the need to figure out a routine during the recovery phase.

If you are unable to walk daily because of joint pain, you may want to look into an aquatics program. Water exercises are non-weight bearing; therefore, they are easier for people who have joint problems and arthritis. Water exercise will also condition your breathing.

Medications – It is important to avoid aspirin and all aspirin containing medications for up to two weeks prior to surgery. With some medical conditions, such as heart disease, check with your cardiologist or primary care provider regarding when to stop your aspirin prior to surgery and keep your surgeon informed. Check labels of over-the-counter medications because many may contain aspirin. Herbal medications such as St. John’s Wort, Ginko Biloba, Garlic, etc. should be discontinued as these have blood-thinning properties. Other herbal supplements such as Kava and

Valerian Root are known to interact with anesthesia and should be stopped at least two weeks prior to surgery. Also check the label of your multivitamin; many items they may contain herbal supplements. Again, remember to tell your surgeon all the medications, vitamins and herbal supplements you are taking. If in doubt, please check with your pharmacist or your surgeon.

You will also want to obtain a pill crusher. After surgery, pills will no longer be absorbed as they are before surgery. Whether they are not absorbed efficiently or are difficult to pass through digestion, crushing medications will allow for efficient absorption to take place. If in doubt if certain medications can be crushed, check with your prescribing physician, primary care provider or pharmacist. Ask for medications that are not extended release; are in capsule form which can be opened and consumed for proper absorption; or have your medications changed to elixir form. If you are taking diuretics, please discuss an alternative with your primary care provider, as we discontinue usage of diuretics post-operatively.

Alcohol and Tobacco – Smoking hinders proper lung function; therefore, it may increase the possibility of anesthetic problems such as breathing problems, but also cardiopulmonary complications (pulmonary embolism, pneumonia, and the collapsing of tiny air sacs in the lungs).

Smoking also stimulates stomach acid production which can lead to ulcer formation. It also raises your chances for other complications such as DVT (deep vein thrombosis or blood clot in the legs), reduced circulation to the skin and prolongs the process of healing. Patients are required to stop


smoking at least 8 weeks prior to surgery. You must also agree to permanently refrain from smoking after surgery. Please ask for information about our smoking cessation program at UMMC.

Alcohol causes gastric irritation and can cause liver damage. During periods of rapid weight loss, the liver becomes especially vulnerable to toxins such as alcohol. You may find that only a couple of sips of wine can give you unusually quick and strong effect of alcohol intolerance. In addition alcoholic beverages are high in empty calories and may cause “dumping syndrome.” For these reasons, we recommend complete abstinence from alcohol for one year after surgery and avoiding frequent consumption thereafter.

Work and Disability – Expected return to work after surgery is about 4 to 6 weeks. This time may vary greatly for each individual. The time you take off from work depends on several factors which include the type of work you do, your general state of health, how quickly you are needed back at work, your general state of motivation, the surgical approach, and your energy levels. It is important to remember that you will not be just recovering from surgery, but also eating very little and losing weight rapidly. You may have heard that someone went back to work full-time in just two weeks.

We would caution you not to rush back to full-time work too quickly. The first few weeks are a precious time to get to know your new digestive system, to get plenty of rest, to exercise and to meet with other post-surgery patients in support group meetings. Some patients do not wish to tell the people with whom they work what kind of surgery they are having. It is perfectly appropriate to tell as much or as little to your employer as you would like. Although you do not need to tell your employer that you are having bariatric surgery, it is recommended to reveal that you are having major abdominal surgery. Explain that you will need two or more weeks to recover, especially if you would like to have some form of financial compensation during your absence. Your employer should have the relevant forms for you to complete. You may want to indicate that you will not be able to do any heavy lifting for several months after surgery.

**** If you are ill before surgery – Should you develop a cold, persistent cough, fever, skin breakdown, or any changes in your condition during the days before your surgery, please notify the clinic immediately. You need to be in the best possible shape for anesthesia.

Scheduling can be adjusted to your condition if necessary ****

Medications before surgery – You will receive instructions on the medications to be taken the morning of surgery. a.

Be sure to take only the medicines you have been instructed to take with a small sip of water the morning of surgery. b.

To decrease the risk of blood loss during surgery, you must avoid or stop taking medications that contain aspirin two weeks before surgery (Bayer, BC, Stanback, or

Goody’s Powder)


c.

Do not take Motrin, Advil (ibuprofen), Mobic, Naproxen, NSAIDs or other arthritis or pain medications prior to surgery. They may increase your risk for bleeding. As always, discuss your medicines with your surgeon well in advance of your surgery to verify which medications to stop prior to surgery. d.

Do not take excessive quantities of Vitamin E for two weeks before surgery as this can inhibit the clotting mechanism and increase your chance of unnecessary bleeding. The small amount in most multivitamins is not harmful.

Before Surgery Picture – Be sure to take a before picture and one every month on your surgery anniversary date. This will help you with motivation and the realization that you are changing!

Measure your neck, upper arms, chest, waist, hips and thighs. A weight chart is provided within this booklet.

Have a support system in place – Your family and friends should be aware of the changes you will have to make in your eating and in exercise. Make sure your family and friends will be supportive and give you the encouragement you will need.

Packing

Pack your suitcase a few days prior to your surgery. You will be able to wear a hospital gown, your own night gown or sleep pants. Please bring a robe to wear as you will be walking in the hall after surgery. We recommend that you bring only the necessities to the hospital. A few things that may make your stay more comfortable:

 This booklet – for review

 Bathrobe

 Address/phone book

 Phone and charger

 Lip balm

 Clothes that are easy to slip on and easily removed are best. Consider a comfortable, loose fitting night gown or sleep pants.

 Skid proof house slippers, tennis shoes or slip on rubber soled shoes for walking in the hall after surgery.

 Personal hygiene items (such as a toothbrush, toothpaste, lotion, deodorant, etc.)

 Eyeglasses, contact lens or denture cases

 A jogging suit, slip-on or loose fitting clothes are suggested for the trip home


Also Bring:

 Blood donation card (if you have one)

 A list of medications, vitamins and herbal supplements you are currently taking, include the dosages, frequency (i.e. twice daily) and a list of allergies to food and/or medications.

 If you use CPAP/BiPAP for sleep apnea you must bring your machine to the hospital for use immediately after surgery in the Recovery area.

 A copy of your Living Will/Advanced Medical Directive, if you have one

 A copy of your insurance card

Do not bring:

 Jewelry, credit cards, or large sums of cash need to be left at home or in a safe location outside of the hospital

 Label belongings with your name. If you bring a pillow, use a brightly colored pillowcase for easy identification.

THE NIGHT BEFORE SURGERY

On the night before surgery, do not eat or drink anything after midnight with the exception of approved medications with a sip of water.

Please bathe with a dye and fragrance free soap (Dial or Ivory) the evening before surgery and again the morning of surgery.


Surgery Day


SURGERY DAY

The morning of your surgery:

After weeks of preparation you are ready for surgery. The following material is related to the day of surgery. The actual surgery could take approximately one to three hours depending on the type of procedure. You will be given general anesthesia which means you will be asleep during the entire surgery. After the surgery you will be moved to the recovery area, and then to a private room where you will stay until you are released from the hospital.

Before leaving home:

 Take all medications as instructed with a small sip of water

 Shower with a dye and fragrance free soap as instructed. (i.e. Ivory, Dial, etc.) You may obtain Hibiclens® or an antimicrobial soap from your local drug store to use the day of surgery and post operatively if you wish.

 Brush your teeth. Upon awakening, you may brush your teeth and rinse with water, but do not swallow the water.

 Wear clothes that are loose fitting and easily removed.

 Do not wear make-up. Remove jewelry and do not wear nail polish.

 Avoid using perfumes, deodorants, shaving creams, and any scented lotions.

 Leave jewelry, valuables, and cash at home. You may wear your wedding band if it cannot be removed.

 You may wear dentures, contacts, glasses, or hearing aids to the hospital, but you will need to remove them just prior to surgery. Bring a case with your name on it to hold your eyeglasses, contacts, hearing aids and/or dentures

 Bring CPAP/BiPAP machine (if you use one for sleep apnea) to be used in the Recovery

Room after surgery. You MUST have this piece of equipment when you arrive at the hospital.

Bring your medications you take at home, or a current list of the medications and how you take them. After this information is verified, give them to a family member for safe keeping.

Reporting to the hospital:

 You will receive a phone call the day prior to surgery requesting that you report approximately one and a half to two hours prior to your scheduled surgery start time. They will tell you an exact time.

 DAY SURGERY PATIENTS (Generally Monday surgeries): Valet parking is available free of charge for Day Surgery patients. Parking in Garage A costs $1 per hour with a maximum daily rate of $10. Report to the “Day Surgery Center” located on the first floor

(second level), just inside the UMMC entrance via the elevator on the left. (a map is located in this booklet under the “Forms/Charts/Maps/Misc.” tab)


 SHORT STAY SURGERY PATIENTS (Generally Tuesday surgeries): If you are asked to report to the Short Stay Surgery area prior to your surgery, you may bring your parking ticket with you and have it validated when you register. Report to the “Short Stay

Surgery” area located on the first floor (second level). Go inside the UMMC entrance and use the elevator straight ahead in the middle of the two staircases. The SSS area is to the left of the first floor elevators to the Adult Hospital. (a map is located in this booklet under the

“Forms/Charts/Maps/Misc.” tab)

 Discounted parking permits for patients (one vehicle per patient) can be purchased from

8am – 5pm, Monday – Friday at the UMMC business office, located on the first floor of the main hospital, and on weekends or nights at obstetrics receiving, located in the basement level of Wiser Hospital. For questions, please speak to the Day Surgery Desk or the

Concierge Desk (located on the first floor next to the Day Surgery Elevator).

 You should have a friend or family member (support person) accompany you.

 You should designate one person to be contacted when your surgery has been completed.

 Bring a copy of your Living Will/Advanced Medical Directive if you have one.

Universal Precautions: At UMMC, we work diligently to prevent the spread of germs within the hospital. Germs are found in blood, urine, stool, lung secretions, and wound drainage. Germs can be spread by the hands of patients, visitors, and hospital personnel. Hand washing is the most effective way to prevent the spread of germs. Universal Precautions are used in each hospital room at UMMC to help prevent the spread of germs. Universal precautions may involve the use of gloves, goggles, gowns, or masks. Remember that by observing hand washing procedures and cooperating with universal precautions, you help us to prevent the spread of germs. It is our goal to make your stay at UMMC as short and as pleasant as possible.

Bariatric Surgery & Anesthesia: A member of your anesthesia team will meet with you before surgery. Please inform them if you have ever had any problems with anesthesia. After an examination and discussion of your medical history, the best anesthetic plan will be determined for you.

In general, anesthesia for bariatric surgery is similar to that required for any other surgery; you will be sound asleep and under the care of your anesthesia team throughout. Some patients may require different monitoring or have their anesthesia delivered in slightly different ways.

Blood pressure measurement may be difficult in some obese patients because of limitations in the size of available blood pressure cuffs. On occasion, it is necessary to place a small plastic tube similar to an IV in the artery of the wrist to aid in blood pressure measurement. This is usually done after you are asleep.

All patients undergoing bariatric surgery have a breathing tube placed in their trachea to aid in ventilation during surgery. The majority of patients have this placed after they are asleep. Based on the anesthesiologist’s evaluation, some patients may need to have the tube placed while still awake.

This is done because the anesthesiologist has determined that it would be difficult, impossible, or unsafe to place the breathing tube while asleep. If you are one of the few patients that will require intubation while you are awake, the procedure will be explained to you in detail. You will then


receive medication to sedate you and numb your mouth, tongue, and throat. Although the procedure may be uncomfortable and give you the sensation that you want to cough, the procedure is necessary for your safety.

Occasionally it can be very difficult to place an IV in an obese patient, and you may require a central line. A central line is an IV that is placed into one of the large veins in your neck, and is usually done after you are already asleep. After surgery you will be transported to the Recovery Room where you will remain until you are awake. If you use a CPAP/BiPAP machine when you sleep at night, it is important to bring your device with you to use in the Recovery Room.

Hospital Admitting Procedures: You will need to be driven to the hospital by a friend or family member the morning of surgery. There will be a waiting room available where your support person or people can stay to wait. Updates (surgery start time, updates during surgery, and/or your surgeon may visit after the surgery is completed) will be given to this support person in this waiting room. If your designated person plans to leave the waiting room in the Surgery Area, please have them supply a cell phone number to the clerk at check in, so that we may contact that person if needed.

Immediately prior to surgery: You will be escorted to a curtain area and allowed one visitor to stay with you until your surgery time. Here you will be asked to change into a surgical gown (all clothing will need to be removed) and a hair covering (bouffant cap). Your clothes will be placed into a “patient belonging” bag and may be given to your support person. Your IV will be started and you may be given a medication to help with nausea. Once the OR (Operating Room) is ready, your support person will be escorted to the waiting area and you will be taken to the OR.

Surgery: You will be transported on a stretcher to the OR. Once you enter the OR the staff will do everything they can to make you feel secure. You will be placed on a special bariatric table and inflatable cuffs may be placed on your arms and/or legs. A strap may be placed across your legs to prevent fall. You will be kept warm with blankets at this time. Many people will be in the OR working quickly to start your surgery on time.

Before, during, and after surgery you will receive medications through an IV in your arm. You will receive medications that will make you drowsy. Once you are asleep, a tube (endotracheal or breathing tube) will be placed in your trachea by a member of the anesthesia team. This will allow him/her to place you on a ventilator to assist your breathing during surgery. A small plastic nasogastric or orogastric (NG or OG) tube may be placed through your nose or mouth into your stomach and a urinary catheter may be inserted into your bladder. At the same time the member of the surgery/anesthesiology team will connect you to monitoring devices to ensure your safety.

The surgical procedure normally lasts about one to three hours. However, the length of surgery is dependent upon the difficulty and/or the number of extra procedures necessary (if any). Seldom is the length of surgery related to the patient’s immediate condition in the operating room, and may go longer without undue side effects or risks.

Recovery Room: After your surgery is completed, you will be taken to the Recovery Room and will remain there until awake, approximately 45 minutes to an hour. Most patients have very little memory about their stay in the Recovery Room. It is common for patients to be drowsy and


sometimes confused when they first wake up.

You will be closely monitored by the nurses who will monitor your blood pressure, pulse, and breathing, and encourage you to cough and do deep breathing frequently to keep your lungs clear after surgery. You will be expected to use a deep breathing exercise machine (incentive spirometry) beginning on the day of your surgery. You may also receive oxygen by a mask or small tube placed under your nose and may receive medications as needed for pain.

You will not be able to eat or drink anything immediately after surgery. By the next day, you will be able to take medications by mouth as well as start drinking fluids.

After surgery, they will wait until you are fully awake and ready to move to the floor. You will stay in a room that is equipped with a television and an area for one person to stay overnight on a fold out small bed/lounge chair.

The staff will closely monitor your vital signs, encourage deep breathing, encourage ambulation as you recover, and report any changes to your surgeon for your length of stay until discharge from the hospital.

Post-Op

Pain Control – You may feel pain where the incisions were made or from the body positioning during surgery. Some patients can experience neck and shoulder pain after laparoscopy. Your comfort is very important to your medical team. Although you may experience some discomfort after surgery, keeping your pain under control is necessary for your recovery. When you are comfortable you are better able to take part in activities such as walking, deep breathing, and coughing. These activities are imperative in order to recover more quickly.

Please remember that you will not be bothering the staff if you ask for pain medicine. Your nurses and doctors will ask you to choose a way that you can describe your pain. This is done to ensure uniform language. Two helpful ways to describe pain include the number/faces scale (0-10 scale,

0=no pain, 10=worst pain possible) or you can use words (none, mild, moderate, severe, and worst.)

No matter which form of pain control you receive (IV, IM injection, liquid, or pill), here are some pointers to help make you comfortable:

1. Tell your nurses and physician if you are having pain, particularly if it keeps you from moving, taking deep breaths, and generally feeling comfortable.

2. Everyone is different. Keeping your nurses informed about how you feel will assist them in taking care of you.

3. Plan ahead for pain. If you are comfortable lying down, you may still need pain medication to get up and walk around.

4. Keep ahead of the pain. Don’t wait for the pain to be at its worst before you ask for pain medicine. Pain medication works best when used to prevent pain.


5. The risk of becoming addicted to pain medicine is very low when it is used for a specific medical purpose such as surgery.

Nausea – You may experience nausea post-operatively and it is very important to stay on top of this. You will have anti-nausea medication prescribed for you. It is very important to let your nurse know if you experience nausea so that it can be addressed with medication.

Exercises that speed up your recovery

To enhance recovery your nurse will instruct you in coughing and deep breathing, turning in bed, and exercising your feet and legs. You will be shown how to use an incentive spirometer to help you expand your lungs. Coughing and deep breathing are important so that you will loosen any secretions that may be in your throat or lungs and to help prevent pneumonia. Deep breathing also increases circulation and promotes elimination of anesthesia.

The proper way to deep breathe and cough is to follow these steps:

1. Inhale as deeply as you can

2. Hold your breath for two seconds

3. Exhale completely

4. Repeat the above steps three times

5. Inhale deeply again

6. Then cough. The cough should come from the abdomen, not from your throat. Hold your pillow on your abdomen for support.

It is important to use your incentive spirometer consistently. A good tip is to use it during commercials while watching television or set your timer on your smartphone as a reminder.

Exercising your feet and legs is important for promoting good circulation. The proper way to exercise your feet and legs is to follow these steps:

1. Push your toes toward the end of the bed (as in pressing down on a gas pedal.)

2. Pull your toes toward the head of your bed, and then relax

3. Circle each ankle to the right, then to the left

4. Repeat three times

It is important to begin ambulation the evening of surgery unless otherwise specified.

Ambulation early on is a critical part of recovery and helps to reduce the risk of clots in the legs or pneumonia.

These exercises should be repeated at least once every hour after surgery, but it is also a good idea to practice these exercises before surgery. The breathing exercises may help to increase lung function and agility.


Discharge Plan

You will sign discharge papers prior to leaving the hospital. Please check your room before leaving to be sure that no personal items are left behind. You will need a family member or friend to drive you home when you are discharged (no driving until your post-op follow up appointment with

us). You will be escorted by an ambassador or member of the nursing staff to the front doors where your family or friend can meet you for pick up. If you live more than two hours away you may plan to stay an additional one to two days in the immediate area. A number of hotels are located nearby (a list is included in this booklet under the “Forms/Charts/Maps/Misc.” tab).

Everyone is different. However, you and your doctor will determine when you are ready to leave.

Prior to discharge from the hospital, you need to make arrangements to have some adult assistance at home at least until your post op follow up visit with us. You will need someone to drive you to and from our office for your post-op follow up visit (7-10 days after surgery). This appointment should be made prior to your discharge from the hospital or shortly after you arrive at home. Please contact us if you have not received a follow up appointment within 24 hours of arriving home at

601-984-1285.


At Home


~ Your Journey Begins After Surgery ~

Specific Recovery Instructions

You may experience many things once you are home recovering. When you get home, plan on taking things easy. Your body is still recovering from the stresses of major surgery and weight loss occurring during the recovery period. Your activity will be restricted to no strenuous activity for three to six weeks after the surgery. You may walk and perform light household duties as tolerated upon your return home. Usually, frequent walks of short duration are better tolerated than one or two long walks that go to or past the point of fatigue. Increase the distance that you walk gradually.

By the time of your six weeks office visit, you should be walking regularly two or more miles unless you have specific problems with your weight bearing joints. In that case, water exercises are recommended. Your surgeon will inform you when you can begin water exercises and other strenuous exercises, i.e. resistance exercises or any form of weight lifting.

Laparoscopic patients should be able to return to all activities within a shorter timeframe than open procedure patients. You may be tired, weak, nauseated, or have vomiting the first few weeks after surgery. Keep up your fluid intake with small, frequent sips as necessary.

Resume traveling short distances as soon as you feel strong enough to make the trip. Do not drive a motor vehicle until after your first follow-up appointment. Do not drive while you are taking prescription pain medication. They can hinder your reaction time and decision making.

The first several weeks after your surgery you may feel weak and tire easily after activity. However, try to be as active as possible. Plan to walk as much as you can tolerate without becoming too tired.

Start with short walks, increasing the distance each day. The more physically active you are, the more recovery is enhanced and the more energy you will have. Continue walking at least four times daily, increasing your walk to two miles by the sixth week. Be consistent and continue to do the exercises that will speed your recovery.

Avoid sitting and standing without moving for long periods. Change positions frequently while sitting, and walk around in lieu of standing still. These strategies can help prevent blood clots from forming in your legs. Avoid lifting anything heavier than 10-20 pounds, do not do any push or pull motions (i.e., vacuuming) during the first six weeks and do not do any heavy work for the first three months.

Remember that most patients may feel tired, less energetic, and sore for several weeks following surgery. Your body is now adjusting to losing weight, as well as healing surgical wounds.

Personal Hygiene

Most patients like to have someone home with them the first few days after surgery for moral and physical support. Because of the nature of abdominal surgery, you may need some help with


toileting. Flushable baby wipes tend to be gentler for personal hygiene, as well as a peri-bottle. You can use a small sports-top water bottle. A long sponge stick can also be very helpful.

Wound Care

Your wounds need minimal care. The sutures used will dissolve, so there is no need to remove any stitches. You may notice a purple hue around your incision sites. This is called Dermabond® surgical glue that takes the place of surface stitches and often lessens the appearance of a scar. This purple coloration of skin is normal.

It is important to keep the wound clean and dry to promote faster healing. You may shower, but pat dry the incision area. After about three weeks, the incision is usually ready for immersion. Ask for the official “go ahead” before you take a bath or submerse in a swimming pool. As you feel stronger, you may enjoy a swim or a soak in the tub.

Despite the greatest care, any wound can become infected. If your wound becomes reddened, swollen, leaks pus, has red streaks, has yellow/green, purulent and/or odorous drainage, feels increasingly sore or you have a fever above 100.5ºF, you must report to us right away. Please do not use any antibiotic ointment or other occlusive ointment on your incisions without instruction from our team.


Urgent Symptoms

Even though we do not anticipate any serious problems, some symptoms that you may experience need to be addressed immediately. If you experience any of these symptoms, contact your surgeon right away:

 Fever (100.5ºF or above)

 Redness, swelling, increased pain and/or pus-like drainage from your wound

 Chest pain and/or shortness of breath

 Nausea and/or vomiting that lasts more than 12 hours

 Pain, redness, and/or swelling in your legs

 Urine output less than four times in 24 hours

 Pain that is unrelieved by pain medication

 Feelings that something is wrong or “impending doom”

For URGENT Symptoms:

Monday-Friday 8:00am-4:30pm:

Call the Weight Management Program at

601-984-1285

Afterhours, weekends, and holidays:

Call UMMC at 601-984-1000 and ask to page

Dr. Ken Vick or the On-Call Surgery Resident

Normal Symptoms

Swelling and bruising – moderate swelling and bruising are normal after any surgery. Severe swelling and bruising may indicate bleeding or possible infection.

Discomfort and pain – mild to moderate discomfort or pain is normal after any surgery. If the pain becomes severe and is not relieved by pain medication, please contact us.

Numbness – small sensory nerves to the skin surface are occasionally cut when the incision is made or interrupted by undermining of the skin during surgery. The sensation in those areas normally does gradually return within two to three months (sometimes longer) as the nerve endings heal spontaneously. Be especially careful not to burn yourself when applying heating pads to the area that may have some post-surgery numbness.

Itching – itching and occasional shooting electrical sensations within the skin frequently occur as the nerve endings heal. These symptoms are common during the recovery period. Ice, skin moisturizers, vitamin E oil, and massage are often helpful.


Redness of scars – all new scars are red, dark pink, or purple. The scars take about a year to fade.

We recommend that you protect your scars from the sun for a year after your surgery. Even through a bathing suit, a good deal of sunlight can reach the skin and cause damage. Wear a sunscreen with a skin-protection factor (SPF) of at least 30 when out in sunny weather.

DEHYDRATION

Dehydration may occur if you do not drink enough fluid. Symptoms include fatigue, dark colored urine, dizziness, fainting, nausea, low back pain (a constant dull ache across the back), and a whitish coating on the tongue. Blood work should be done if these symptoms persist, in order to establish the severity of dehydration. Dehydration may lead to bladder and kidney infections. Contact us if you believe that you may be dehydrated. In some cases you need to be admitted to the hospital so that fluids can be administered. To prevent dehydration:

 Take a sports bottle with you everywhere so you can sip water all day.

 Drink at least 48-64oz of fluid per day.

Increase this amount if you are sweating

 Avoid beverages containing caffeine – they are diuretic and can dehydrate

NAUSEA



 you. Unsweetened herbal iced tea is okay to use.

If you have difficulty drinking because of nausea, suck on ice chips.

Note: If your urine is dark and your mouth is dry, you are not drinking enough.

Nausea can be related to insufficient chewing, fullness, sensitivity to odors, pain medication, not eating, post-nasal drip, and/or dehydration. Nausea that occurs in the first days after surgery can be suppressed with medications called anti-emetics. In some cases, nausea can be so severe that it prevents patients from taking in adequate amounts of liquids. Persistent vomiting can lead to dehydration, electrolyte imbalance, and vitamin deficiencies. If this happens, call us or return to the hospital; you may need to receive intravenous fluids.

Odors can sometimes be overwhelming after surgery. Many former patients have found that putting a few drops of peppermint essential oil on a handkerchief or cotton ball can be very helpful if you are dry heaving. Avoid perfumes and scented lotions. If food odors bother you, try to have someone else prepare your meals or prepare bland foods.

 Learn to recognize when you are full.

This may not happen immediately, but by eating very slowly, it will become easier.

 Should you have difficulty drinking because of nausea, you may want to try peppermint tea, fennel tea,


decaffeinated green tea, or water with lemon (hot or cold).

 Sucking on a cinnamon stick can help alleviate nausea.

 If you believe that your pain medication is the cause of your nausea, please call to have the prescription changed.

 Stay hydrated – fluids should be continuously sipped all day long to prevent dehydration. You need a minimum of one and a half to two liters of fluids per day. Increase this amount by 20% if you are sweating.

 Take your nausea medication as prescribed.

VOMITING

Vomiting is often times associated with eating inappropriately. It is very difficult to gauge in the beginning how little food will satisfy your hunger. Chew your food well, keep it moist, and eat only half of what you anticipate eating. If there is still space and you still feel hungry, then you may always eat a little more. Chances are that you are going to feel full with very little. A couple of teaspoons may be all that you can take in at one time.

If you overeat after surgery, you may vomit. Sometimes fullness occurs quickly. Allow yourself time to recognize the feeling of fullness. Typically with Roux-en-Y Gastric Bypass, a profound feeling of satisfaction follows the fullness within a few minutes, and makes further eating a matter of indifference.

These may cause vomiting:

 Eating too fast

 Not chewing food properly

 Eating food that is too dry

 Eating too much food at once

 Eating solid foods too soon after surgery

 Drinking with a straw

 Lying down after a meal

 Eating foods that do not agree with you

 Drinking liquids either with meals or right after meals


If you begin vomiting that continues throughout the day, stop eating solid foods, and sip clear liquids (clear and very diluted sugar free juice, broth, and herbal tea.) Should you have difficulty swallowing foods or keeping foods down, please call. Vomiting may indicate that the stomach pouch is blocked. If vomiting continues for more than 24 hours, contact us because vomiting can lead to severe dehydration, a situation that needs to be taken seriously.

BOWEL HABITS

It is normal for you to have one to three bowel movements of soft stool per day. It may be foul smelling and associated with flatulence (gas). Most of these changes resolve as your body heals and you adapt to changes. Please call if you have persistent diarrhea.

After restrictive surgery, the amount of food consumed is greatly reduced, and the quantity of fiber or roughage, consumed may be much smaller. Correspondingly, the amount of bowel movements will be diminished, causing less frequent bowel activity and sometimes constipation. If this becomes a problem, a stool softener may be indicated to avoid rectal difficulties. MiraLAX® is generally our recommendation.

Keeping your bowel movement regular:

 Remember that your stools may be soft until you eat more solid food.

 Lactose intolerance and high fat intake are generally the culprits of loose stool and diarrhea.

Avoid all high fat foods and discontinue the use of all cow milk products. Yogurt is okay.

 If cramping and loose stools (more than three per day) or constipation persist for more than two days, please call us.

Flatulence (gas): Everyone has gas in the digestive tract. Bariatric patients may have a shortened bowel, thus causing gas to be more odorous and expelled more forcefully. Gas comes from two main sources: swallowed air and normal breakdown of certain foods by harmless bacteria that are naturally present in the large intestines. Many higher carbohydrate foods cause gas. The foods that are known to cause more gas are beans, vegetables, some fruits, whole grains/wheat and bran, cow’s milk and cow’s milk products, foods containing sorbitol, and dietetic products. Here are some helpful hints:

 Eat your meals more slowly, chewing food thoroughly.

 Lactose intolerance is generally the culprit of gas, too. You may wish to discontinue the use of all cow’s milk products for a while. Yogurt is okay.

 Avoid chewing gum and hard candy.

 Avoid drinking with a straw

 Eliminate carbonated beverages (a requirement after surgery).

 Remedies include lactobacillus acidophilus, natural chlorophyll and simethicone.


HERNIA

You may notice a bulge under the skin of your abdomen. What you are noticing are the bowels that are not being contained in the abdomen because of a weakness in the abdominal wall at the site of the incision. You may feel pain when you lift a heavy object, cough, or strain during urination or during bowel movements. The pain may be sharp and immediate. In some cases the pain may be a dull ache that gets worse toward the end of the day or after standing for a long period of time.

Minimize the risk of developing a hernia by avoiding heavy lifting for three months after surgery. If you notice that you may have a hernia, please call for a consultation. Surgery is the only way to fix a hernia. If the hernia comes out and will not go back in when you lie down, and is associated with severe pain and vomiting, it can result in an emergency. Call our office or your primary care physician on an emergency basis.

THRUSH/YEAST

You may notice that after surgery you have a white, cottage cheese-like coating on your tongue. The tongue could also be very red and inflamed. Most likely you have thrush, which is a yeast overgrowth in your mouth. Oftentimes this is caused by large amounts of antibiotics around the time of surgery. Call your primary care physician if you should have an oral infection or a rash on your skin.

Vaginal yeast infections are caused by yeast called Candida albicans. Yeasts are tiny organisms that normally live in small numbers on the skin and inside the vagina. The acidic environment of the vagina helps keep yeast from growing. If the vagina becomes less acidic, too many yeast can grow and cause a vaginal infection. Yeast infections can be very uncomfortable, but are usually not serious. Symptoms include itching and burning of the vagina and around the outside of the vagina

(vulva), a white vaginal discharge that may look like cottage cheese, and swelling. Yeast infections are so common that most women will have one at some time in their lives. Half of all women have more than one yeast infection in their lives. If you have symptoms of a yeast infection, call your primary care physician or your gynecologist. You can help prevent yeast infections by not wearing tight-fitting or synthetic clothing, wearing cotton underwear, not wearing pantyhose every day, and not douching or using feminine hygiene sprays.

ANEMIA

It is recommended that all menstruating women take an iron supplement in order to prevent anemia.

Please contact your primary care physician in order to find out which iron supplement is best for you. Signs of iron deficiency anemia include pallor (paleness of skin), decreased work performance, weakness, difficulty maintaining body temperature, fatigue, dizziness, and shortness of breath. Iron deficiency may also be caused by low vitamin A. Vitamin A helps to mobilize iron from its storage


site, so a deficiency of vitamin A limits the body’s ability to use stored iron. This results in an

“apparent” iron deficiency because hemoglobin levels are low, even though the body can maintain an adequate amount of stored iron.

TRANSIENT HAIR LOSS/SKIN CHANGES

Hair thinning or loss is expected after rapid weight loss. In most cases, it is temporary.

Unfortunately, that does not make it any less disheartening. During the phase of rapid weight loss, calorie intake is much less than the body needs and protein intake is marginal. The body is in a state of starvation. One of the side effects is hair thinning or hair loss. This is a transient effect and resolves when nutrition and weight stabilize. The hair loss usually occurs anywhere from three to nine months after surgery. For the same reason skin texture and appearance may change. It is not uncommon for patients to develop acne or dry skin after surgery. Protein, vitamin, and water intake are also important for healthy skin. You can minimize the loss of hair by taking your multivitamins daily and making sure that you consume your recommended amount of protein per day. Nioxin shampoo has proven helpful for some patients, as well as biotin supplements. We advise patients to avoid hair treatments and permanents – no need to stress your hair from the outside, too.

SCARS

Scars are expected after any surgery. The size of the scars depend on the type of procedure (open versus laparoscopic), the sutures used, and how your body heals. Scars are a fact of life. But there is a way to make them less visible should this be a concern of yours. Once your incision is fully healed, you may start using silicone pads and scar minimizing creams to make the scars look softer, smoother, flatter, and closer to your skin’s natural color. However, you should avoid scar minimizing creams that contain steroids. Keep your scars out of the sunlight to help them heal properly and remember to use sunscreen.

LONG-TERM COMPLICATIONS

The most frequent later complication is weight gain caused by enlargement of the pouch, enlargement of the outlet (Roux-en-Y Bypass), and last, but not least, patient non-compliance.

The development of gallstones is related to the rapid and significant amount of weight loss and therefore is highest in the first six months after surgery. Gallstones are not a complication of surgery, but rather a complication of rapid weight loss. Obese persons have a very high rate of gallstone formation compared to normal weight persons, mainly because of the many diet/weight loss episodes that obese persons undergo. By age 50, nearly 50 percent of morbidly obese women


have developed gallstones. A medication called Actigall (Ursodiol) is given for 6 months postoperatively to minimize the chance of this occurring.

Bowel obstruction caused by a blockage from adhesions (scar tissue) can occur as it can after any abdominal operation, trauma, and intra-abdominal infection.

Stomal ulcer is an acid-peptic ulcer that occurs on or near the anastomosis (connection) between the stomach pouch and the bowel, “the stoma.” (Roux-en-Y Gastric Bypass). An ulcer may also rarely occur in the usual duodenal ulcer position. There is a higher risk of developing ulcers after bariatric surgery. Patients who use non-steroid anti-inflammatory drugs (NSAIDs) such as ibuprofen,

Aleve®, etc., and smokers have an even higher incidence of ulcers. This can be treated with the same kind of medications that are currently so popular for the treatment of duodenal and stomach ulcers, however we ask that you refrain from use of these medications as well as nicotine usage.

Only rarely is surgery required as treatment.

Late stomal stenosis, or narrowing of the outlet of the stomach pouch, is a complication that can occur in Roux-en-Y Gastric Bypass patients. This situation often requires a re-operation.

Iron deficiency anemia is a complication of significance in the long term. It usually occurs in menstruating women who do not take extra iron supplements and is almost always preventable. It is not difficult to treat, but must be recognized in order to be treated. This is one of the important reasons for long term follow-up and compliance with follow up appointments.

SEXUALITY/BIRTH CONTROL/PREGNANCY

You may resume sexual activity when you feel physically and emotionally stable. Women need to use a mechanical form of birth control, as fertility may be increased with weight loss and oral contraceptives may not be fully absorbed. If using oral contraceptives, always use an additional form of birth control.

Many severely obese women are also infertile, because the fatty tissue soaks up the normal hormones and makes some of its own as well. This completely confuses the ovaries and uterus, and causes a lack of ovulation. However, as weight loss occurs, this situation may change quickly. This happens often enough for us to give special warning.

We strongly advise women in the childbearing years to use a very effective form of birth control during the first 18-24 months after surgery. Pregnancy is not advisable during periods of active weight loss because it puts another large demand on the body’s nutritional and metabolic supplies.

This precaution is important in order to avoid damage to the baby and the mother. If you become pregnant, along with extra servings of protein, vitamins, and blood tests, we ask that you arrange for your OB/Gyn to contact us. We will be able to discuss specific information about your surgery, so the specialists can have a collaboration of their efforts.


Successful pregnancies are possible after weight loss surgery. Consult with you obstetrician prior to conceiving to be absolutely sure that your body is ready. If the obstetrician feels it is safe, you may start planning a pregnancy after weight loss stabilizes. We suggest 18-24 months after surgery, once your weight is stabilized, to begin discussing pregnancy.



Long-term

Success


~ Long-Term Success ~

FOLLOW UP

Follow-up is extremely important after bariatric surgery. Read this surgery guide carefully before going to office visits, so that you can have some questions ready for the staff. Lifelong follow-up appointments are expected and need to be scheduled with the office staff. Of course, visits with other specialists are encouraged, should you have any problems. The normal schedule for follow-up visits are approximately 7-10 days, six weeks, three months, six months , nine months, twelve months, eighteen months, twenty four months post-surgery and then annually thereafter. Longterm, the surgeon expects to see you once a year. It is probably a good idea to have your annual physical exam scheduled with your primary care physician before your annual surgical appointment.

The primary care physician can have testing done which can then be reviewed with you by your surgeon.

EXPECTED WEIGHT LOSS

The greatest weight loss will occur in the first three months after Roux-en-Y Gastric Bypass surgery.

Most patients experience a fairly rapid weight loss in the first three to six months following surgery.

Most studies suggest that patients lose an average of 65-80 percent (sometimes more) of excess weight the first 12-18 months with maintenance of excess weight loss greater than 75 percent after 5 years.

With Roux-en-Y Gastric Bypass, after 18 months the stomach pouch has stretched slightly to hold a little more food. This stabilizes the weight loss. At this time, it is critical to adhere to the low fat, low sugar diet, and exercise recommendations outlined in this guide to maintain your weight loss.

Weight loss for restrictive procedures such as the Adjustable Gastric Band is much less than that of the Malabsorptive procedures such as the Roux-en-Y Gastric Bypass. The Adjustable Gastric Band procedure does not require stomach cutting and stapling or gastrointestinal re-routing to bypass normal digestion. As the name indicates, the band is adjustable. So if the rate of weight loss is not acceptable, the band can be adjusted through an epidermal port (a small reservoir which is placed under the skin of the abdomen.) It is designed so that it can be inflated or deflated at any time after the surgery to assist progression of weight loss. Most studies suggest that patients lose an average of

50-75 percent (sometimes more) of excess weight in 18-24 months with maintenance of excess weight loss greater than 50 percent after five years. The rate of weight loss for gastric sleeve falls in the middle of RYGB and LAGB.

After five to 15 years post-surgery, studies have shown that most patients keep off at least half of their excess weight. Thus, there may be some weight regain. However, patients are much less obese even long after surgery than before surgery.


NOTE: Research has shown that weight loss surgery patients who exercise three or more times per week for a minimum of 30 minutes lose an additional 12 percent of their excess weight in six months compared to their cohorts who do not exercise as strenuously.


Lifestyle Changes

You cannot lose weight without having a healthy lifestyle. Here are some simple things you can do right now to keep yourself and your friends and family on track:

 Get rid of all the junk food in your house (no, the kids don’t need junk food either).

Restock your cupboards with healthy snacks your whole family can enjoy.

 Have allotted time for fun and outside play.

 Have a daily schedule to ease the chaos and decrease some of the stress in your life. This may mean taking some activities out of your schedule or your kid’ activities. Often, we plan to do more than we have time for.

 Cut the time you and your family spend each day watching TV or using the computer.

Spend more time doing more active things such as playing outside with the kids or going for a walk.

 Plan your social life with activities that do not include food, such as going out dancing or spending a day in the park rather than going out to dinner.

Maintaining the Weight

The goal of surgery is not to allow you to eat more, but to allow you to lose weight with the fewest possible restrictions to your diet. It is not automatic, and your behavior after surgery plays a very large part in your outcome. How you use the tool will affect your weight loss. Please follow the recommended guideline in this guide. Your window of weight loss is anywhere from 12 to 18 months. With exercise you can control the weight loss and may see weight loss for up to 24 months.

By eating only at mealtime and only until you feel full, your daily food intake will be greatly decreased enough to provide weight loss. The weight loss will vary from week to week and may plateau for days and up to two weeks at a time. If you are at a plateau during the first six months post-op that lasts longer than two weeks, please call the office. Gradually, the rate of weight loss will decrease and your weight will stabilize. Your responsibility is to avoid snacking and grazing

(continuous nibbling); choose healthy foods; be active and exercise daily; and nurture the process of recovery from obesity. Participate in group meetings and continue to use this guide to help you through the surgery process. Be sure to keep your regular office appointments so that your weight loss can be maximized and your health monitored.

Again, surgery is a tool, something to help you accomplish your health goals. There will be adjustments that you will need to make. Our staff will be glad to guide, support, and motivate you.

We know that you can do it!

The Eight Rules of Weight Loss

There are eight rules that we have found helpful for weight loss success. All successful patients who have had bariatric surgery have these things in common.


1.

Consumption of an adequate amount of liquid, preferably water, is crucial. You should consume a minimum of one and a half to two liters of liquid each day. This can only be done slowly, sipping fluids throughout the day. Never drink more than two ounces of liquid over a 10 to 15 minute period and this amount is even further reduced in the early post-op phase. On very hot or humid days, or when exercising, you should drink additional glasses of water. This is necessary in order to prevent dehydration.

2.

Avoid “grazing” on small amounts of food throughout the day. This may sabotage your weight loss and result in the inability to lose an adequate amount of weight. Follow the dietary suggestions of meals and nutritious snacks.

3.

The primary source of nutrition should be protein. Between 70 to 75 percent of all calories consumed should be protein based (eggs, fish, meat, etc.). Carbohydrates (vegetables, fruit, and bread) should make up only 10 to 20 percent, and fats (butter, cheese, etc.) only 5 to 15 percent of the calories that you eat. A diet consisting of 600 to 800 calories and 60 to 70 grams of protein should be the goal for the first six months; however each individual should follow their specific daily calorie/protein goal set forth by the registered dietician.

4.

Avoid drinking liquids when eating solid foods. Liquids should be avoided for a period of

30 minutes before and 30 minutes after eating meals.

5.

Avoid foods and liquids which contain sugar or high fructose corn syrup. Not only will they slow down your weight loss, but they may make you sick! Sugar may cause dumping syndrome in surgical patients. Dumping, in short, is when sugars go directly from your stomach into the small intestine causing heart palpitations, nausea, abdominal pain, and diarrhea.

6.

Stop eating and drinking when you begin to feel full. Listen to your body’s signals. Do not look at the food that is left on your plate. Overfilling your stomach pouch will cause your stomach/pouch to stretch and may prevent weight loss success, causing long term problems and complications. Overfilling will also cause discomfort and can lead to nausea with associated vomiting.

7.

It is essential that, within the first six weeks after surgery, you begin a regular exercise program. Our research indicated that this will increase your overall weight loss by 12 percent in six months.

8.

Attend support group meetings and workshops. They will help you stay focused and motivated and help you work through the changes that weight loss brings. Plus, you might just make a few new friends.

Reconstructive/Plastic Surgery

Patients who lose more than 100 pounds may also face another challenge – excess skin. This condition is especially noticeable on the face, upper arms, breast, and abdomen. Skin folds under the arms, breasts, abdomen, and legs can cause chaffing, as well as cutaneous bacterial and yeast infections. Reconstructive surgery is indicated for these patients.


Reconstructive surgery can help give patients more self-confidence and a better body image. It is not unusual that patients who have reconstructive surgery will also lose several pounds of excess skin. This results in better fitting clothing. Reconstructive surgery to improve your appearance should be delayed until your weight loss has stabilized for at least one year. We will be glad to recommend an experienced surgeon.

Commitment to Long-Term Follow-up

Follow-up is very important. Bariatric surgery is a major operation that changes the way you eat and the way your stomach and intestines function. Although we understand many of these changes that occur in the first few years after surgery, we do not know the lifelong effects of weight loss on your nutrition and body. We are concerned that there may be some nutritional deficiencies that occur long-term and if not checked or treated may result in further problems. You will need periodic blood counts and blood tests for vitamin B-12, folate levels, and iron levels. Initially we will obtain these test every three to six months or as needed, and then every one to two years or as needed.

Follow-up is also important because of the effects of weight loss. We know that one-third of patients may develop a hernia in the abdominal incision that may require surgery. Some patients will develop loose skin around the waist and arms that may need to be removed. In addition, follow-up is important to stay in touch with your caregivers and support groups. Initially you will be seen for follow-up in our clinic multiple times the first year and a half, in addition to keeping your regular appointments with your primary care doctor. We will then need to see you annually.

You play a critical role in the long-term success of bariatric surgery. You, along with the bariatric team, must commit to honesty, responsibility, and cooperation. You will need to:

 Make a personal commitment to improve your health.

 Discuss your health history with your surgeon.

 Discuss any questions or concerns you have.

 Learn all you can about the surgery before making a decision.

 Follow all instructions on preparing for surgery.

 Commit to following all instructions described in this Bariatric Booklet. You must also commit to the change in nutrition, activity, and post-surgery care.

We want your surgery and weight loss to be just as successful as you do! One of the things you can do to stay healthy after your surgery is to keep your follow-up appointments with your medical and nutritional support team.

A serious complication of surgery is usually preventable malnutrition. After the initial high-risk period following surgery, the long-term risks of bariatric surgery are quite low. However, sometimes devastating micronutrient and vitamin deficiencies can occur. Most studies suggest that these illnesses can be prevented by good nutrition and careful attention to aggressive vitamin and mineral supplementation.


Many successful patients will stop taking their vitamins when they think that they have returned to

“normal.” However, it is very important that patients commit to long-term follow-up so that their physician can perform yearly monitoring of their blood levels to detect any nutrition deficiencies and continue to encourage patients to take their vitamins.

Another important part of successful weight loss is staying active! Every single day, take advantage of your new opportunity to take control of your weight by getting some exercise.

Permanent Lifestyle Changes

1.

Take daily chewable multivitamin – we generally recommend 2 chewable Flintstones

Complete® (See section under Nutrition labeled DIET GUIDELINES: VITAMINS

& MINERALS)

2.

Take daily chewable calcium citrate supplements (See section under Nutrition labeled

DIET GUIDELINES: VITAMINS & MINERALS)

3.

Drink 48-64 ounces of sugar-free and calorie-free liquid daily.

4.

Eat 60-80 grams of protein daily; eat protein-rich foods first in meals.

5.

Return to the office for long-term follow-up.

6.

Eat three small portioned meals and between meal nutrition packed snacks.

7.

Eat slowly, chew food thoroughly, and remove all distractions when eating.

8.

Do not take aspirin, Aleve, Ibuprofen, Goody’s, BC, Mobic, Stanback powders, or NSAIDs.

9.

Eat only nutritional snacks; avoid unnecessary snacking or grazing.

10.

Exercise (walking, biking, swimming, treadmill, etc.) for one hour daily.

11.

Consume no sugar sweetened food or beverage of any kind ever again.

12.

Do not take large pills or capsules ever again.

13.

Contact our office immediately for any problems related to your bariatric surgery.

14.

No Carbonated Drinks

15.

No Caffeine

16.

No Smoking


Medications

REQUIRED MEDICATIONS:

1.

Actigall (Ursodiol): Prescription Medication a.

Dose: The physician will determine your dosage. b.

Notes: For patients who still have their gallbladder, this is a medication that is used to prevent gallstones after surgery. This medication is to be taken twice daily. It is best to take this medication with food or milk. You should not use antacids that contain aluminum while taking Actigall. c.

Notify your nurse or your physician if severe stomach pain, especially on the right upper side, severe stomach pain, especially on the right upper side, severe nausea and vomiting, diarrhea, constipation, gas or bloating, metallic taste in mouth, itching, dry skin, or hair thinning occurs after taking this medication.

2.

Multivitamins/Calcium: Over the Counter a.

Dose: Take an approved chewable multivitamin. We generally recommend 2

Flintstones Complete® (they are easy to find). Remember, you need to take vitamins for the rest of your life. b.

Notes: Numerous multivitamin brands are acceptable. Select one that includes iron in the list of vitamins and minerals supplied in the Nutrition section, especially if you are a menstruating woman. If they cause nausea, stop them for a few days, and then restart by taking one a day. Also remember to take your Calcium supplement twice daily. You should space out your multivitamin and calcium supplement as

these should not be taken together. You may take an over the counter B12 supplement.

3.

Omeprazole (Prilosec): Prescription/Over the Counter a.

Dose: The physician will determine your dosage b.

Notes: These medications widely used to treat ulcers, heartburn, and other conditions caused by too much acid in the stomach. They work by reducing the secretion of stomach acid. The production of stomach acid is reduced within 30 minutes to an hour after taking one dose. c.

Omeprazole is well tolerated and has few side effects. Contact your physician if abdominal pain, diarrhea, headache, nausea and vomiting occur. Do not take with alcohol or any other medicines. d.

If taking Carafate (Sucralfate), do not take these medications as the same time. They should be spaced by 1 to 2 hours.


OPTIONAL MEDICATIONS:

1.

Polyethylene Glycol (MiraLAX): Over the Counter a) Dose: 1 capful mixed in 8 oz of water. b) Notes: Relieves constipation by bringing water into the bowels to help the digestive system cause a bowel movement. This water also softens the stool, making it easier to pass.

2.

Promethazine (Phenergan): Prescription Medication a) Dose: Suppository or tablet (crushed) every 6 hours as needed for nausea b) Notes: Promethazine is effective in relieving nausea and vomiting. It produces marked sedation (sleepiness) in most patients. In general, side effects are minimal. It is more effective than diphenhydramine in treating nausea.

3.

Odansetron (Zofran): Prescription Medication a) Dose: One disintegrating tablet every 8 hours for nausea b) Notes: This generally does not make you drowsy like Phenergan and is sometimes a better first choice for nausea.

4. Sucralfate (Carafate): Prescription Medication a) Dose: Take 2 teaspoons (10 ml) every 8 hours up to 3 times daily to relieve the discomfort

of indigestion.

b) Notes: Do not take Omeprazole or any other PPI at the same time. They should be spaced

by 1 to 2 hours.

5. Simethicone (Gas X): Over the Counter a) Dose: Take every 6 hours as needed for gas and bloating.

b) Notes: You may use chewable tablets, dissolvable strips or drops.


WEIGHT LOSS SUPPORT GROUPS

Support Groups

The Department of Bariatric Surgery/Weight Management will provide you with Support Group meetings monthly.

These will last approximately 60 minutes and consist of:

 Support from other Bariatric Patients (new and established patients)

 Discussions from health care professionals that will cover several pertinent topics

 Open discussion with other patients

UMMC Bariatric Support Group is the third Monday of each month, unless otherwise stated.

Meetings begin at 7:00 pm at the Grant’s Ferry location. These meetings offer informative speakers as well as an opportunity to meet with other bariatric patients.

RESOURCES

Websites www.ummchealth.com/weight www.ObesityHelp.com www.bariatricpal.com

Organizations

American Obesity Association (www.obesity.org)

American Society for Metabolic and Bariatric Surgery (www.asmbs.org)

*** Please join our Facebook page ***

University of Mississippi Medical Center Bariatric & Weight Management http://www.facebook.com/ummcbariatric


Activity

&

Exercise


EVERYDAY ACTIVITIES

Bathing: You may shower when you first return home. Position yourself to avoid direct spray of water on your incisions. Clean your incisions with mild soap and warm water and pat dry. Do not pick at the glue used to close your incisions.

Walking: Take short walks about every 2 hours, increasing your distance each day. Do not walk on uneven surfaces such as lawns or gravel. Do not over extend yourself. Start out slow, then overtime increase in time and distance.

Restricted Activities: Until you see your doctor for your first post-surgery check-up, do not attempt any of the following:

Returning to work

Driving a car

Participation in sports

Engaging in sex

Taking a tub bath

Lifting over 10 pounds

Vacuuming or doing heavy housework


EXERCISE

FIRST STEPS

You will need to avoid strenuous activity until released by your physician. You may walk and perform light household duties as tolerated upon your return home. Usually frequent walks of short duration are better tolerated than one or two long walks that go to or past the point of fatigue. Increase the distance that you walk gradually. By the time you are six weeks postsurgery, you should be walking regularly unless you have specific problems with your weight bearing joints. In the latter case, water exercise is recommended. You can start water activities about four weeks after surgery.

STARTING AN EXERCISE PROGRAM

You are already aware that bariatric surgery is merely a tool to weight loss. To receive the maximum benefits from your surgery, you must incorporate exercise into your daily routine.

Patients report exercise as a key factor in their ability to maintain their weight. If you want to feel good, build muscle strength and muscle mass, you must exercise. Exercise helps you lose weight and stimulates the production of “the good feeling” hormones called endorphins.

Exercise also helps to keep your bone tissue dense and strong, increases strength and balance, boosts energy, and improves quality of life. Research has shown that patients who exercise three or more times per week for a minimum of 30 minutes lost an additional 12 percent of their excess weight in six months. The mistake that many patients make is that they do not exercise until they feel “all recovered” or try to start exercising when they realize they are not on course to reach their goal weight. Patients who work hard on exercise early after surgery find it very rewarding. As the weight falls off the capacity for exercise improves dramatically, with significant improvements on a week-by-week basis. Do not cheat your body of this important aspect of weight loss. Make a long-term commitment to exercising!

Yes, exercise is hard. It is difficult to stay motivated. It is not always easy to find an exercise that you like. Look into forms of exercise that you may not have tried before. Explore yoga, dancing, roller skating, T’ai Chi, etc. Exercise does not mean that you have to be in a gym for several hours a day. If it has been some time since you have exercised regularly, then it is best to start slowly. Before surgery, begin exercising 10 minutes twice a day, and then add five minutes a week until you can stay active for 45 minutes per day. This may assist in making exercise a permanent part of your daily routine after surgery. Just being active is not enough to lose weight and keep it off.

There are three forms of exercise: Cardiovascular, Strength Building, and Flexibility.

Cardiovascular exercise is also known as aerobic exercise. Aerobic exercise uses your large muscles and can be continued for long periods. For example: walking, jogging, swimming, and cycling are aerobic activities. These types of exercises drive your body to use oxygen more efficiently and deliver maximum benefits to your heart, lungs, and circulatory system. A simple


definition of cardiovascular exercise is any exercise that raises your heart rate to a level where you can still talk, but you start to sweat a little. At least 20 minutes of cardiovascular exercise three or four days a week should be enough to maintain a good fitness level. Any movement is good, even house or yard work. But if your goal is to lose weight, you will need to do some form of cardiovascular exercise for five or more days a week for 30 to 45 minutes or longer.

Strength-building exercises are known as anaerobic exercise. Anaerobic exercise does not have cardiovascular benefits, but it makes your muscles and bones stronger. Strength-building exercises require short, intense effort. People who lift weights or use any type of equipment that requires weights are doing strength-building exercise. Strength-building exercise makes your muscles and bones stronger and increases your metabolism. Strength exercises also make your muscles larger. Your muscles use calories for energy even when your body is at rest. By increasing your muscle mass you are burning more calories all of the time. If you strength train regularly, you will find that your body looks leaner and you will lose fat. Strength-building exercises should be performed two to three times a week for best results. Always warm up your muscles for five to ten minutes before you begin lifting any type of weight or before performing any resistance exercises.

Flexibility exercises, which are also anaerobic, tone your muscles through stretching and can prevent muscle and joint problems later in life.

A well balanced exercise program should include some type of exercise from each category.


EXERCISE: TIPS FOR GETTING STARTED

~Your surgeon will tell you when it is safe for you to start exercising~

Guidelines for exercise

1. Do not do anything that causes you pain. If you are experiencing pain, decrease the amount of time you are exercising or change to a different type of exercise. If the pain continues, talk to your doctor.

2. Exercise a minimum of 30 minutes per day. When you first start exercising, you may not be able to do all 30 minutes at once. Try breaking your exercise into three 10 minute sessions.

Then gradually increase your time until you can exercise for 30 minutes at a time.

3. Always have a warm-up and cool-down period. These periods should last about 5 minutes before and after you exercise. You should do the same activity that you are planning to do for exercise, but at a slower rate.

4. Always be safe. If you are exercising alone, make sure that a friend or family member knows where you are going and about what time you should be back. Always wear a medical identification bracelet if you have a health problem such allergies, diabetes, or high blood pressure (you can find these bracelets at your local drug store). Make sure that you have comfortable shoes that do not rub your feet and that have good cushioning for your joints.

Wear loose, comfortable, clothing that will keep you cool in the summer and warm in the winter.

5. When you first start exercising, start off slowly. Over a period of several months, you should be able to gradually increase both the intensity and duration of your exercise.

A sample walking program

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9 and after

Warm-up

Time (Walk slowly)

Fast Walk

Time (Walk briskly)

5 minutes 5 minutes

5 minutes 8 minutes

5 minutes

5 minutes

11 minutes

14 minutes

5 minutes 17 minutes

5 minutes 20 minutes

5 minutes

5 minutes

5 minutes

23 minutes

26 minutes

30 minutes

Cool-down

Time (Walk slowly)

5 minutes

5 minutes

5 minutes

5 minutes

5 minutes

5 minutes

5 minutes

5 minutes

5 minutes

Total Time

15 minutes

18 minutes

21 minutes

24 minutes

27 minutes

30 minutes

33 minutes

36 minutes

40 minutes

LOSS OF BONE AND MUSCLE MASS

When the body is in a state of stress and trying to combat starvation and malnutrition, it hoards its precious fat until any other usable fuel has been burned. Practically, the body will prefer to burn muscle mass before consuming its precious fat. If muscle is not regularly used for exercise (every day) it will be consumed to meet the body’s energy needs. This concept is similar with calcium storage. Calcium is stored in the bones. Strong bones require calcium, phosphorous, and other nutrients in addition to strength-building exercise. Obese persons tend to have strong bones


because of their obesity. When major, rapid weight loss occurs and adequate mineral supplementation is lacking, osteoporosis is more likely.

Loss of muscle mass and osteoporosis are preventable. Follow the nutritional guidelines in the diet section to maintain optimal nutritional status. In addition, it is very important during active weight loss to exercise vigorously every day. We recommend at least 20 minutes a day of aerobic exercise and strength-building exercises. Devote attention to the upper body strength as well. Many persons find after a few weeks or months of regular exercise, that they actually begin to enjoy it and start to work out even more! Fairly vigorous exercise (for more than half an hour every day) can greatly enhance fat-burning and hasten weight loss.

Seriously obese persons are very strong and powerful – after all, just getting out of bed, you lift more than some people pick up all day long. It would be upsetting to have this muscle power lost, especially when you need it to enjoy life. Save your muscles, keep your energy; eat your protein and

EXERCISE!

COMMON WORKOUT MISTAKES

1.

Not stretching. Stretch before and after aerobic activity. Flexible muscles are far less likely to be pulled than tight ones.

2.

Skipping warm-up. Like stretching, muscles need time to adjust to the demands placed on them. Rather than running on the treadmill, take a few minutes to walk, build up stamina, and then hit your stride.

3.

Skipping cool down. Because of time constraints, many people head straight to the shower after the last repetition. Instead, take a few minutes to lower your heart rate and stretch your muscles again to improve flexibility and help prepare the body for your next workout.

4.

Pretending that you are ready for it all. Yes, we know, you suddenly have this amazing amount of energy and think, you can do anything. That is great; however you must take it slowly in the beginning. Lifting too much weight is the best way to injure yourself.

Increasing the weight slowly and steadily over time is a far more effective and safer way to increase muscle strength.

5.

Being a “weekend warrior.” This mistake is made by trying to fit a week’s worth of exercise into a Saturday afternoon. For weight loss, it is more effective to sustain a moderate routine workout rather than to exercise intensely for only a few minutes.

6.

Acting like you are a camel. Only camels can go for extended periods of time without water. To the rest of us, water is a necessity. Drink plenty of water before, during, and after your workout.

7.

Climbing a steep incline while on the treadmill. What’s the point of cranking up the machine to level 10 if you are just going to support your weight on the side rails? It is much more effective to lower the incline/intensity to the point at which you can maintain good posture while lightly resting your hands on the rails for balance.

8.

Posing, instead of training. Yes, we have all seen them. They look great on the bicycle, because they are not sweating while entertaining a crowd with their stories. They are,


however, not exercising. Don’t become one of them! While it’s true that you don’t want to overdo it, sitting on a bicycle without pedaling won’t burn many calories. You should exercise intensely enough to sweat.

9.

Believing more is better. The most effective way to train is to control the weight – the weight should not control you. When you have to jerk the weight, you are likely to jerk on the muscles and joints, too. This again can lead to strain and injuries, with the muscles of the back being particularly at risk.

10.

Eating for a marathon. If you are trying to watch your liquid calorie intake, watch out for most drinks that advertise high energy. High energy often means high calorie. Drink water and eat high protein foods at your regular meals and snacks.

TEN TRICKS FOR STICKING WITH THE PROGRAM

1.

Look at exercise like a prescription medication. You do not have to like exercise, but you need to do it in order to stay healthy. You also have to do it in order to lose weight. If you have a condition that requires a medication every day, you are going to take this medicine every day. Your body needs exercise every day, so give it what it needs.

2.

Do research. Find out what types of classes are offered. Check out water exercises or gentle yoga classes. You will have a greater likelihood of sticking to an exercise that is tailored to your needs and that you enjoy. Explore new types of exercise. Shop around for a gym that feels right. Visit multiple locations to find one that is right for you.

3.

Change your routine. So you love to walk, but you are bored with it. Sometimes, just changing the direction of your route can make all the difference. Find new places to go walking, change the time of day, or offer to walk your neighbor’s dog.

4.

Find a buddy. Let’s face it; most athletes would not be where they are now without a coach. Why should you be any different? We all need someone to push us and make us go the extra mile, especially when it comes to exercise. Find a friend, a neighbor, or personal trainer to meet you at the gym or at the park.

5.

Find your rhythm. Listen to music, audio books or do meditation while you exercise.

Fifteen minutes on the stationary bike can seem like an eternity without music, but with the right music to occupy your brain, it will not seem so long.

6.

Participate in group sports. You don’t need to join the soccer team, but participating in a group activity increases the chances that you will stick to it. Choose water exercise, yoga, or stretching classes. Choose places and times where other people are actively involved in exercise.

7.

Know what makes you give up the program. If going on vacation throws you off your fitness plan, try incorporating exercise into your vacation. If boredom makes you give up, stay interested by changing types of exercise and times.

8.

Make a schedule. If you don’t put exercise into your daily schedule, most likely you will do everything but exercise. Plan on babysitters, schedule specific activities on specific days, like walking 20 minutes on Monday, yoga class on Tuesday, etc.


9.

Use a workout log. Write down the exercise you do and see how you have improved. Just like weight loss, sometimes one does not see the scale drop, but the inches seem to melt away. It is difficult to keep up with exercise when you do not see the results. Write down the number of repetitions, the weight used, the length of walk, the time, etc.

10.

Stay active between workouts. Walk as much as possible between workouts. Park further away. Always keep a good pair of walking shoes in your car, should you have unexpected time to take a walk.

OVERCOMING EXCUSES NOT TO EXERCISE

1.

I don’t have time. a.

Set a time and stick to it b.

Watch less TV and turn off the computer. c.

Remember that exercise is a stimulant and leads to more productive use of time.

2.

Exercise is work. a.

Work is work, and most people do it 40 hours a week. b.

In order to lose the weight and get the most from surgery, you only need four hours of exercise per week. That is only 2.3 percent of your week. Think about it!

3.

I’m too tired. a.

Exercise improves energy levels throughout the day. b.

Exercise improves the quality of your sleep.

4.

I might fail. a.

Exercise is not a contest! b.

If you stick with the program, you will succeed no matter what! c.

Remember to start slowly and gradually increase your intensity and duration.

5.

I hate exercise. a.

Everyone likes some exercise, you just have not found something you like that fits your schedule – keep searching! b.

Try exercising with a friend. c.

Listen to music or an audio book. At least this way, your focus will not be on the exercise.

THE WALKING WORKOUT

Recent research indicates that walking is one of the best ways to be in charge of your life. Besides the well documented health benefits, the beauty of walking is you can do it at your own pace.

Walking is the first type of exercise that we recommend both before and after surgery. If you are new to exercise and you are also recovering from surgery, you can walk 10 to 20 minutes four or five days a week. As you get stronger, you can increase the distance and speed of your comfort level.

As with any type of exercise, it is still important to warm up, then stretch. Start by walking for just five minutes and then do a few gentle stretches. Your muscles will stretch better if you walk a little first. Ask a fitness professional which stretches are best for you. Your local bookstore may carry


books or audio CDs which offer practical tips for getting the maximum aerobic, strength, postural, and conditioning out of your waking program.

Consistency is probably the most important part of your walking routine. The more time you can devote to walking each day, the healthier you’ll be. Remember that short walks are better than none at all. Health, like life, is a journey. What you need to do is take the first step.

WATER FITNESS

As with regular exercise, you must wait until your physician releases you for water exercise. Once you are released, you may start water exercise (usually about three to six weeks after surgery). Many of our clients like water programs, which are non-weight bearing and gentle on painful joints. Water fitness can improve strength, flexibility, and cardiovascular health, decrease body fat, facilitate rehabilitation after surgery, improve functional living, and even enhance other sports skills. Water classes today offer more versatility than ever, but how do you find the right class for your goal, interests, needs, and skills?

Find the facility first. Look at your local YMCA, community center, health club, and area hospitals.

Look for a well-maintained pool, adequate locker rooms, and lifeguard on duty. Health clubs and the YMCA now offer more specialized classes with different fitness levels. Whichever class you decide to try, start with the lowest level, and use the smallest water weight at first. Many people make the assumption that because the exercise is in the water, they cannot injure themselves.

Most importantly, you should feel comfortable in the environment. If the water is too cold, find the staff to be lacking empathy, or do not feel at ease in your class, then this is not the right class for you. Water exercise, like any other type of exercise, should be done in a relaxing environment. If this is not the case, it is a sign to look for something else.

CHOOSING A PERSONAL TRAINER

There is a reason that movie stars and athletes use personal trainers; working with a personal trainer is one of the fastest, easiest, and most successful ways to improve your health. In fact, personal training has proven so effective that it has spread well beyond the work of the rich and famous.

Today, personal trainers help people of all fitness, social, and economic levels make lifestyle changes that they could not achieve by themselves.

Consider the following things a personal trainer can do:

 Improve your overall fitness. A trainer will monitor and fine tune your program as you go, helping you work your way off plateaus.

 Reach a healthy weight. Remember that surgery is a tool for weight loss. Body fat reduction, weight reduction and management, body shaping, and toning can all be achieved with the aid of a qualified personal trainer who can help you set realistic goals and determine strategies, all while providing the encouragement you need.


 Learn to stick to it. Sticking with well-intentioned plans is one of the biggest challenges that exercisers face. Qualified personal trainers can provide motivation for developing a plan that places a high priority on health and activity. A trainer can help you brainstorm an agenda to overcome your biggest obstacles to exercise.

 Focus on your unique health concerns. Most personal trainers are familiar with the special needs of morbid obesity, arthritis, and diabetes. Your trainer can work with your physician, physical therapist, and the bariatric staff to plan a safe, efficient program that will enable you to reach your health goals.

 Find the right way to work out. You will learn the correct way to use equipment with the appropriate form and technique for cardiovascular work outs and free-weight training.

 Stop wasting time. Get maximum results in minimum time with a program that is specifically designed for you. Workouts that use your strengths and improve on weak points are more efficient and effective.

 Learn new skills. Do you want to learn to skate, golf like a pro, or get ready for an adventure vacation? An individualized program can improve your overall condition and develop the specific skills you need.

 Enhance your mind, body, and spirit. A personal trainer can act as a door to personal growth experiences. Many personal trainers provide mind-body activities, such as Tai Chi sessions.

 Benefit from the buddy system. What could be better than making a commitment to regularly meet with someone who will provide you with individualized attention?

Make sure that your trainer has a college degree in fitness. Ask if your trainer belongs to professional fitness and exercise associations and regularly attends workshops or conventions.

You can find a personal trainer through your local health club or community center.


Nutrition


The University of Mississippi Medical Center

Grants Ferry

Obesity Clinic

Your complete guide for

Nutrition Following

Vertical Gastric Sleeve

Surgery

If you have any questions about your diet before or after the surgery, please contact the Obesity Clinic Dietitian at (601)815-8728.


INTRODUCTION

Vertical gastric sleeve surgery is a useful tool that will help you make the lifestyle changes necessary to lose weight and keep it off. These lifestyle changes include adjusting both the amount of food you eat and types of food you eat. You will also have to keep a food journal daily throughout your

weight loss journey. Regular exercise is also expected as a lifestyle change to allow for greatest results. Because you will be eating very small amounts, you will not be able to get enough of some vitamins, minerals, and other nutrients without careful planning. Surgery should be your final option after multiple unsuccessful attempts at long-term maintained weight loss.

You should have a class or other appointment before your surgery so that the guidelines and information in this booklet are explained to you by a registered dietitian. This booklet is yours to keep and will help you to remember the guidelines and information that the dietitian discusses with you.

It is important for you to keep ALL follow-up appointments after your surgery. At some of these appointments, the registered dietitian will meet with you to discuss your diet. At most of your appointments, you will have lab (blood) work done to make sure that you are not deficient (lacking) in any nutrients. Your healthcare providers will be able to tell by your labs if you are developing a deficiency long before you start feeling symptoms of the deficiency.

In order for you to understand the nutrition guidelines after the surgery, there is some basic information that you must understand first. This booklet covers several different areas:

– Basic Nutrition

– Tips on Limiting Fat

– Changes to the body after surgery

– Diet Guidelines

– Checklist: Are you ready for the surgery?

REMEMBER: It’s a good idea to read over this booklet several times before your surgery. You will probably notice new things each time you read it, and you will be better prepared for the surgery!

Notice: Use of specific product names in this handout is for examples only. The University of

Mississippi Medical Center does not endorse any brand names. If you have questions about a product, please call your doctor or dietitian.


BASIC NUTRITION: NUTRIENTS

Nutrients – These are the things that our body must have in order to live. There are 6 main groups of nutrients in food. These are:

1. Carbohydrates – This group contains starch, sugars, and fiber. Starch and sugar both break down into glucose, the sugar in your blood. Sugar is what your body uses for energy. Too much carbohydrate will raise blood sugars in people who have diabetes or glucose intolerance.

2. Protein – Protein is an important part of the structure of all body cells. Protein is also used to build skin, hair, and muscle in your body. Your body needs a certain amount of protein each day to stay healthy.

3. Fat – Fat is an important nutrient used by the body for many roles. Some of these roles include fat-soluble vitamin absorption, organ protection, body heat insulation, and nerve cell protection.

Because fats are higher in calories, it is important to be mindful of portions.

*Carbohydrates, Proteins, and Fat all contain calories. If you eat more calories than you use in a day, your body will store the extra calories as fat. It does not matter where the extra calories came from – your body will always store the extra as fat.

4.

Vitamins – Vitamins do not provide energy for your body, since they cannot be changed into glucose. This does not mean that vitamins aren’t important! Vitamins play an important part in every chemical process that happens in your body. This means that even though vitamins cannot be changed into energy, they are used by your body to change other nutrients into energy. The vitamins are: A, Thiamin (B1), Riboflavin (B2), Niacin (B3), B6, B12, C, D, E, K, Folate,

Pantothenic acid, and Biotin.

5. Minerals – Like vitamins, minerals do not provide energy for your body, but they do play an important part in your body’s chemical processes. The main difference between minerals and vitamins is that minerals are much smaller and less complex than vitamins. The minerals that your body needs are: Calcium, Phosphorous, Potassium, Sulfur, Sodium, Chloride, Magnesium,

Iron, Zinc, Copper, Manganese, Iodine, and Selenium.

6. Water – Most people need at least 6-8 cups of water each day. If you do not get enough water, you will become dehydrated and feel very tired and weak.


BASIC NUTRITION: FOOD GROUPS

Our foods are divided into food groups according to how much carbohydrate, protein and fat are in each food. You may be familiar with these groups if you are familiar with the Food Guide Pyramid.

These groups and their nutrients are:

• Breads, cereals, starchy vegetables – mostly carbohydrate, some protein, can be low-fat or highfat. (About 80 calories per serving.)

• Fruits – carbohydrate only (About 60 calories per serving)

• Milk – mostly carbohydrate, good amount of protein, can be fat-free or high-fat (About 90 calories per serving if low-fat or fat-free product is used)

• Vegetable – very little carbohydrate, little protein. (About 25 calories per serving)

• Protein (Meat and meat substitutes) – mostly protein, can be low-fat or high-fat

(About 50 calories per ounce, but can be up to 100 calories per ounce if high-fat)

• Fat – fat only (About 45 calories per serving)

What makes up a healthy diet?

A healthy diet is one that includes foods from ALL food groups in amounts that give you the right number of calories with healthy food selections being made. The exact amount of calories is personalized for each individual and will depend on how quickly you are losing weight. The clinic dietitian will work with you to create a weight loss plan both before and after the surgery that is most suitable for you.

Why is “Low-fat” such a big deal?

Sometimes foods in the starch, milk, and protein food groups can be very high in fat. These foods will be much higher in calories when compared to low-fat foods in the same food group. Choosing high-fat foods throughout the day versus low-fat options will result in greater calorie intake and make weight loss either more difficult or unachievable. Unless you read the labels, you may not know which foods are high in fat. It is a good idea to choose products with less than 3 grams of

fat per serving. The following page contains a chart with high-fat food products from each food group.


TIPS FOR LIMTING FAT

You should watch the amount of fat that you are eating so that you can control your total calories.

This means that you have to watch the number of servings of fat that you eat each day. You also have to watch for fat that is “hidden” in your foods. Below is a list of all of your food groups. Each food group has a list of low-fat, medium-fat, and high-fat foods.

FOOD GROUP Low-Fat (choose these most often)

Medium-Fat

(choose these 1-2 times/week)

High-Fat (choose these no more than 1 time/ week)

Breads, Cereals,

Starchy Vegetables

Whole-grain loaf bread, pasta, rice, potato, oatmeal, grits, cream of wheat, lowfat boxed cereal, corn, peas, kidney beans, pinto beans, black beans, pretzels, bagels

Biscuits, cornbread, muffins, low-fat crackers

Yeast rolls, dinner rolls, croissants, highfat crackers, potato chips

Fruits

Vegetables

Milk & yogurt

Proteins (meats & meat substitutes)

All fruits & 100% fruit juices

*You must be careful to avoid added sugar in fruit juice and canned fruits

All vegetables

Skim milk, fat-free yogurt

Chicken, turkey, lean cuts of beef (from round or chuck portions), lean cuts of pork, low-fat hot dogs, turkey bacon, turkey sausage, low-fat cheese, tuna fish packed in water, baked fish, egg whites,

2 % milk

Regular ground beef, mozzarella cheese, ricotta cheese, feta cheese, ribs, whole eggs

Whole milk, regular yogurt

Sausage, salami, bologna, regular hot dogs, American cheese, cheddar cheese, Swiss cheese, bacon egg substitute, shellfish, fat-free cottage cheese, wild game

You should also watch the amount of fat that you add to your foods. You should add no more than

3 teaspoons of fat each day. Each teaspoon is equal to 5 grams of dietary fat. You will start this during stage 3 after surgery.

Common examples of foods in the fat group include the following: margarine, mayonnaise, salad dressing, canola oil, olive oil, peanut butter, cream cheese, sour cream, shortening, butter.


CHANGES AFTER SURGERY: USEFUL TOOLS

Vertical gastric sleeve surgery provides you with tools that will help you make changes in the way you eat. The most obvious of these tools is the change in the size of your stomach. Your new stomach will be shaped like a banana with a volume of roughly 4-6 fluid ounces. This means that you will be full after eating only ½ - ¾ cup of food! The new size of the stomach helps you make changes in portion control, or how much you eat. When you are not eating as much, you are getting fewer calories, so you lose weight.

Another useful tool provided by your vertical gastric sleeve surgery is the dumping syndrome. If you eat concentrated amounts of sugar (like what is in cakes, cookies, and pies), you will have dumping syndrome. The symptoms of dumping syndrome are light-headedness or dizziness, nausea, sweatiness, and diarrhea. You can prevent dumping syndrome by not eating concentrated amounts of sugar. If you do “mess up” and eat something sweet, the dumping syndrome usually makes sure that you don’t want to eat sweets again!

After your surgery, your tastes and food preferences often change. Many of your food cravings will go away. This is another useful tool that the surgery provides.

Make these tools work for you

If you do not follow the diet guidelines in this booklet, you can “lose” all of these useful tools forever. Remember, these tools can only help you make lifestyle changes. They do not guarantee lifestyle changes! Here are eight ways to help you make the tools work for you:

1. Always stop eating or drinking as soon as you feel satisfied. Pushing yourself to eat more will cause the stomach to stretch. You will then have to eat more to feel full, which means you will be eating more calories.

2. Stay away from any foods that you have trouble controlling portions eaten. Those can be called “trigger” foods, and are usually different for each person. Don’t go looking for lowfat/low-sugar versions of your “trigger” foods!

3. Eat slowly! If you are eating fast, you may be satisfied before you can feel it. You may then overeat even though you do not mean to. Remember, you should chew 20-30 times with each bite and should also aim to take 30 minutes to eat each meal!

4. Do not drink with your meals. Drinking may cause you to fill up too quickly. It is also easier to eat too much if you are also drinking with meals. Try not to drink 30-45 minutes before meals, during meals, and 30-45 minutes after meals.

5. Do not drink liquids that have calories, except for milk/protein liquids. Liquids that contain calories include regular soft drinks, Gatorade, Powerade, Kool-Aid, sweet tea, coffee with sugar.

6. Always eat your protein first. This will help prevent a protein deficiency.

7. Take your multi-vitamin and calcium supplements each day. This will help you avoid vitamin and mineral deficiencies.

8. Exercise regularly, 30 minutes a day.


Additional Weight Management Tips

 Avoid emotional eating. If you tend to turn to food to cope with various feelings and emotions, develop a list of other things you can do besides turning to food. We recommend a list of five things other than food such as reading a book, prayer, calling a friend, going for a walk, or taking a relaxing bath for example.

 You MUST keep a daily food journal. Food journaling in a way that allows you to count calories (electronically or manually) is extremely beneficial. Research supports the relationship between food journaling and weight loss where those who food journal tend to lose more weight versus those who do not. Food journaling allows you to grow in knowledge of nutritional content of foods and fluids you consume to aid with long-term weight management by making more informed decisions. Food journaling also helps you hold yourself accountable along with being held accountable by the weight management team.

 Stay away from trigger foods. Trigger foods are any foods or fluids that you have difficulty controlling portions with. If you cannot moderate portions for a particular food or fluid, it is usually best to avoid it altogether. This means not having the food or fluid at home in many cases and also means not purchasing low-fat, light, or fat-free versions of the particular trigger food.

 Plan ahead. Many individuals struggle to appropriately plan ahead throughout the week to allow for healthy, portion-controlled meals on a daily basis. You will have to consider when and what is reasonable for you to do throughout the week and plan accordingly. For example, if you can only cook on Sundays and Wednesdays throughout the week, you may have to batch cook at these times where you prepare large quantities of foods on these days and portion them out for the other days throughout the week.

 Avoid mindless eating. Be intentional about what and how much you are about to eat.

Choose a relaxing, quiet place to eat that allows you to enjoy the different aspects of your meal. DO NOT eat while also doing something else. Often times, being in a distracting, busy environment can result in one consuming excessive portions which could lead to complications. You should be working towards distinguishing between hunger and satisfaction.


CHANGES AFTER SURGERY: COMPLICATIONS

Even though the change in the size of your stomach is a useful tool, it can cause you to have serious problems if you do not plan your eating correctly. These problems are often called complications from the surgery, and can happen very soon after your surgery or a long time after your surgery

(even 3 or more years).

Complications of the Vertical Gastric Sleeve Surgery

Dehydration

Nausea

Vomiting

Dumping Syndrome

Constipation

Protein Deficiency

Vitamin and Mineral Deficiency – most common are iron, calcium, and B12

Following our diet guidelines for portion size, specific foods, and supplements will help

prevent these complications.

Returning to the Obesity Clinic for regular check-ups will also help prevent complications. The clinic dietitian will talk to you about your diet, and your doctor along with your nurse practitioner, will assess your total health. Even if you are getting the amounts recommended, you could still have a deficiency. Remember that vitamin, mineral, and protein deficiencies can be seen in lab work before you have physical symptoms of the deficiency.

A note about lactose intolerance

Another complication of the surgery can be lactose intolerance. This occurs when your body is not able to digest lactose, the natural sugar found in fresh milk. Many people have lactose intolerance even before vertical gastric sleeve surgery. If drinking milk or eating ice cream causes you to have stomach cramps, gas, or diarrhea, then you may have lactose intolerance. Eating yogurt and cheese should not cause the same symptoms, because most of the lactose in yogurt and cheese is usually broken down during processing. Milk and milk products will be a good source of protein for you after the surgery, but if you have lactose intolerance, you must use products that are lactose-free.

Any product with lactose mentioned in the diet guidelines will have an ** beside it.


DIET GUIDELINES: PREVENTING COMPLICATIONS

~ Here’s a list of complications, along with the cause and ways to prevent them ~

Complication

Dehydration

Nausea and

Vomiting

Constipation

Vitamin and

Mineral

Deficiency

Possible Causes

Not enough fluid

Vomiting

Too much food

Eating too fast

Not enough fiber

Dehydration

Protein Deficiency Not enough protein

Not enough vitamins and/or minerals.

Ways to prevent it

Make sure you drink at least 6 cups (48 oz. of liquid each day).

See ways to prevent vomiting.

Follow our guidelines for portion control.

Always stop eating when you feel full.

Make sure that you eat slowly, and chew your food carefully. Your meals should last about

30 minutes.

Vomiting may also be caused by a blockage. If you have more than 1 or 2 vomiting episodes per day, or if you vomit after everything you eat, you should call your doctor immediately!

Try to eat more vegetables, fruits, and whole grains.

Please note: You should limit bran, whole grain bread, and raw fruits and vegetables immediately after the surgery. These foods should be added in slowly so that your stomach can get used to them. Do not take any fiber pills or laxatives without talking to your doctor first.

See ways to prevent dehydration.

Make sure that eat protein at each of your 3 meals. You should get at least 50-60 grams of protein per day. See Diet Guidelines: Protein.

Always take your multi-vitamin and any other supplements recommended by your dietitian or doctor. See Diet Guidelines: Vitamins and

Minerals


DIET GUIDELINES: PROTEIN

You will need 60-70 grams of protein each day. This will start a few days after your surgery, when your doctor advances you to a Full Liquid Diet. You will need to make sure that you get 60 grams of protein each day, even after you are eating solid foods.

How to get your protein

During the first few weeks, you will not be able to eat foods, so you must drink your protein. Even after you start to eat solid foods, you will still have to drink some of your protein to get 60 grams in each day. Below are some high-protein liquids and also some protein supplements. If you choose to use something that is not on this list, you must ask your dietitian or doctor if they are right for you.

Some products may contain things that would be harmful to you after the surgery.

High Protein Liquids:

**Skim milk 8 grams per 8 oz

Soy milk

Lactaid®

Dairyease ®

8 grams per 8 oz

8 grams per 8 oz

8 grams per 8 oz

Optisource® 12 grams per 4 oz

Boost w/Glucose Control® 16 grams per 8 oz

**Premier Protein® 30 grams per 10 oz

EAS Advantage Carb Control® 17 grams per 11 oz

Six Star Ready to Drink® 20 grams per 11 oz

Lean Body On The Go® 25 grams per 14 oz

Muscle Milk® 20 grams per 11 oz

Cytosport Whey Isolate 32 grams per 16.9 oz

*** For all other protein supplements you are interested in, please contact your dietitian for pre-approval ***

Protein powders – can be mixed with any liquid

Beneprotein® 6 grams per 1 scoop (1 ½ Tbsp)

Promod® 5 grams per 1 scoop (1 ½ Tbsp)

3

***Please note that powders can clump up and separate over time. This may interfere with the actual amount of protein you consume daily and can also be very unappealing when drinking small amounts of fluid at one time.***

Other protein supplements to add to liquids or solid foods

No-sugar-added Carnation Instant Breakfast® 4 grams per packet

*Non-fat powdered milk 10.8 grams per ¼ cup

Solid foods

Any 1 oz. of meat 7 grams

2 egg whites 7 grams

¼ cup egg substitute 7 grams

¼ cup non-fat cottage cheese 7 grams

** Contains Lactose

¼ cup tuna fish in water 7grams

1 oz low-fat or fat-free cheese 7 grams

6 oz. low-fat, light yogurt 8 grams


DIET GUIDELINES: VITAMINS AND MINERALS

Multi-vitamin supplements

Because you will not be eating large amounts of food, you will need to take a multi-vitamin supplement with minerals. This supplement will need to be chewable (avoid gummy/ chewy multivitamins), because you will not be able to swallow a whole adult vitamin. Some choices are listed below. If you want to take a different multi-vitamin, ask your doctor or dietitian first.

Centrum Adult Chewable Multivitamin®

Flintstones Complete®

One-A-Day for kids: Scooby-Doo Complete®

One-A-Day for kids: Bugs Bunny Complete®

Centrum children’s chewables: Rugrats Complete®

Centrum Kids®

**There are symbols to look for on the labels of calcium supplements that indicate that an independent laboratory has tested the product. The symbols pictured below from left to right include the Consumer Labs International insignia, the Natural Products Association symbol, the

NSF (NSF International) mark, and the USP (United States Pharmacopeia) verified mark.** https://www.health.ny.gov/diseases/conditions/osteoporosis/calcium_supplements.htm


DIET GUIDELINES: VITAMINS AND MINERALS

Calcium Supplements

Calcium helps to keep your bones strong. It may be difficult to meet daily recommended intake due to the limited amount of food you will be eating daily. Osteoporosis, or weak and brittle bones, is the complication from not getting enough calcium. However, osteoporosis will not show up until you have been deficient in calcium for years.

There are different types of calcium in supplements. Calcium citrate is absorbed more easily than calcium carbonate. A calcium supplement with vitamin D included will help with absorption. Iron decreases how much calcium is absorbed, so we recommend that you do not take your calcium

supplement with your multivitamin.

Take 1200-1500 mg of a chewable calcium supplement daily (2-3 chews per day).

Limit 1 dose to 600 mg (maximum body can absorb at one time).

Separate doses by at least 4 hours.

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

 Caltrate® 600 plus chewables – take 2 per day

 Tums with Calcium – take 2 per day

 Viactiv chews – take 2 per day

***Ask your registered dietitian about any other brands before using as your calcium supplement. ***


DIET GUIDELINES: THE STAGES OF YOUR DIET

After the surgery, your stomach will not be able to hold as much food or liquid as it will eventually.

Your stomach will also have to be gradually introduced to larger amounts of liquid and solid foods slowly. This slow introduction will be done in different stages. The first stages will start in the hospital. The stages of your diet will be:

Stage 1: Clear Liquid

Stage 2: Full Liquid

Stage 3: Pureed

Stage 4: Solid Foods

There are two things that will change in each stage:

• Amount: The portions that we recommend are maximums. You CAN do less if you need to.

• Consistency: You will start off with liquids, move to pureed foods, and then move toward normal solid foods.

There are some things that will not change in each stage. These are summarized in the following rules:

• Always stop eating when you feel satisfied!

• Always eat your protein first. This will help you to get your 60 grams of protein each day.

• Always measure your liquids and foods before you start drinking or eating. This will help you to portion control.

• Avoid high-calorie foods. This will mean avoiding sugar (which will also prevent dumping syndrome) and limiting fat. You can refer to the “Limiting Fat” section of this handout for tips on limiting fat. The eating guidelines that were discussed earlier will not change at any stage of your diet.

DIET GUIDELINES: 24 HOURS PRIOR TO SURGERY

You should consume only clear liquids the day before your surgery. Beginning at midnight the night before your surgery, you should stop drinking anything at all. All clear liquids should be fine with the exception of anything that is red. Review the clear liquids diet information for assistance with appropriate clear liquid fluid selections. If you still have questions, please call the dietitian for clarification.

Serving Conversion Tips:

It will be useful to know serving conversion throughout the different stages of the diet. The tips below will help ensure you consume accurate portions as part of your post-surgery meal plan.

 2 Tablespoons = 1 ounce = 1/8 cup

 4 Tablespoons = 2 ounces = ¼ cup

 8 Tablespoons = 4 ounces = ½ cup

 16 Tablespoons = 8 ounces = 1 cup


DIET GUIDELINES: STAGE 1 CLEAR LIQUIDS

(This diet will last 1-2 days)

Summary: A clear liquid diet focuses on keeping you hydrated.

Foods Allowed: Water, Sugar-free drinks (like Crystal Light®), sugar-free Jell-O, sugar-free popsicles, diet Snapple®, and clear broth (fat-free broths only!). You can also use Splenda®,

NutraSweet®, and Equal®.

Foods Not Allowed: Drinks with sugar (like Gatorade®, Powerade®, Kool-Aid®), drinks with carbonation (anything that fizzes), drinks with caffeine, any solid foods.

Amounts: No more than 1 oz. in 15 minutes. You will need to make sure that your nurse brings you a medicine cup to measure out your liquid.

Estimated daily calorie intake during phase: Minimal

Reminders: You need at least 6 cups of liquid to stay hydrated.

***Remember, 2 tablespoons = 1 ounce. This means it will take 2 hours of drinking 1 once every 15 minutes to drink just one cup of fluid. Since you need 6 cups of fluid each day, this means you will be drinking 1 ounce every 15 minutes for 12 hours each day.***

Sample Menu Clear Liquids:

7:00 AM – 1 fluid ounce Crystal Light®








9:00 AM – 1 fluid ounce water



10:00 AM – 1 fluid ounce diet Snapple®






12:00 PM – 1 fluid ounce water



12:45 PM – 2 tablespoons sugar-free Jell-O®












4:15 PM – 1 fluid ounce diet Snapple®

















DIET GUIDELINES: STAGE 2 FULL LIQUIDS

(This diet will start in the hospital and last 2 weeks after you go home. Your surgeon will tell you when you can advance to the next stage)

Summary: This diet will keep you hydrated and also allow you to get your 60-70 grams of protein each day.

Foods Allowed: All foods on Clear Liquid Diet, fat-free milk, nutrition supplements (like Premier

Protein® or Boost with Glucose Control®), and protein powders mixed with liquids.

Foods Not Allowed: Liquids not allowed on Clear Liquid Diet, whole milk, any other solid foods.

Amounts: No more than 1 oz. in 15 minutes. You may be able to handle 2 oz. every 30 minutes during the second week of stage 2. You should ask your nurse to bring you a medicine cup for measuring in the hospital. You will need to make sure that you have medicine cups or other small measuring tools at home to measure your liquids.

Estimated daily calorie intake during phase: 400-600 calories

Reminders:

 You will need 60-70 grams of protein each day, so drink your protein first!

 You need at least 6 cups (48 fluid ounces) of liquid to stay hydrated.

 Always measure out what you are going to drink before you start drinking.

 Keep a food journal.


Sample Menu Full Liquid:




8:00 AM – 1 fluid ounce Premier Protein®






















2:30 PM – 1 fluid ounce Premier Protein®























DIET GUIDELINES: STAGE 3 PUREED

(This diet will last about 3 weeks. Your surgeon will tell you when you can advance to the next stage)

Summary: This diet will start to get your stomach ready for solid foods. Your surgeon will tell you when it is okay to start this diet. Only try one new food at a time. If a food makes you sick, wait several weeks before you try that food again. Do not eat foods and drink liquids at the same

time!

Foods Allowed: All foods on Clear Liquid Diet, all foods on the Full Liquid diet, egg whites, egg substitute, fat-free cottage cheese, applesauce, any fruits that have been pureed (you can use a blender for this), any vegetables that are pureed, any meats that are pureed, and all baby foods.

Foods Not Allowed: Liquids not allowed on Clear Liquid Diet, whole milk, any solid foods that are not pureed, and sweets.

Amounts: No more than ½ cup in 30 minutes. Build up to 8 oz. or 1 cup in 1 hour over the course of 3 weeks.

Estimated daily calorie intake during phase: 500-800 calories

Reminders:

 You will need 60-70 grams of protein each day, so drink your protein first!

 You need at least 6 cups (48 fluid ounces) of liquid to stay hydrated.

 Do not eat and drink together.

 Always measure out what you are going to drink or eat before you start drinking or eating.

 Keep a food journal.

 Introduce new foods one at a time. This allows you to identify foods you will be more intolerant to after the surgery.

7:00A – ½ cup egg substitute

Sample Menu Pureed:

1:00P – 4 oz water

7:30A – ½ cup applesauce

8:00A – 4 oz diet Snapple®

8:30A – 4 oz diet Snapple®

9:00A – 4 oz water


2:00P – 4 oz Crystal Light®

2:30P – 4 oz Crystal Light®

3:00P – 4 oz Premier Protein®

9:30A – 4 oz water

10:00A – ¼ cup cottage cheese, ¼ cup canned peaches

11:00A – 4 oz Crystal Light®

11:30A – 4 oz Crystal Light®

12:00P – 2 oz pureed chicken, ½ cup mashed potatoes, 1 tsp margarine, 1 tsp fat-free gravy


5:00P – 2 oz pureed fish, ½ cup peas,

1 tsp margarine



7:00P – ½ banana, mashed

8:00P – 4 oz decaf tea

8:30P – 4 oz decaf tea


DIET GUIDELINES: STAGE 4 SOLID FOODS

(This diet will last you the rest of your life!)

Summary: Your doctor will tell you when to start adding in solid foods. Add new foods in one at a time. The most important thing to remember when you start eating solid foods is to chew! You want to turn your food into liquid before you swallow it. This usually means chewing about 30 times.

Foods Allowed: All foods on Clear Liquid Diet, all foods on the Full Liquid diet, egg whites, egg substitute, fat-free cottage cheese, applesauce, all soft fruits, all cooked vegetables, low-fat meats foods, low-fat starches.

Foods Not Allowed: Liquids not allowed on Clear Liquid Diet, whole milk, high-fat meats, high-fat starches, sweets. See Tips on Limiting Fat.

Amounts: No more than 8 oz. or 1 cup in 60 minutes. You can use normal kitchen measuring cups to measuring your foods at this point.

Estimated daily calorie intake during phase: 800-1,000 calories initially until reaching final personalized daily calorie goal.

Reminders: You need at least 6 cups of liquid to stay hydrated.

-You will need 60-70 grams of protein each day, so eat and drink your protein first!

-Do not eat and drink together.

-Always measure out what you are going to drink or eat before you start drinking or eating.

-You will be eating between 4 and 6 times each day. You should make sure that you eat fruits and vegetables each day. You should follow the meal patterns on the next page to make sure your meals are balanced.

***Consumption of more fibrous meats such as chicken and steak will require very small bites and may be more difficult to swallow. You should discuss this with the bariatric team before starting these foods. ***

~You will see a sample menu of a solid food diet on the next page~


SAMPLE MENU: SOLID FOODS

(You should eat at least two vegetables and two fruits each day, along with your proteins

and liquids. This will keep your diet balanced)

Time

6:00 AM

7:00 AM

Food group

Fluid

Protein

Amount (Menu idea)

8 fluid ounces water

½ cup egg substitute

8:00 AM

9:00 AM

10:00 AM

Fruit

Starch

Fat

Fluid

Protein

Fruit

Fluid

½ cup sliced melon

½ cup grits

1 tsp. margarine


¼ cup cottage cheese

½ cup canned peaches

8 fluid ounces Diet Snapple 11:00 AM

12:00 PM

1:00 PM

2:00 PM

Protein

Vegetable

Starch

Fluid

Protein

Starch

Fat

Dairy

Fluid

Protein

Starch

Vegetable

2 ounces baked chicken

½ cup turnip greens

½ cup black-eyed peas

8 fluid ounces un-sweet, decaf tea

¼ cup tuna fish

2 small whole wheat crackers

1 tsp mayonnaise

8 fluid ounces fat-free milk 3:00 PM

4:00 PM

6:00 PM


1 ounce meatball

½ cup spaghetti noodles

½ cup green beans

7:00 PM Fluid 8 fluid ounces water

Note about the above menu: The above menu provides 1,000 calories and 7 cups of fluid. The clinic dietitian will work with you to determine the number of calories you need.

Note about fat: You may have up to 3 servings of fat each day. See Tips for Limiting Fats.

~Your registered dietitian will help you practice meal planning to ensure you get the nutrients you need~


CHECKLIST: ARE YOU READY FOR SURGERY?

You should be able to check off everything on this list. Otherwise, you are not ready for surgery!

� I eat at least 3 times a day (breakfast can be a Slimfast or yogurt shake).

� I eat at about the same time each day.

� I have decreased my portion sizes.

� I eat at least 3 servings of vegetables a day (1 serving = ½ cup).

� I eat at least 2 servings of fruit each day (this does not count the fruit that you are drinking.)

� I have cut in half the amount of fat that I add to foods.

� I am choosing low-fat products more often than I choose high-fat products.

� I only eat sweets, desserts and/or candy one time per week.

� I only eat fried foods one time per month.

� I have increased my activity.

� I have cut out my caffeine drinks I have each day.

� I have cut out my carbonated drinks I have each day.

� I drink at least 64 oz. of water each day.

� I sip all of my drinks slowly.

� I take a multivitamin each day (chewable).

� I have practiced (at least twice) chewing my foods 30 times before swallowing.

� I have practiced (at least twice) not drinking for 30 minutes before, during, or 30 minutes after a meal.

� I have medicine cups at my house to use for measuring after the surgery.

� I have a set of measuring cups to use for measuring after the surgery.

� I have a set of measuring spoons to use for measuring after the surgery.

� I have a liquid measuring cup to use for measuring after the surgery.

� I have an alarm clock, kitchen timer, or stop watch to use to remind myself to drink after surgery.

� I have tasted and purchased a supply of the supplements I will use to get most of my protein after the surgery.

� If I have decided to use fat-free milk, I have purchased something lactose-free as a “back-up” in case I become lactose intolerant.



Pre-Op

&

Long Term

Nutritional Plans


~ Gastric Surgery Pre-Op Meal Plan ~

This pre-op meal plan is to be started 1-2 weeks before surgery to assist with surgical outcomes by shrinking the size of the liver making surgery safer and easier. It will also serve to demonstrate your commitment to make lifestyle changes resulting in successful weight loss.

The following meal plan provides approximately 800 calories and will assist with weight loss before the surgery:

Breakfast: Lean Body On The Go® (any flavor – available at Wal-Mart, Walgreens, or GNC)

OR EAS Advantage Carb Control Ready-To-Drink® (Wal-Mart, Walgreens, or Target)

OR Premier Protein (Sam’s Club, Target)

Lunch: Meat (3-4 ounces) and vegetable (2 servings of non-starchy vegetables or 1 serving of a starchy vegetable)

Meal Replacement: Lean Body On The Go® (any flavor – available at Wal-Mart, Walgreens, or

GNC) OR EAS Advantage Carb Control Ready-To-Drink® (Wal-Mart, Walgreens, or Target) OR

Premier Protein (Sam’s Club, Target)

Dinner: Meat (3-4 ounces) and vegetable (2 servings of non-starchy vegetables or 1 serving of a starchy vegetable)

Notes:

 Drink sugar-free, caffeine-free, non-carbonated beverages between meals for this 2 week pre-op meal plan.

 If picking a starchy vegetable, limit the portion to ½ cup cooked. If picking a non-starchy vegetable, limit the portion to 1 cup cooked or 2 cups raw.

 At this time you should be practicing the following:

1.

Cut foods into small, bite-sized pieces.

2.

Practice chewing thoroughly (30 times is recommended).

3.

Drink liquids 30 minutes before and after meals.

4.

Begin taking a multiple vitamin with iron and a calcium supplement.

5.

Cut out all caffeinated and carbonated beverages.

6.

Try practicing sipping liquids (1 fluid ounce) every 15 minutes at 1 hour interval once daily to help adjust to stages 1 and 2 of your meal plan post-surgery.


~ See the EXCHANGE LIST below for EXAMPLES of foods and portions ~

Exchange Groups:

Meat options:

1 serving = 0 grams of carbohydrate, 7 grams of protein, 0-3 grams of fat, and 35-55 calories.





Beef: Round, sirloin, flank steak, tenderloin, roast (rib, chuck, rump), steak (T-bone, porterhouse, cubed), ground round (at least 90% lean) 1 oz

Pork: Ham, Canadian bacon, tenderloin, center loin chop 1 oz

 Veal: Lean chop, roast 1 oz

 Lamb: Roast, chop, leg 1 oz

 Poultry: Chicken, turkey (dark meat no skin), chicken (white meat with skin) 1 oz

Non-starchy vegetable options:

 Fish: Salmon (fresh or canned), tuna

(canned in water), catfish, oysters, sardines (canned), herring 1 oz

 Wild game: Rabbit, duck, or goose (no skin) 1 oz

 Cheese: Low-fat cottage cheese, partskim ricotta cheese ¼ cup

 Egg: 1 item

 Egg white: 2 items

 Tofu: 3 oz soft/ 2 oz firm

1 serving = 25 calories, 2 grams protein, 5 grams carbohydrate, and 0 grams fat.

Non-starchy vegetables contain 2-3 grams of fiber per serving.

½ cup = 1 serving of cooked vegetables or vegetable juice

1 cup = 1 serving of raw vegetables

 Artichoke

 Cabbage

 Okra







Tomato

Bean sprouts

Eggplant

 Spinach

 Asparagus

 Carrots

 Onions









Summer squash

Beans (green, wax,

Italian)

Cauliflower

Pea pods

 Peppers

 Greens (collard, mustard, turnip)

 Beets

 Rutabaga

 Broccoli

 Kohlrabi

 Brussel sprouts

 Leeks

 Sauerkraut

 Water chestnuts

 Zucchini

 Celery

 Endive

 Escarole

 Cucumber

 Lettuce

 Green onion

 Mushrooms

 Radishes

 Kale


Starchy vegetable options:

1 serving = 80 calories, 3 grams protein, 15 grams carbohydrate, and 0 grams fat.

 Corn: ½ cup

 Peas: ½ cup

 Beans: ½ cup







Potato: ½ cup

Sweet Potato: ½ cup

Butternut squash: ½ cup

~ Example Menus ~

Breakfast and Snack examples:

 Lean Body On The Go®

 EAS Advantage Carb Control Ready-To-Drink®

 Premier Protein Ready-To-Drink®

 Cytosport Whey Isolate®

Lunch/ Dinner/ Supper examples:

 Baked chicken breast (3 ounces) and steamed broccoli (1 cup cooked

 Grilled tilapia (3 ounces) and boiled okra and tomato (1 cup)

 Grilled steak (3 ounces) and baked sweet potato (1/2 cup)

 Pork tenderloin (3 ounces) and steamed squash (1 cup)

 Steamed salmon (3 ounces) and salad (2 cups)

 Turkey burger (3 ounces) and California mixed vegetables (1 cup)

 Steamed tilapia (3 ounces), corn (1/4 cup), and steamed broccoli (1/2 cup)

Fluids to drink between meals: Water, Crystal light, Sugar-free Kool Aid, Sugar-free Hawaiian

Punch, or any other sugar-free, caffeine-free, calorie-free beverage.

You can create as many examples as you wish with the above exchange list foods. Make sure your portions are accurate.


Time

~ Gastric Surgery Long-term 1000 Calorie Meal Plan ~

The following meal plan is developed to assist you with life-long, healthy eating habits to both continue your journey with weight loss and maintain your weight loss after your weight loss goal has been achieved. Each square next to the respective food group represents one serving from that food group. Servings will be distributed throughout the day, and your dietitian will help you plan how to do this. Your meal plan provides a balanced array of nutrients to allow for continued weight loss and for long-term weight maintenance. However, you should still continue taking your supplements per physician recommendations.

1000 Calorie Meal Plan

2 fa

Example Menu

Food Liquid Protein


Time




Example Menu



Time




3 fruit servings

Example Menu



~ See the EXCHANGE LIST below for EXAMPLES of foods and portions ~

Exchange Groups:

Protein:

The following foods contain 45-65 calories, 7 grams of protein, 0 grams of carbohydrate, and

0-3 grams of fat per serving.

 Beef (Select or choice grades): ground round, sirloin, roast, steak

(flank, porterhouse,

T-bone), tenderloin

 Beef jerky, 1ounce

 Block cheese fatfree, 1 ounce

 Chicken, skinless:

(chicken breast, chicken breast tenderloins, Cornish hen), 1 ounce











Cottage cheese fatfree, ¼ cup

Egg substitute, ¼ cup

Egg whites, 2 items

Pork, lean:

(canadian bacon, ham, pork tenderloin, loin chop), 1 ounce

Processed sandwich meats with 0-3 grams fat per ounce:

(chipped beef, ham,



 turkey, turkey ham, turkey kielbasa, turkey pastrami), 1 ounce

 Salmon canned, 1 ounce

Shrimp, 1 ounce

 Tofu light, ½ cup

 Tuna canned in water, ¼ cup

Turkey, lean (90% lean ground turkey, turkey cutlet), 1 ounce

Dairy:

The following foods contain 100 calories, 8 grams of protein 12-15 grams of carbohydrate and 0-5 grams fat per serving.

 Buttermilk low-fat or fat-free, 1 cup

 Evaporated fat-free milk, ½ cup

 Goat’s milk, 1 cup

 Kefir, 1 cup

 Skim milk, 8 fluid ounces

 Soy milk, 1 cup

 Yogurt, 2/3 cup

 Yogurt fat-free, 2/3 cup

 Yogurt light, 1 c


Starch:

The following foods contain 80 calories, 3 grams protein, 15 grams carbohydrate, and 0 grams fat per serving.

 Animal crackers, 8 items

 Baked beans, 1/3 cup

 Baked chips, 15-20 items

 Bagel, ¼ large or ½ small

 Beans, ½ cup

 Biscuit, 1 small

 Bread, 1 slice

 Bread reduced calorie, 2 slices

 Couscous, 1/3 cup cooked

 Cereal, unsweetened, 3/4 cup

 Cereal, sweetened,

½ cup

 Corn, ½ cup

 Cornmeal, 3 tablespoons dry

 English muffin, ½ item

 Flour, 3 tablespoons dry

 French fries, ½ cup

 Granola ¼ cup

 Graham crackers, 1 and ½ sheets

 Grits, ½ cup

 Lima beans, ½ cup

 Lentils, 1/3 cup

 Melba toast, 4 slices

 Millet, 1/3 cup cooked

 Naan Indian bread,

¼ item (8 inches by

2 inches)

 Oatmeal, ½ cup

 Pancake, 1 item at 3 inches across

 Pasta, 1/3 cup cooked

 Peas, ½ cup

 Pita, 1 small

 Popcorn unbuttered, 3 cups

 Potato, ½ cup

 Pretzels, ½ cup

 Quinoa, 1/3 cup cooked

 Raisin bread, 1 slice

 Rice, brown or white, 1/3 cup cooked

 Rice cakes, 2 items at 4 inches across

 Roll, 1 small

 Saltine crackers, 6 items

 Sweet potato, ½ cup

 Tortilla, 1 small

 Waffle, 1 at 4 inches across

 Wheat germ, 3 tablespoons dry

 Wild rice, ½ cup cooked

 Winter squash, ½ cup


Fruit:

The following foods contain 60 calories, 0 grams protein, 15 grams carbohydrate, and 0 grams fat per serving.

 Apple, 1 small

 Apple juice, ½ cup

 Applesauce, ½ cup

 Apricots fresh, 4 whole

 Apricots canned, ½ cup

 Banana, 1 small or

½ large

 Blackberries, ¾ cup

 Blueberries, ¾ cup

 Cherries, 12 items

 Cherries canned, ½ cup

 Cutie orange, 2 small

 Dates, 3 items

 Figs, 2 medium

 Figs dried, 1.5

 Fruit cocktail, ½ cup

 Fruit juice, ½ cup

 Grapefruit, ½ large

 Grape juice, 1/3 cup

 Grapefruit juice, ½ cup

 Grapes, 17 small items

 Honeydew melon, 1 cup cubed

 Kiwi, 1 item

 Mango, ½ cup

 Melon, ¾ cup

 Nectarine, 1 small

 Orange, 1 small

 Orange juice, ½ cup

 Peach, 1 medium

 Pear, ½ large

 Pineapple canned,

½ cup

 Pineapple fresh, ¾ cup

 Plums, 2 items

 Prune juice, 1/3 cup

 Raisins, 2

Tablespoons

 Raspberries, 1 cup

 Strawberries, 1.25 cups

 Tangerines, 1 small

 Watermelon, 1.25 cups


Non-starchy Vegetables:

The following foods contain 25 calories, 2 grams protein, 5 grams carbohydrate, and 0 grams fat per serving. Serving size is ½ cup cooked or 1 cup raw.

 Artichoke

 Artichoke hearts

 Asparagus

 Baby corn

 Bamboo shoots

 Bean sprouts

 Beets

 Bok choy

 Broccoli

 Brussels sprouts

 Cabbage

 Carrots

 Celery

 Collard greens

 Cucumber

 Egg plant

 Green beans

 Green onions

 Leeks

 Mushrooms

 Okra

 Onion

 Pea pods

 Peppers

 Radishes

 Rutabaga

 Salad greens

 Sauerkraut

 Spinach

 String beans

 Summer squash

 Tomato

 Tomato sauce and juice

 Turnip greens

 Water chestnuts

 Watercress

 Zucchini

Fats/Oils:

The following foods contain 45 calories, 0 grams protein, 0 grams carbohydrate, and 5 grams fat per serving. Heart friendlier fats are bolded below.

 Avocado, 2 tablespoons

 Butter, 1 teaspoon

 Canola oil, 1 teaspoon

 Coconut oil, 1 teaspoon

 Cream, 1 teaspoon

 Creamer, 1 teaspoon

 Margarine tub spread, 1 teaspoon

 Mayonnaise, 1-2 teaspoons

 Nuts, 4-8 items

 Almonds

 Cashews

 Hazelnuts

 Pecans

 Walnuts

 Olive oil, 1 teaspoon

 Olives, 4-6 items

 Peanut butter, 2 teaspoons

 Peanut oil, 1 teaspoon

 Salad dressing, 1-2 teaspoons

 Sour cream, 1 teaspoon


Behavior

Modification


~ SURGERY IS NOT A MAGIC CURE FOR WEIGHT PROBLEMS ~

Modification in nutritional intake must be maintained as discussed in nutrition classes.

Water consumption is a must.

Regular physical activity must become a habit.

Modification of previous behaviors is extremely important to your success.

Characteristics of patients that are most successful include:

 Attendance at all follow-up appointments and participation in lifelong maintenance

(maintenance classes and support group meetings).

 Follow nutrition recommendations set forth by the Registered Dietitian. Never skip meals and eat as directed. Focus should be given to protein.

 Increase in physical activity to a moderate or high level. This level of physical activity becomes a daily habit.

 Plan ahead for situations that may increase exposure to “risky” foods.

 Remove foods from the home that may be a temptation. If you can’t have it, don’t have it around.

 Use smaller plates and shallow bowls. This will make you feel as if you are eating more.

 Eat meals in one particular place in the home.

 Ensure you have a strong support system, including family, friends, and co-workers.

 Know your most vulnerable times for “cheating” and plan a defense before temptation strikes (Go for a walk, etc.)

 Get rid of clothes that you no longer fit into.

 Use non-food items as rewards for success, not food.

 Follow the recommendations given for water intake.

 Monitor food intake and exercise

 Journaling (keep a food and exercise diary). You may wish to use an online journal such as www.sparkpeople.com

or www.myfitnesspal.com

o Monitoring your Intake and Activity o Record everything you consume, including snacks o Record the food and the amount o Record immediately after eating o You may wish to include physical activity and feelings/thoughts o Use tools such as pedometers or an exercise tracking app on your phone (i.e.

MapMyWalk)


WHY IS MONITORING SO IMPORTANT?

o Eating and exercise patterns become clear. o You gain more control over eating. o You increase understanding of why you eat the way you do. o You learn more about calorie intake and output. o You become aware of your behaviors and your triggers for overeating.

My Eating Triggers:

Trigger 1:

Trigger 2:

Trigger 3:

Trigger 4:


BEHAVIOR CHAINS

 Include events that lead to certain behaviors such as overeating.

 Triggers can influence behaviors at any point in the behavior chain.

 Identification of triggers can help you to break a link at any point in the behavior chain that would lead to negative behaviors.

BEHAVIOR CHAIN EXAMPLE

Buy cookies

Leave cookies on the counter

Bored and tired on Saturday afternoon

Urge to eat

Go to the kitchen

Eating rapidly until feelings of fullness

Take cookies to the den

Eat cookies while watching

TV

Too full to go to the gym

Feeling guilty like a failure

Restraint weakens further

More eating


BEHAVIOR CHAIN


SUPPORT SYSTEM

Research shows that people with a strong support system have better health outcomes.

Personal relationships represent a source of support when it comes to weight loss efforts. These relationships can also hinder progress when it comes to weight loss.

Ask for the support that you need.

Set limits on unwanted supporters.

Identify those people who will be part of your support system. Write their initials in the column located below.

Relationship Initials

Spouse/significant other

Coworkers/Boss

Friends

Children

Parents

Siblings

Others


Place the initials of each person listed next to the type of support you want from that person. You may list as many support people as you would like for each type of support.

Do not recognize my weight loss efforts. ___________________________________________

Recognize my efforts and praise my success. _________________________________________

Do not tempt me with inappropriate foods by eating in front of me or leaving these foods lying around. _____________________________________________________________________

Do not pressure me to eat inappropriate foods. ______________________________________

Become my exercise partner._____________________________________________________

Provide encouragement to eat appropriately. ________________________________________

Tell me when you notice a change in my attitude and appearance. ________________________

Allow me to choose the foods that I will eat. ________________________________________

Don’t’ make me feel guilty about practicing better health habits. _________________________

Ask for updates on my weight loss progress. ________________________________________


GOAL SETTING

Make sure all goals are realistic:

Ask yourself the following questions:

1.

How much weight do you plan to lose and how do you plan to achieve this?

2.

Do you expect that losing weight will be easy?

3.

What have your past experiences been?

4.

How will your life be different, once you lose weight?

Take Responsibility

It is important to remember that your success ultimately depends upon your actions and behaviors.

You must take responsibility for your own actions.

While others influence your actions, you are the person in control.


Emotional Considerations

Bariatric surgery has both physical and psychological effects. Please do not take these changes lightly. All patients need to consider this before and after surgery. Some of the feelings that you may experience include depression, frustration, anxiety, anger, disappointment, loss, helplessness, euphoria, excitement, joy, and others. Many of these feelings have their foundation in physiological changes. Short-term, the immediate sense of loss of food is often a cause for distress. You may experience rapid reduction in estrogen levels (in women) and/or symptoms of depression, not unlike the ‘baby blues.” Long-term, you may experience changes in body image and further awareness of the social implication of obesity. Bariatric surgery is not a fix for your everyday problems with your spouse, friends, family members, employment, or social life. This surgery may allow you to begin to gain control over one aspect in your life; your weight.

Although you have elected to have weight loss surgery to resolve your obesity, weight loss also changes the lifestyle you knew so well. Even with its problems and tensions, obesity was comfortable, simply because it was known. Now, that life is gone. When the reality of the new situation confronts you, it is natural to begin a longing for your old way of life.

This expresses itself in several stages. These stages include denial, anger, bargaining, depression, and finally, acceptance. People go through these stages differently. It is natural for some patients to experience denial before they have surgery, because they focus on the positive. They seem to understand the risk and complications, but often do not recall hearing about the emotional and physical stress that follows. After surgery is performed, some patients try to bargain for extra space in their stomach pouches. They overeat, experience the painful consequences, and may become angry for getting into this situation. This anger may also surface when other discomforts or complications develop throughout the recovery period. These feelings are difficult to accept or express openly, and depression may follow. Feelings of sadness and crying episodes can be common occurrences. These emotional responses to surgery are completely understandable. They cannot be eliminated, but must be experienced and worked through. Adapting to the changes taking place in your body and your relationship with food can take many months. The final stage of acceptance will occur when you feel at peace with the changes brought about by surgery.

In the past, one of the best methods for coping with life stressors may have been to eat. This method will no longer be useful, especially while your new stomach pouch is at its smallest. One of the keys to success with this surgery is to learn to replace those comforts with healthy activities.

Replacement methods for coping will need to be learned, but this will take time. Try not to sabotage yourself. The experience of such rapid bodily change will likely be accompanied by many emotional ups and downs, depending on your age and sex.

You can do many things to help yourself through the recovery and adjustment period. One of the most important is to recognize and understand the experience of loss. Expect to have ups and downs as the weeks go by. If you feel teary and depressed, have a good cry. Do not suppress your


emotions as they will continue to surface. Use your journal to get you started. Going for a walk and adding other physical activities will help you manage this changing phase of your life.

Your adjustment and acceptance may also be eased by the realization that bariatric surgery, with resultant weight loss, will not solve your personal or relationship problems. You cannot expect a perfect body or a perfect life after the weight loss. In fact, many new problems will develop because of the many new opportunities. These will need to be recognized and addressed. Try to be as positive as possible. As new challenges pop up, recognize them and develop a problem solving approach.

Adjust your expectations. Set realistic goals and stay occupied with work, hobbies, and exercise.

You will also feel more positive if you look your best. Pay attention to hygiene, hairstyle, and clothes. Women may want to experiment with make-up. Take a walk, listen to music, meditate or pray. Do things you always wanted to do. Enjoy the process of rediscovery. Talk to your spouse, family doctor, friends, and other patients for support.

If at any time you feel overwhelmed or otherwise need more assistance, please contact us. We will be glad to refer you to the best possible resolution.

Counseling

Occasionally, personal adjustment or relationship problems will persist after surgery and should be addressed in professional counseling. Emotional counseling may be needed during the phase of adjusting to the new physique and the many changes that follow surgery for clinically severe obesity.

We can recommend counselors who are qualified and experienced in working with people who have had weight reduction surgery. Do not hesitate to request this. Major changes can cause new problems to emerge or old ones to intensify. Experience has shown us that in the period of stress, starvation, and weight loss that occurs following surgery, mild to severe depression is common. You and your support person should look for the signs of depression; persistent sad, anxious or empty mood; loss of interest or pleasure in activities (including sex); restlessness, irritability , or excessive crying; feelings of guilt, worthlessness, helplessness, or hopelessness; changes in sleep patterns; decreased energy; fatigue, “feeling slowed down”; thoughts of death and suicide; difficulty concentrating, remembering, or making decisions; and persistent physical symptoms that do not respond to usual treatment. Effective drug and psychological treatments are available. With treatment, patients can improve and return to normal quickly. Unfortunately, most depressed persons do not recognize their depression. You and your support person need to be aware of the risks of depression in the recovery period and if present, we need to discuss possible treatment.

Professional counseling can be a positive step towards a healthier adjustment.

Family & Friends

You can expect your family and friends to have varying reactions to your surgical experience and the weight loss that follows. Although you hope your loved ones will be supportive and helpful during your ups and downs, this may not always be the case. First of all, your partner or spouse has


become adjusted to you and your obesity. This may result in a resistance to the change, taking the form of disagreement, mood swings, or refusal to support your dietary or exercise regimen. Keep communication channels open; recognize signs of distress in your partner as he/she adjusts to the changes in your body and behavior. These changes will require your partner to relate in new ways to you. This takes time, effort, and patience. If you are experiencing serious ongoing problems in your relationship, some short-term professional counseling may be helpful.

Friends and extended family members also must adjust. Many of them will be positive and genuinely delighted for you. They will stick with you through highs and lows, and relate to you as the lovable, unique person they have grown to appreciate. Others have become secure in your obesity and will have difficulty adjusting to the new body you are developing. If they are also obese, they will be consistently reminded of their continuing problem as you lose weight. They may be quick to point out sagging skin, wrinkles, and other disadvantages. They may envy your courage or physical health. Be open about your appreciation of them and their concerns for you. Recognize their ambivalence and talk with them about their own feelings. And finally, let people pull away if they need to for a while. Some time may need to pass before they sort it out for themselves. Your main responsibility is to care for yourself. Others are responsible for their own feelings and actions.

Hopefully, most close family members and friends will eventually adjust and be supportive of you.

Body Image

Keep in mind that as your body undergoes changes in weight and size, it is likely you may not see your body as other may view it. It takes time for your mind to catch up with what your body is doing. This is similar to the phantom limb phenomenon, where a person who has lost a limb continues to experience pain or feeling from the missing part, and in fact, feels that they still have a limb. As you lose weight, you may actually be surprised when you see your reflection in a store window or mirror. You may not feel like this person is you. It is normal to feel like you are still the same size as you were before, but there are some definite ways to help you work through this.

Here are some examples:

 Take a picture of yourself prior to surgery and every few weeks during your weight loss and compare the changes.

 Try on clothes in a smaller size. You’ll be surprised how quickly you will be changing sizes.

 Have someone point out a person in a public place who is about the same size as you. This helps you have a new frame for reference.

 Take measurements of yourself prior to surgery and every few weeks thereafter and record the results.

 Save an outfit from your pre-op size and try it on every few weeks or whenever you need a lift.

 Accept compliments graciously. Don’t minimize or qualify your weight loss. You have worked hard for the outcome you have been complimented for. Simply say, “thank you.”


The Internet

We greatly encourage support, both before and especially after surgery. Group support and being connected to other patients is vital to a successful surgical result. The Internet is a way to help fill the void between group meetings. We also want to stress the need to maintain a cautious, objective approach to what you read, especially when it does not agree with your own intuition. Try to stay on chat groups recommended by our staff. We urge you to ask us directly if you have any questions about the surgical process. Please feel free to contact our staff with any concerns or questions – we’ll either have the answer or do our best to find it for you.

Stress Eliminators

 Love yourself. Add yourself to your list of “loved ones.” Make taking care of your physical, emotional, social, and physical needs a priority.

 Listen to music. Let the rhythm drain away your stress.

 Breathe deeply. Inhale through your nose and exhale through your mouth slowly and imagine that you are inhaling calmness and exhaling stress.

 Laugh often. Have a giggle. Watch a comedy on TV, listen to music, or read the Sunday funnies. Laughter is the best medicine.

 Speak up for yourself. People who feel they have some control are less subject to stress. If you don’t like the way something is going, say so politely. In order for change to occur, you must take action.

 Let go. Learn the difference between what you can control and what you cannot. Stop worrying about things that are beyond your control. Use that energy to make changes you can. Focus on your own happiness.

 Manage your time. To avoid feeling rushed, plan out how much time you will need to accomplish tasks, to get ready to go places, to travel, to eat, etc.

 Get a hug. Humans are social beings and we often require safe, nurturing physical contact.

 Practice meditation. Spend at least 15 minutes a day relaxing your mind. Sit comfortably, breathe calmly, perhaps listen to some soft music and just clear your mind.

 Treat yourself with compassion. Give yourself permission to make mistakes, to play without feeling guilty, to change your mind, and to set aside time only for you.


Miscellaneous

Information:

Forms, Charts,

Maps, etc.


Hotels near University of Mississippi Medical Center

Cabot Lodge Millsaps

2375 N. State St., Jackson

Americas Best Value Inn Jackson

804 Larson Street, Jackson

Studio 6 Extended Stay Hotel Jackson

881 East River Place, Exit 96, Jackson

Red Roof Inn


Comfort Inn East

614 Monroe Street, Jackson

Best Western Executive Inn


Old Capitol Inn

226 N. State St., Jackson

601 948-8650

601 982-1011

601 355-3599

601 969-5006

601 952-8282

601 969-6555

601 359-9000




Weight Loss Chart

50

52

54

56

40

42

44

48

58

60

32

34

36

38

26

28

30

14

16

18

20

22

24

10

12

6

8

Starting Weight: ________

2

4




Gastric sleeve surgery booklet - University of Mississippi Medical

For Urgent Symptoms:

Monday-Friday 8:00am-4:30pm:

Call The Weight Management Program at

Afterhours, weekends, and holidays:

Call UMMC at 601-984-1000 and ask to page Dr. Ken Vick or the On-Call Surgery

Resident

Welcome

Overview

Weight Loss

Surgery

Operations

Preparation Steps

Surgery Day

At Home

Long-term

Success

Activity

&

Exercise

Nutrition

The University of Mississippi Medical Center

Grants Ferry

Obesity Clinic

Your complete guide for

Nutrition Following

Vertical Gastric Sleeve

Surgery

If you have any questions about your diet before or after the surgery, please contact the Obesity Clinic Dietitian at (601)815-8728.

~You will see a sample menu of a solid food diet on the next page~

Pre-Op

&

Long Term

Nutritional Plans

~ Gastric Surgery Pre-Op Meal Plan ~

~ Example Menus ~

~ Gastric Surgery Long-term 1000 Calorie Meal Plan ~

~ Gastric Surgery Long-term 1200 Calorie Meal Plan ~

~ Gastric Surgery Long-term 1500 Calorie Meal Plan ~

Behavior

Modification

Miscellaneous

Information:

Forms, Charts,

Maps, etc.

Hotels near University of Mississippi Medical Center

Weight Loss Chart

Starting Weight: ________

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