The following are dietary guidelines to help manage patients following gastric bypass surgery.

Patients typically go home on a liquid only meal plan for three weeks. After three weeks they can be advanced to soft foods for the next five to six weeks then gradually converted to regular consistency foods over the next six to nine months.

Included here are suggestions for making this a safe and smooth transition.

• Stage 1: Clear Liquids Only
• Stage 2: Modified Full Liquids
• Vitamins and Minerals
• Stage 3: Soft Foods
• Stage 4: Solid Foods
• How to Make Your Transition to Solid Food a Success

Stage 1: Clear Liquids Only

On the day after surgery, if your swallow study is OK, you will begin sips of water (One ounce each hour while you are awake). Please do not use straws or drink carbonated beverages, as these will cause you to swallow more air/gas, which is poorly tolerated and uncomfortable.

You will start with small amounts of water to avoid overfilling your new stomach and possibly tearing your sutures, and to test that it empties well. If you tolerate water, the next day you will be advanced to the Stage 2 diet that consists of two ounces (two medicine cups) of a high protein nutritionally complete fluid each hour while awake (your choice of Boost, Boost Plus, Choice DM, Skim milk or Carnation Instant Breakfast with Low fat milk).

In addition to the protein liquid, if tolerated you may have two ounces (two medicine cups) of a non-carbonated, non-caffeinated beverage (water, decaf tea, or decaf coffee) every 15 minutes for a total of eight ounces (eight medicine cups) per hour.

Stage 2: Modified Full Liquids

When you go home:

Starting on the day you go home from the hospital, you should drink two ounces (60 ml) of a high protein liquid every hour, on the hour, while you are awake. This must be a nutritionally complete liquid which would pass through a standard strainer.

In addition, if you are thirsty, you can have another two ounes of any non- carbonated, non-caffeinated, liquid every 15 minutes after the hour. This liquid should not be high calorie and can be with or without protein.

Your first priority is to drink enough fluid to prevent dehydration; protein is a secondary priority. You should drink a total of six to eight cups of fluid each day to avoid getting dehydrated. This will take some effort on your part because you may not feel hungry or thirsty at first. For best tolerance, do not use straws, take small sips, and start with room temperature liquids.

Sample Meal Schedule

8 a.m. 2 oz. Boost High Protein
8:15 a.m 2 oz. water (optional)
8:30 a.m 2 oz. beverage (optional)
8:45 a.m. 2 oz. water (optional)

You should choose a high protein drink with no more than 30 grams of sugar and at least 10 grams of protein in an eight-ounce serving.

Protein

Protein is essential to aid in healing and healthy weight loss after surgery. It may also help avoid (but not necessarily prevent) hair loss associated with rapid weight loss. Try to consume at least 45-60 grams of protein per day.

Stage 2: Modified Full Liquids

High-Protein Liquids

• Sugar-free Carnation Instant Breakfast and skim or 1 percent milk
• 8 fl. oz. skim milk with 1/3 cup nonfat dry milk powder (16 total grams of protein)
• Boost High Protein or Ensure High Protein, available at grocery stores
• Whey or soy protein(Carb solutions, Spiru-tein, Designer Whey)
• EAS high protein drinks
• Ensure or Boost (Glucerna or Choice DM) available at grocery stores
• Isopure (available at nutrition specialty stores)

Tip: To increase the protein content of your liquids, add dry milk powder or protein powder.

Low-Calorie Liquids

• Water
• Crystal Light
• Sugar-free Koolaid/Wyler’s drink mix
• Unsweetened decaffeinated tea
• Decaffeinated coffee
• Clear juice diluted 50/50 with water
• Fruit2O
• Broth
• Sugar-free popsicles
• Propel Fitness Water

You will remain on this liquid-only diet for three weeks. Please do not start solid foods until your three-week follow up visit with your surgeon and dietician.

Vitamins and Minerals

Due to the change in size and function of your stomach you will need to take a complete vitamin/mineral supplement every day.

For the first three weeks post op your multivitamin will need to be chewable or liquid. We suggest you start with an adult chewable vitamin such as Centrum Chewable (take one daily) or Children’s Flintstones (take two daily). Thereafter you can change to an adult complete multiple vitamin with minerals (ex: Centrum Advanced Formula, One-A-Day Maximum). You can take generic equivalents but be sure to compare the contents to the recommended vitamins to make sure they have adequate nutrients of at least 18 mg of Iron, 15 mg of Zinc, and 400 mcg of Folic Acid.

After the first month you will need to add a calcium supplement as well. Calcium citrate is the preferred form of calcium since it is better absorbed. You will need to take 1,200 mg of calcium daily. For best absorption take no more than 600 mg of calcium at one time (ex) 600 mg in the a.m. and another 600 mg at bedtime (Citracal, or Bariatric Advantage Chewable Calcium Citrate are acceptable options).

Follow-Up

At your three-week follow up clinic visit you will have a diet advancement class with the program dietitian. In this class you will learn how to successfully incorporate soft solid foods back into your meal plan.

Please do not start solid foods until after your three-week clinic visit!

Stage 3: Soft Foods

During your three-week clinic visit, you will have an hour session with the Nutritionist to explain how to add these new foods. Please do not begin stage 3 on your own before this visit. You will slowly begin adding soft foods to your meal plan over the next six to eight weeks. After your new pouch tolerates the soft foods you can add easily tolerated solid foods to your meal. Remember your new stomach is still healing so treat it gently.

During this phase, you must still focus on high protein foods and avoid foods that are high in fat, sugar, or fiber. You will probably still need to get some of your protein from supplements until you are able to eat enough solid food to meet your nutritional needs, (see the list of protein supplements on page 2).

Getting enough protein in your diet will help you stay healthy and maintain your muscle mass as you lose weight. During meals, eat the high protein foods first; making sure you fit them in. You will be instructed to add only one new food at a time and observe your reaction to it. If you do not tolerate a food well, the problem may be with the food itself, how you prepared it, or the way you consumed it.

Learn to recognize when you are full. Indications of fullness may be a pressure or fullness in the center of your abdomen just below your rib cage or feelings of nausea, regurgitation, or heartburn. Please stop eating when you feel full.

If you have a problem with vomiting, it is most often the result of eating inappropriately and rarely a complication of surgery. Common eating related causes of vomiting are: eating too fast, not chewing food properly, eating too much food at once, eating solid foods too soon after surgery, drinking liquids either with meals or right after meals or eating foods that do not agree with you.

Following are lists of foods allowed and those to be avoided for Stage 3 of your diet progression. The foods on the avoid list are there because most patients don't tolerate them for the first two to three months after surgery. Some patients do tolerate these foods, but it is best to start with the foods on the allowed list. Once you have learned how to eat with your new gastric pouch and have healed from surgery, you can start to add other foods one a time over the next few months. If you follow these suggestions you should transition to solid foods and lose weight successfully!

Recommended Food for Stage 3: Soft Foods

High-Protein Foods

• Eggs (cooked with minimal fat)
• Light/low-fat yogurt
• Low-fat cottage cheese
• Soft fish (baked, broiled, grilled)
• Small or baby shrimp, scallops, crab
• Tuna-fish (fat-free mayo is okay)
• Tender cooked or ground poultry
• Tender cooker or ground beef or pork
• Bean and lentil dishes and soups
• Fat-free refried beans
• Low-fat luncheon meats (turkey, roast beef, sliced thin)
• Shredded or soft low-fat cheeses
• Tofu (soy) mixed in soup or vegetables

Other Foods

• Oatmeal, cream of wheat, grits (thinned)
• Softened cold cereal
• Cooked, soft vegetables
• Soft fruits without skin or canned in natural juices
• Crackers and pretzels chewed well
• Potatoes
• Low-fat soups
• Very dry toast
• Soft lettuce (green leaf or Boston bibb)

Soft Foods to Avoid

Sticky Foods

• Bread (may tolerate if toasted)
• Sticky rice
• Pasta (especially overcooked or large noodles)
• Melted stringy cheese
• Macaroni and cheese
• Peanut butter

Crunchy Foods

• Raw vegetables
• Fruit/vegetable skins
• Nuts
• Popcorn
• Chips
• Coconut
• Iceberg lettuce

Tough or Rubbery Foods

• Tough meat (steak, pork chops, ham, hot dogs)

High-Fat Foods

• Butter, margarine, oils
• Sour cream
• Cream cheese
• Mayonnaise
• Gravy
• Fat back, bacon
• Sausage
• Whole milk
• Salad dressing
• Hard cheeses
• Fried foods
• Bologna, salami
• Chips
• Desserts

Remember, your gastric bypass surgery is a crutch to help you lose weight, but it is not magic. If you overeat or eat mostly high calorie foods or beverages this will reduce the amount of weight you lose. Try to eat protein-dense foods to get the most nutrition from the smaller amount of foods you will be eating.

Stage 4: Solid Foods

Congratulations, you made it to stage 4. It is now 10-12 weeks post surgery and you are ready to progress from soft solids to regular consistency foods. Below you will find some tips on how to transition from soft foods to solid foods. Remember you will begin to try solid foods one at a time, to test your tolerance to them. Do not worry if you cannot tolerate or do not want foods you used to eat. Most people experience some problems at first, especially with meats and breads. Most people find it easier to tolerate seafood first, ground or tender cooked pork and beef next then ground or tender cooked poultry.

Eventually, you will probably be able to eat most of what you were eating before surgery, only in much smaller amounts. A few patients become vegetarians. Overall you should be making healthy food choices including lean meat or vegetable protein, low fat dairy, incorporating fruit and vegetables as you are able; and avoiding empty calorie or “junk” foods as they are typically high in fat and sugar. Remember you must be very careful with foods or beverages high in sugar as they may cause the Dumping Syndrome.

Long term, patients must choose foods with good nutritional value. Each meal should have at least three ounces of protein (such as eggs, cottage cheese, fish, poultry, beans, meat, or tofu). Learn to read food labels and limit fat and sugar intake, choose low fat (five grams or less per serving), low sugar (five grams or less per serving) and lean protein foods. The volume you can tolerate will always be limited so choose foods wisely to avoid filling up on foods with little nutritional value.

How to Make Your Transition to Solid Food a Success

1. Eat slowly and be aware of when you feel full. When you feel full, stop eating! If you continue to eat, you may develop intense chest pain and vomit. You may only be able to eat a few bites of food at a time, eating up to six “meals” a day.
2. Chew, chew, chew! You need to make sure you chew your food very well before you swallow it. This makes it easier to digest and pass from your gastric Pouch into your small intestine.
3. Avoid drinking fluids 30 minutes before and with your meals. If you fill up your small gastric pouch with liquid, you won't have room for your food. Furthermore, the liquids may accelerate passage of the solid food out of the stomach and possibly cause some discomfort. If you need to, take only small sips of liquids while eating, but don’t drink large amounts during meals.
4. Drink enough fluid between meals to meet your fluid requirements. You need six to eight cups of fluid per day to avoid dehydration. You may need to carry a water bottle with you and sip on low/no calorie liquids throughout the day to get enough fluids.
5. Avoid sticky foods. These foods can stick together and form a ball in your gastric pouch, causing nausea and sometimes vomiting. Sticky foods include: white bread, rolls, buns, pasta (especially if overcooked and large pieces), rice that clumps together, macaroni and cheese.
6. Avoid crunchy, hard to digest foods for the first two to three months. Crunchy and hard to digest foods include: raw vegetables, nuts, popcorn, chips, coconut, olives, pickles, tough fruit/vegetable skins (such as apple, cucumber skin), dried fruit, corn, iceberg lettuce.
7. Avoid tough or rubbery meats. Avoid steak, pork chops, ham, and other tough meats for the first few months. Meat is a great source of protein, but it needs to be soft and tender for you to digest it. Try a slow cooking method to make your meat tender, such as a crock-pot, boiling or cooking at a low temperature over a long period of time.
8. Avoid food/beverages high in sugar. High sugar foods can cause "dumping syndrome." After gastric bypass surgery, some people feel light-heated, sweaty or faint soon after consuming sugar.
9. Avoid extremes in the temperature of your foods and beverages. Some patients experience spasms or cramps with very hot or cold food/beverages.
10. Limit high fat foods. These foods may make you feel nauseated. They are also high in calories and will slow down your weight loss. Try changing to a fat-free comparable product. If you don't like the fat-free product, try the light product, which usually has half the fat and calories of the regular product.
11. Only try one new food at a time. This way if you cannot tolerate the food you will know exactly what your new pouch does not like.

The Bariatric Surgery Diet Manual