The Gastric Bypass/ Sleeve Gastrectomy procedures provides a physical and hormonal method to weight reduction.

Restriction: A stomach pouch 20-30ml in volume – about the size of an egg) is created by permanently dividing the stomach. Due to this you will only be able to manage a very small amount of food.

Hunger and appetite: Hunger and appetite can be variable. Some people feel hunger and a desire for food, others do not. It is useful to establish if your hunger is actual physical hunger or emotional hunger. If you lose your appetite, try to have something small and nutritious at least three times per day to keep your mood and energy levels high.

It might be tempting to skip meals if you are not hungry as a way to speed up weight loss but this will result in you becoming malnourished or developing unhelpful eating behaviours, such as grazing throughout the day. If you are struggling to eat all of your meal, eat the protein portion of the meal first, then the vegetable portion followed by the carbohydrates.

You should try to include all types of textures now (remembering to chew really well). If it is a new food, put only a very small amount in your mouth and chew extra well.

Keeping a food (and mood) diary is a helpful way to monitor your food intake and eating pattern. It can help to identify if you are eating regularly or perhaps if you are snacking inappropriately, or eating for emotional reasons rather than for physical hunger. We recommend you keep your own food diary, noting the time you eat, what you eat and in what portions, how hungry you are at the time (on a scale of 1 to 10, where 0 = not hungry at all and 10 = starving) and any
feelings you experience before and after your meals. Use the example in appendix 1 to create your own food diary. It is helpful to bring this with you to your Dietitian appointments so we can explore this together.

Dumping Syndrome: A common consequence of the Gastric Bypass/ Sleeve Gastrectomy is dumping syndrome. This is caused by the stomach contents moving too quickly through the small intestine. Sugar particularly can be absorbed very quickly and cause a rapid swing in your blood sugar level. The symptoms of dumping syndrome are; nausea, sweating, dizziness and diarrhoea. If you have one of these events take a rest and work out what food caused it to prevent it happening again. It is typically caused by high sugar foods. In order to avoid dumping syndrome, avoid very high sugar or fat foods such as chocolates, sweets, cakes, desserts, biscuits and fruit juices. As a guide when looking at food labels, low sugar is less than 5g of sugar per 100g of the food/fluid and low fat is less than 3g of fat per 100g (appendix 2)

NOTE: Yoghurt provides sugar in the form of lactose, so the guide should be 7g sugar per 100g.

Weight loss: Most of the weight loss will occur in the first two years following surgery. However, during the first 6-12 months you will lose weight at a rapid rate (as a guide around 3-6 kg per month). During the second year after surgery it is still possible to lose weight but the more motivation you have to maintain good dietary habits and exercise the more potential you have for weight loss.

Exercise/daily activity: Aim to do some activity every day. Weight loss not only leads to fat loss but protein loss as well. Losing muscle leads to weakness as well as a drop in the metabolic rate, meaning foods are not burned up as quickly. Exercise will help maintain muscle tone, accelerate weight loss and increase confidence. 

People can usually take more exercise following the procedure, perhaps because of easier breathing or less pain in their back/knees.

Try to start with a daily walking plan. Walking is beneficial as it is a weight bearing exercise and can help to protect your bones from osteoporosis. Gradually over time you will be able to build up your stamina and move on to other forms of activity. If walking is difficult try water-based exercises such as swimming or water aerobics, which puts less pressure on the joints.

For a full list of different types of activities, and the national guidelines, visit the NHS Live Well website. For a variety of exercise videos, instructions and exercise plans, visit The NHS Fitness Studio.

The following advice is designed to reduce the likelihood of any complications following surgery. It is therefore very important that you follow this advice closely. There are four stages. Do not be tempted to skip stages or rush things. The advice is designed to help you to get all the nutrients you need while helping the wounds in your digestive system to heal and helping you to recover from surgery.

We recommend that you spend two weeks in each stage. You should be led by your body and how you are feeling. Do not try to copy or follow anyone else who has had a Gastric Bypass/ Sleeve Gastrectomy; everyone is different. If you progress too quickly and then struggle, go back to the previous stage for a few days more, until you feel comfortable to move on to the next stage.

You should aim to be eating ‘normal’ solid textured foods approximately two months after your operation. If you are concerned or begin to struggle with food you previously could manage please contact the Dietitians on 07904 912 441.

How to eat – all stages

This will be the same no matter what stage post surgery you
are:

1. Have no more than a small teaspoon size mouthful or less, it is easier to chew.
2. Chew your mouthful to the consistency of a smooth puree, mixing food with saliva until no lumps or bump sare left and then swallow. Take care to avoid food going to the very back of your mouth as it may be swallowed before you’ve chewed it adequately. Instead keep bringing it to the front of your mouth to check you have chewed to a puree
3. Put your spoon down between each mouthful, wait 60 seconds, to allow time for the food to settle in your stomach, before taking another mouthful
4. If all is well repeat steps 1-3
5. Pain or discomfort usually occur if the food hasn’t been chewed fully or been eaten too quickly
6. Checks – Have you eaten too much? Too fast? Or not chewed fully to a puree?

Immediately after your surgery, once your surgeon has advised that you may sip freely:

Start taking your calcium twice daily, iron once daily, a multivitamin / mineral supplement once daily if prescribed (please note over the counter multivitamins and minerals need to be A-Z complete and taken twice daily) and commence Stage One (as below). Remember tablets must be either dissolvable, liquid or crushed for one month after surgery.

• All drinks should be smooth (no bits or lumps). It is advisable to avoid using a straw to drink for the first few weeks as this can add extra gas which can feel uncomfortable.
• Start with small sips and if these feel comfortable, gradually increase the amount you take in one go. Be careful not to gulp your drinks as this may result in discomfort or vomiting.
• Aim to have a minimum of 2 litres (4 pints) each day to avoid becoming dehydrated. At least 1-1.5 litres of this should be nutritious liquids (see below).
• Avoid all fizzy drinks.
• Whilst it is fine to drink tea, coffee, squash, water, etc., you should make sure these are in addition to any drinks with a nutritional content (see below), not instead of.

Nutritious liquids:

The focus of nutritious liquids is to provide protein and other important nutrients to help with wound healing during the early postoperative phase.

• Skimmed or semi-skimmed milk fortified with skimmed milk powder (1-2 tablespoons per 200ml).
• Nestle Build-Up®, Complan® (or own-brand equivalents) – please take with caution and note that these supplements are only suitable for people with diabetes in the quantities prescribed below.
• Slimfast®, powder or ready-made (with caution as may cause Dumping Syndrome).
• Smooth soup. You should choose protein based soups such as chicken, lentil, ham and pea or fish. Soups needs to be thin and with no lumps (homemade or tinned), fortified with 1-2 tablespoons of skimmed milk powder.
• Smoothies (fruit blended with milk and milk powder). Homemade is best. Avoid shop-bought varieties, which are generally too high in natural sugars and low in protein.

If you would like to enjoy fruit juice on occasion for variety, limit this to a small glass. 100ml of fruit juice provides almost no protein and is therefore not a good choice as a nutritious liquid.

If you feel ready after two weeks, move on to Stage 2.

• It is still important to avoid lumps at this stage. Make sure foods are blended well. Having a hand blender or liquidiser is useful during this stage.
• Texture-wise you are aiming for yoghurt consistency.
• Because portions are small aim to eat 4-6 ‘meals’ a day, a little and often approach. Aim to have about 1-2 tablespoons of the below suggestions every couple of hours during the day.
• Start with 1-2 tablespoons per meal and increase this gradually, if and when this feels comfortable (to no more than 4 tablespoons per meal). Using a ramekin-sized dish may be helpful, you many only tolerate ½ a ramekin dish at this stage
• Chew well and eat slowly. Stop as soon as you feel comfortable.
• Do not drink at meal times. Wait at least 30 minutes before and after you eat before you drink anything.
• Make sure you include a protein source at each meal. Meat, chicken, fish, beans and lentils are all good protein sources. This is important to help wound healing.
• Use milk to blend foods rather than water to increase the nutritional content.

Other items which puree:

Low fat cottage cheese, canned fish, e.g. tuna, pilchards, salmon, mackerel in tomato sauce, silken tofu, all boiled vegetables

When you feel ready after two weeks, move on to Stage 3.

• The texture you are aiming for now is mashed food you could eat with just a fork or spoon. If your fork passes easily through the food it is the right texture. If you have to force your fork through it is probably a stage 4 food and best avoided.
• Lumps are now allowed. It is important you chew all food well and take your time.
• You should reduce the frequency of meals to 3-4 a day (or three meals plus a snack) and avoid eating in between. 
• Try to establish a routine for having three meals a day, even if you are not hungry initially at these times. This will help you to lose weight in the long term.
• Continue to separate drinks from meals.
• You do not need to add any extra milk, fruit juice, Slimfast®, etc., any more as you can now get enough nutrition from other foods.

Meal ideas (1 of the following)

Portions: You will aim for 3-4 tablespoons or a 120ml ramekin, although you may find you only manage ½ ramekin as the food is denser.

Breakfast:

• Low sugar cereal (not muesli) with skimmed / semi-skimmed milk, or porridge
• High protein, low fat or diet yoghurts / fromage frais
• Scrambled eggs with avocado
• Baked beans

Light meals/ lunch ideas:

• Minced meat, chicken, turkey or Quorn®, Cottage pie, shepherd’s pie, Bolognese sauce or chilli con carne
• Soft fish such as sole, plaice, sea bass in sauce / fish pie
• Soft ready meals, e.g. cauliflower cheese, lasagne, macaroni cheese
• Silken tofu and lentils can be used as vegetarian protein sources

With one of the following:

• Soft (overcooked) pasta OR
• Couscous, quinoa, amaranth, millet, barley OR
• Mash potato, sweet potato,inside of a jacket potato OR
• Cauliflower rice OR
• Spiralised butternut squash or courgette

And soft (overcooked) vegetables (tinned or soft).

Evening meal: Same as light meals/ lunch options

Snack ideas:

• High protein / low fat / diet yoghurts, fromage frais
• Soft fruit e.g. blueberries, strawberries or banana
• Low fat cottage cheese / quark
• Sugar-free mousse / custard, low fat rice pudding

Now aim for main meals per day with three components - protein, carbohydrate and the fresh component (vegetable, salad or fruit). Because your portion size is small, protein needs to be the main component.

Proteins: These are needed for the immune system, wound healing, maintenance of muscle tissue and is one of the building blocks for every cell in your body. Rapid weight loss can cause protein loss in addition to fat loss, causing a loss of muscle mass, weakness and reduced immune function. Protein loss can be minimised by focusing on protein in the diet, favouring high protein foods.

Focusing on protein in the diet, favouring high protein foods is very important. High protein foods should make up half of you meal e.g. lean low fat meats, fish, chicken, pork, eggs, pulses (peas, beans and lentils), tofu, nuts and low fat dairy products (cheese, milk, yoghurts, fromage frais). Please see appendix 3 for more information.

Carbohydrates: These are needed to keep your energy levels up, so that protein is not used for energy and is saved for maintaining muscle mass and the immune system. Portion sizes of carbohydrates should be small as they make you feel full quickly, with little space left for protein and vegetables.

Baby new potatoes, sweet potato, wholegrain seeded bread, wholemeal pitta bread, basmati or brown rice, pasta, couscous, quinoa, buckwheat, bulgar wheat, wholegrain breakfast cereals and oats are all good sources of carbohydrates. Try to choose wholegrain varieties where possible. Choosing carbohydrates with a low glycemic index can help with weight management and be part of a balanced healthy diet. See appendix 4 for more information.

Vegetables, salad or fruit: These should be taken with each meal as these contain vital vitamins and minerals and fibre which keep our bodies healthy. They also contain vitamin C which helps your body absorb iron from the iron tablets or multi-vitamins you are taking.

Fats: These are an important part of our diet; they provide the body with energy and with some important vitamins (for example vitamin A and D. They also provide essential fats, which the body is unable to make itself. However, eating too much fat or the wrong balance of fats can be unhealthy. You will need a small amount of fat in your meals but will get sufficient from semi-skimmed milk, low fat cheese, small portions of low fat margarine, low fat mayonnaise, olive oil, nuts and avocado.

Omega-3 fats are a type of polyunsaturated fat and are called ‘essential’ fatty acids as the body cannot make enough. The best sources are oily fish such as salmon, mackerel, herring, sardines and pilchards. Other sources include nuts and seeds e.g. walnuts and pumpkins seed; vegetable oils e.g. rapeseeds and linseed; soya and soya products e.g. beans, milk and tofu; and green leafy vegetables as well as enriched foods including some eggs, milk and yoghurts. Appendix 2 for more information.

You do not need to add any extra liquid calories or additional protein any more. You no longer need to have extra milk, skimmed milk powder, fruit juice or Slimfast®.

You should aim to have a side-plate sized meal which looks similar to the below food plate model:

Meal planning ideas

Breakfast:

• 1 small bowl of breakfast cereal or porridge. You should be able to work up to about ¾ cup of cereal with skimmed or semi-skimmed milk.
• Overnight oats – ¼ teaspoon ground cinnamon/ 50g rolled porridge oats/ 2 tablespoons of natural yoghurt/ 50g mixed berries/ ½ tablespoon of nut butter.
• High protein, low fat or diet yoghurts/ fromage frais with fruit and 1 tablespoon of almonds or other nuts/ seeds or 1 tablespoon of high protein museli.
• 1 egg (boiled, poached, scrambled with milk, baked) with 1 x slice or ham/ chicken or turkey or smoked salmon plus spinach/ tomato/ avocado/ cucumber.
• Egg breakfast muffins cooked with any variety of fresh vegetables, meat or low fat cheese.
• Omelette made with a variety of fresh vegetables, meats or low fat cheese.
• Banana protein pancakes – 2 bananas/ 2 eggs blended with ½ cup almond flour and ½ teaspoon of baking powder add ½ teaspoon of vanilla extract/ cinnamon/ berries to taste (suitable to be frozen).
• Start with ½ a slice toast. You may be able to build up gradually (over several months) towards two slices of toast with topping (see below for ideas).
• Start with half a toasted English muffi n with spread and build up to a whole muffi n (over several months).
• Start with ½ a crumpet with spread and build up to a full crumpet.

Protein based topping ideas for bread:

• Peanut butter with banana, low fat cream cheese with tomatoes, greek yoghurt with fruit (strawberries), almond butter with banana, cottage cheese with fruit (pineapple or blueberries), hummus with cucumber, avocado with egg.

Light meals/ lunch ideas:

• Start with two Ryvitas™/ crispbread with topping (read on for topping ideas). Gradually build up to four Ryvitas™/ crispbread over time.
• Try ½ a small pita pocket with filling/ topping. Gradually build up to a full pita pocket with filling/ topping.
• If you can tolerate Ryvitas™/ crispbread then try ¼ of a toasted sandwich. Build up to ½ then a full toasted sandwich over several weeks and then, if you can tolerate that, try a fresh, untoasted sandwich.
• Use romaine lettuce leaves as a wrap with filling.
• Try a small jacket potato with filling.
• Start with ½ - ¾ cup cooked pasta dish. Build up to 1 cup if the pasta is a penne, shell or spiral shape.
• Start with ½ - ¾ cup cooked rice dish – this measure should include any sauce.
• Mixed Salad with protein e.g. chicken, lean meat, fish, seafood, smoked salmon, ham, light halloumi, feta, light mozzarella, cottage cheese, falafel, egg, beans and lentils, nuts and seeds.
• Frittata/ omelette made with eggs, a variety of fresh vegetables, meats or low fat cheese.
• Soup made with added protein e.g. chicken, fish, meat, beans and lentils, nuts and seeds.

Topping ideas:

• Lean shaved meats – ham, corned beef, chicken or turkey
• Egg or seafood – one egg, tuna, salmon, sardines, prawns, oysters, smoked salmon or crab meat
• Peanut butter
• Avocado
• Light or low fat cheese e.g. cream cheese, halloumi, feta,
• mozzarella, cheddar, cottage cheese
• Salad – lettuce, tomato, cucumber, onion, beetroot etc.
• Chutney, pickles, salsa etc

Main meal/dinner ideas – use a side plate or small dessert bowl to serve your meals: 

Try one of the following:

• Small chicken drumstick OR
• serving spoon of minced meat, chicken, turkey, Quorn® OR
• one serving spoon of stewed or slow cooked meats OR
• a small fish fillet (size of the palm of your hand) OR
• ¼ cup of lentils/ pulses OR
• Silken tofu

with one of the following:

• 1-2 small baby new potatoes OR
• Serving spoons of mashed potato OR
• Serving spoons of sweet potato OR
• the inside of a jacket potato OR
• ¼ cup of cooked pasta OR
• ¼ cup basmati or brown rice OR
• ¼ cup of couscous, quinoa, amaranth, millet, barley,
• buckwheat OR
• ¼ cup cauliflower rice OR
• Serving spoon of spiralised butternut squash or courgette

With one of the following:

• Vegetables, salad or fruit

You could also try one small commercial frozen ready meal that contains less than 500kcals (2000kJ) per serving.

Use moist cooking methods initially by adding sauces to protein foods or slow cooked methods such as stewing or using a slow cooker.

Snack ideas:

Below are some healthy snacks that would be suitable to eat following a Gastric Bypass/ Sleeve Gastrectomy:

• High protein / low fat/ diet yoghurts, fromage frais
• Fruit
• Sugar-free mousse/ custard, low fat rice pudding
• Reduced fat hummus with chopped raw vegetables
• Wholegrain crackers (e.g. Ryvita®) with low fat cream cheese, cottage cheese or peanut or nut butters
• Nuts and seeds
• Rolled ham / chicken slices with raw vegetables inside
• Fish / meat / chicken / lentils / tofu wrapped in lettuce

Try to avoid or limit unhealthy snacks such as crisps, biscuits, cakes and chocolate which are easy to eat but high in calories and low in nutrients. If you have too many of these snacks they may slow your weight loss, reduce vitamin and mineral intake and cause Dumping Syndrome.

You should aim to follow all of the following skills post-surgery for long-term weight maintenance.

Regular eating pattern: a good diet takes planning. Now that you only have a small stomach you can no longer go all day without food and have one big meal when you are hungry. Instead you will need three small meals at regular times in the day with no more than 4-5 hours between meals, even if you do not feel hungry. You should not graze or go for long period without eating. hours between meals. Plan ahead, and you should eat main meals even if you do not feel physically hungry after surgery.

Ensure adequate meal balance: Main meals should be ½ Protein, ¼ Carbohydrates and ¼ Veg/Salad. Remember to always eat the protein first (where possible)

Prioritise protein: aim for half of your plate to be filled with a protein source and any snack to ideally be protein based

Reduce snacking between meals: Aim for no more than 1 snack per day. If you feel hungry between meals, take a drink first to make sure you are not confusing hunger with thirst. If you are genuinely hungry, then opt for a protein containing snack to promote a feeling of fullness for longer (see 'snack ideas')

Eat slowly: Aim for 20-30 minutes with each meal and put a small amount of food in your mouth at a time (size of a thumbnail) and chew this very well (at least 20 times). Remember that normally your stomach churns food up and breaks it down to allow for digestion – the stomach has less space to do this after surgery. Eating at a table without any distractions and putting down cutlery between mouthfuls can
help.

Volume: do not attempt to over-eat, you will find that your intake increases over time but listen to your body and stop eating when you feel comfortable, before you are full. It is important that you recognise the feeling of fullness as it may be different to the feeling before surgery. Often people describe it as a feeling of pressure or pain in the centre of their chest. Ideally you want to stop before you get to this point as overeating may stretch your stomach pouch, cause discomfort and may lead to vomiting.

Do not drink with meals. Wait at least 30 minutes before and after a meal before you have a drink. Make sure you have at least 2 litres of fluid a day. Suitable drink choices include:

• Water
• No-added sugar squash
• Tea and coffee
• Herbal teas
• Up to 1/2 a litre skimmed / semi-skimmed milk per day

Avoid carbonated drinks (lifelong). The gas in the carbonated drinks can cause discomfort following surgery, this includes alcoholic carbonated drinks such as Champagne and beer.

Reduce your intake of meltable calories: Meltable calories are food that are high in fat & sugar. Foods high in sugar/fat can cause Dumping Syndrome and weight re-gain. The symptoms of Dumping Syndrome are diarrhoea, nausea, light-headedness and cramping.

Get out and be active: Aim for 150 minutes of moderateintensity aerobic activity per week OR 10,000 steps per day e.g. walking, water aerobics, bike riding. In addition to aerobic activity, aim to include strengthening activities at least twice per week; for example yoga, pilates, lifting weights or a resistance band. Strength and resistance exercises work all the major muscle groups (upper and lower body, abdominal and back muscles).

Problem foods: Everyone is different after surgery and have differing tolerance levels. The foods listed may cause discomfort at first, but that doesn’t mean you need to avoid them for too long. The aim is to learn a good eating technique, so that you can eat all food textures, so that your nutritional intake is not limited.

If you have a problem with a specific food, don’t avoid it forever, try it again a few weeks later. When you try new foods, try them one at a time to gradually build your confidence with a greater range of foods.

Over-cooking high protein foods such as meat, fish, eggs in a dry environment can make the food tough and difficult to chew.

Nutritional Supplements: You will need to take nutritional supplements post-surgery. A multi- A-Z multivitamin (Forceval once per day or over the counter twice per day), Calcium & Vitamin D (twice daily), Iron (once daily), Vitamin B12 injections (3 monthly) via the GP. Take calcium supplement two hours apart from any supplements containing iron so they are absorbed fully. 

Your calcium intake and bone health: Calcium is the most abundant mineral in the body and is key part of bones and teeth. Post-bypass, due to the reduced volume of food being eaten, the body may become deficient in calcium. A poor diet, low in calcium rich foods can lead to a calcium deficiency and a medical condition called Osteoporosis. Osteoporosis is a condition where the bones become weak and prone to fracture; the first sign of the illness may be a fractured bone.

To help build healthy bones it is important to:

• Eat a varied diet
• Have at least three portions of food from the dairy food group each day. These foods are rich in calcium and readily absorbed e.g. low fat yoghurt and high protein yogurts, semi or skimmed milk, reduced fat cheese in moderation.
• Aim for a total daily calcium intake of 1000-1200mg from food and supplements combined.
• Always take your multivitamin and mineral tablet each day forever. These tablets contain calcium.
• A glass of milk, a 150g portion of plain yogurt or a 30g portion of hard cheese contains approximately 200-250mg calcium.
• For supplements, calcium citrate is better absorbed than calcium carbonate after a bypass, but either can still be used.
• Ensure you have some exposure to the sun when here. Our bodies can make Vitamin D via the action of sunlight on our skin. Vitamin D is vital for the absorption of calcium. The correct wavelength of sunlight is only present in the UK from May to September.
• Good sources of vitamin D include: fortified margarine, breakfast cereals, egg yolk and oily fish. Despite having a good intake of these foods, many people still need a vitamin D supplement particularly in the winter months.
• Follow the blood test protocol advised by the Bariatric Team to check your vitamin D, parathyroid and adjusted calcium levels.
• Note blood tests CANNOT test your calcium status in the bone and only tests possible indicators. Ensure all are in range.
• Take some weight bearing exercise, such as walking, each day. Start gradually and build up your distance with time.

Ensure you have a good fluid intake each day, drinking a minimum of 2 litres. Dehydration with calcium supplementation can make you more likely to suffer from kidney stones.

If you have any concerns about your calcium intake, please consult your Dietitian for further advice.

Are there any foods I should avoid after a Gastric Bypass/ Sleeve Gastrectomy?

You may find it difficult to tolerate some foods, and this varies from person to person. Common foods known to cause problems include dry meat, soft white bread, rice, stringy or very fibrous vegetables, sweetcorn, nuts, dried fruit, pips and seeds. Avoid these until you have established yourself on your solid diet and always try new foods cautiously. If you do not tolerate a food, try it again in a few weeks’ time. There is a lot of adaptation in the first few months. It is highly likely you will manage with time.

Can I drink alcohol after a Gastric Bypass/ Sleeve Gastrectomy?

It is not recommended that you drink alcohol for the first six months after your operation. Remember that you will feel the effects of the alcohol much more quickly than before due to quick absorption time. Please take special care when driving as it may affect your legal limit and your reaction speed.

Remember that alcohol is very high in calories in a small volume (particularly alco-pops and stronger wines or lagers) and contains no nutrients. It can also stimulate appetite – another reason not to drink frequently.

Why should I limit foods high in sugar or fat afterwards?

These foods are high in energy (calories) and if you eat too much of these foods it will make it hard to lose weight after surgery. Avoiding or minimising the amount of meltable calorie foods you eat that are high in fat and sugar such as crisps, biscuits, cakes, ice cream, sweets and other confectionary foods will help you stick to a healthy diet and optimise your long-term weight loss.

Can I buy convenience food?

There is a place for these products in your diet. Take care what you select and look for healthy options. Choose quantities that match your new stomach size and opt for foods with a low fat and sugar content.

Can I use meal replacements?

These foods will not help you learn the eating behaviour needed to achieve lifelong weight management.

Also, liquids will pass through your stomach more quickly than food, with no sense of fullness and a return of your hunger soon after drinking.

Should I take protein powder?

We do not advise the addition of protein powders to your food. If you are tolerating high protein foods, each mealtime and for some snacks, you are probably eating sufficient protein to maintain your muscle mass. The focus after surgery needs to be on improving your protein intake from normal food.

Occasionally, if a Dietitian is concerned that protein intake is not progressing, a daily scoop of whey protein isolate or soy protein added to meals or snacks, maybe recommended.

We prefer you to not to become over reliant on these supplements with long-term food issues resulting. If you are at all worried, speak to your Dietitian

Are fruit smoothies and lattes recommended?

They can contain a lot of sugar and fat, reducing weight loss. Fruit smoothies made with just fruit or vegetables are low in protein. However, making your own fruit smoothies with the of addition of low-fat yogurt or milk as the basis and adding fruit is much better. It is recommended you do not have anymore than 150ml of home-made fruit smoothie per day due to that damage the sugar can cause to your teeth. As an alternative a piece of fruit with a high protein yogurt can be a more satisfying snack.

Lattes also can also add up to high calories and may have added sugar, they can stop you eating your regular meals by making you full. You can have low sugar versions made with skimmed milk but ensure you are not skipping meals and living on drinks all day.

Will I need to take vitamins after my operation?

You will need to take supplements lifelong post Gastric Bypass/ Sleeve Gastrectomy. A complete multivitamin and mineral supplement, iron, calcium and vitamin D are recommended. You will also need to have vitamin B12 injections every three months which you will need to arrange with your GP. Some people need additional supplements; this will be assessed by regular blood tests at your review appointments.

It is important to take your calcium supplement two hours apart from any supplements containing iron (e.g. multivitamin and mineral). Taking them together reduces the absorption rate.

Please note you may be required to purchase an over the counter multivitamin and mineral supplement yourself (for the rest of your life) if you GP will not prescribe this.

Different supplements have different amounts of each vitamin and minerals in, so it is important to use recommended supplements or to check with your Bariatric Team at UCLH.

• “Over The Counter” complete multivitamin and mineral supplement, e.g. Sanatogen A-Z Complete, Superdrug A-Z multivitamins and minerals, Tesco Complete multivitamins and minerals, Lloyds pharmacy A-Z multivitamins and minerals twice daily.
• Calcium & Vitamin D (aim for 800mg calcium and 20mcg Vitamin D) ask pharmacist for guidance of how often you need to take it depending on brand chosen.
• Iron: 200 mg ferrous sulphate or 210 mg ferrous fumarate or 300 mg ferrous gluconate once daily).
• Three monthly vitamin B12 injections at your GP surgery. We do not usually recommend oral B12 as a replacement of your B12 injections as it is not absorbed as well by the body.

Baricol® Complete: can be bought via their website (see below) in a variety of flavours and as a chewable or effervescent tablet. This tablet combines all the supplements the GP would prescribe to you separately (including B12) reducing the total amount of vitamin and mineral supplements taken per day and stopping your B12 injections.

NHS Prescription Prepayment Certificate
Tel: 0300 330 1341

Baricol® Complete
Tel: 01794 874240 

Vomiting

You should not expect to be sick regularly after a Gastric Bypass/ Sleeve Gastrectomy. If you are, it may be linked to the way you are eating. Try to think if you have done any of the following:

• Eaten too much
• Eaten too quickly
• Not chewed the food enough
• Had a drink too close to the meal time

If you continue to be vomit and it cannot be explained by the above, you should contact the Bariatric Team or your GP.

Constipation

If you are suffering with this, check you are drinking enough fluid. You should have at least 2½ litres a day. Try to choose high fibre foods such as wholegrain products, fruit and vegetables. Regular exercise will also help to alleviate constipation. If constipation persists then you can safely take laxatives such as Resource® Optifibre®, milk of magnesia or non-bulk forming laxatives for example Senna or Lactulose.

What to do if food gets stuck?

This may happen if you have eaten a food that was too solid, eaten too fast or too much, did not chew your food enough, or as a result of eating certain ‘problem’ foods. This will feel uncomfortable and you may wretch or vomit. It usually resolves itself, but you can try repeatedly swallowing small quantities of cold sparkling water as the fizz may help to dislodge the lump. If the trouble persists, please call the Bariatric Team during working hours.

Feeling low or overwhelmed

Surgery is a major event and many people go through a period of psychological readjustment after the surgery. If you notice that you are feeling low or overwhelmed, please speak to your clinician. They can support and/or signpost you. They may refer you to a bariatric psychologist for an assessment, so that the appropriate next steps in terms of psychological support can be identified. Please note that the bariatric psychologists cannot provide mental health crisis support.

If you are in crisis or feel that you cannot keep yourself safe, please contact your mental health team (if you have one) or your GP. If urgent, attend your local A&E department.

You will be sent a letter to advise you of your first Dietitian appointment and it should take place at approximately 12 weeks after discharge.

If you do not receive a letter, please call the Bariatric Secretary team to make sure your correct address is updated on your patient record, and to request a letter.

If you have questions or concerns about your dietary intake in the interim, please contact the Dietitian on 07904 912 441.

• The British Obesity & Metabolic Surgery Society
• Weight Loss Surgery Information
• Weight Concern
• Obesity Empowerment Network
• One you
• One you – Every Mind Matters
• Recipes

Books:

• Living with Bariatric Surgery, by Dr Denise Ratcliffe
• The Emotional First Aid Kit: A practical guide to life after
• bariatric surgery, by Cynthia Alexander. (Matrix Medical Communications)
• Overcoming Weight Problems, by Jeremy-Gauntlett-Gilbert and Clare Grace. (Constable and Robinson Ltd)
• Eating Mindfully: How to end mindless eating and enjoy a balanced relationship with food. Second edition. By Susan Albers (Raincoast Books)
• 50 ways to sooth yourself without food, by Susan Albers.
• But I deserve this Chocolate, by Susan Albers

UCLH cannot accept responsibility for information provided by other organisations.

Please do not hesitate to ask a member of the Bariatric Team any further questions you may have. All of us are happy to help you.

Pathway Co-ordinator (Monday to Friday 09:00-17:00)
Direct line: 020 3447 9419 / 020 3447 5463
Switchboard: 020 3456 7890 ext. 67022 / ext. 75463
E-mail: uclh.bariatrics@nhs.net

Specialist Nurse (Monday to Friday 09:00-17:00)
Mobiles: 020 3447 3282

Dietitian (Monday to Friday 09:00-17:00)
Mobiles: 07904 912441
Address: Bariatric Department, 250 Euston Road, London, NW1 2PG
Website: www.uclh.nhs.uk

Appendix 1 – Food and Mood diary

Appendix 2 – Fats

There are two main types of fats – saturated fats and unsaturated fats. Unsaturated fats can be either polyunsaturated or monounsaturated.

Saturated fats are found in animal products fatty meats and meat products, butter, ghee, lard, and dairy products including cheese and cream. Products that contain these fats such as cakes, pastries and biscuits are also sources of saturates.

Some vegetable fats such as cocoa butter, palm oil and coconut oil also contain saturated fats. In general saturated fats are considered to be less healthy.

Unsaturated fats are found generally in plant foods such as seeds, nuts, olives and avocados. They can be either polyunsaturated (e.g. sunflower, soya, corn and sesame oils) or monounsaturated (e.g. olive and rapeseeds oils). Unsaturated fats are considered to be healthier fats.

Omega-3 fats are a type of polyunsaturated fat and are called ‘essential’ fatty acids as the body cannot make enough. The best sources are oily fish such as salmon, mackerel, herring,sardines and pilchards. Other sources include nuts and seeds e.g. walnuts and pumpkins seed; vegetable oils e.g. rapeseeds and linseed; soya and soya products e.g.beans, milk and tofu; and green leafy vegetables as well as enriched foods including some eggs, milk and yoghurts.

Trans fats are naturally present in low levels in some dairy foods and meats, but also found in processed & hardened vegetable oils. They can be found in ‘partially hydrogenated vegetable fats/oil’ but many manufacturers now avoid using hydrogenated fats or have reduced the amount of trans fats in their products to very low levels, because they are considered unhealthy and contribute to heart problems??.

Look at the label

The nutrition panel on the back or side of food packs can be used to tell us the amount of fat and saturates in 100g of food and per portion. Some food labels also include the amount of mono and/or polyunsaturated fat present 

Red shows that the fat levels are higher in a product. It does not mean that we shouldn’t eat it, but we should keep an eye on how much and how often. Green means the food is low in fat. Our diet is likely to be made up of a variety of foods with different colour codes but we should aim to eat more food with green and amber colours than red.

Some foods have additional information on packs such as claims to be ‘low in fat’ or ‘low in saturated fat’. There are specific criteria which must be met to make these claims.

• ‘low in fat’ – 3g of fat or less per 100g, or 1.5g of fat per 100ml for liquids
• ‘fat-free’ – 0.5g of fat or less per 100g 0r 100ml
• ‘low in saturated fat’ – 1.5g of saturated or less per 100g or 0.75g per 100ml for liquids
• ‘saturated fat free’ – 0.1g of saturates per 100g or 100ml

Appendix 3 – Protein Sources

Appendix 4 - Glycemic Index (GI)

What is GI?

Each time you eat or drink something sugary or starchy, the blood glucose level in your body rises. Some of these are quickly digested and cause quick and sharp rises in your blood glucose levels - they are called high GI foods and drinks. Low GI foods and drinks are more slowly digested and will make your blood glucose rise more slowly. These are sometimes called ‘slow release’ carbs.

Starchy and sugary food and drinks contain carbohydrates:

• Starchy foods such as bread, pasta, chapattis, potatoes, yam, noodles, rice and cereals.
• Fruit and fruit juice.
• Some dairy products such as milk and yogurts.
• Sugar and other sweet foods.
• Non-diet soft drinks

GI and weight management

There is some research to suggest that slow, steady rises and falls in glucose may help control appetite. Although
many low GI foods are filling, there isn’t enough evidence to suggest that all low GI foods can help you to feel full.

GI and balanced eating

Here are some everyday examples of lower GI carb choices.

• Multigrain, granary, rye, seeded bread, sourdough bread
• New potatoes in their skins, sweet potato, yam, cold boiled potatoes
• All pasta cooked till al dente, instant noodles
• Basmati rice, long grain or brown rice
• Bulgur wheat, barley, couscous, quinoa
• Porridge, muesli, some low-sugar oat and bran-based cereals

Many low GI foods are a good source of fibre or wholegrains. A healthy way to use the GI principles is to incorporate a range of lower GI carbs that are also rich in fibre and low in saturated fat.

For weight management, you also need to think about reducing your overall calorie intake by incorporating lower calorie foods into your meals and snacks. Consider the overall balance of your meals by looking at labels and choosing foods that are lower in saturated fat, salt and sugar, and keep an eye on your portion sizes.