YOU WILL NOT BE ALONE. Bariatric patients have to make significant changes to their lifestyle after their surgery. This includes changes to their diet as well as changes to their daily routines and the inclusion of an exercise program into their lives. Dr. Neil Floch, Dr. Craig Floch and their team will provide you with unending support and guidance through out your post-operative period and beyond. Our team, including the doctors, office staff and support groups will always be at your side to encourage and support you.

MOST WEIGHT LOSS SURGERY PATIENTS RECOVER FROM SURGERY WITHOUT COMPLICATIONS. Although you will have some discomfort from the surgery, you will have to get out of bed and start walking the same day. This activity is crucial in preventing surgical complications, such as blood clots.

If you have been diagnosed with sleep apnea through a sleep study, you will remain on breathing monitors in a monitored bed until you are breathing well on your own.

The hospital stay for patients who undergo the Laparoscopic Roux-en-Y Gastric Bypass procedure is usually two days. Patients who have the Laparoscopic Adjustable Gastric Banding procedure will go home the same day or remain overnight. Before you are discharged, you will receive full instructions for your care at home. An appointment will be scheduled to see your surgeon about one week after your weight loss surgery.

• You will wake from surgery in the recovery room, and your doctor will see you there and speak to you. But, you may not remember it because of the anesthesia, so he will speak to your family.
• You will remain in the recovery room for approximately 1-2 hours. You may experience some nausea and/or pain. You may see drains protruding from your belly, which will be removed before you go home. If you have sleep apnea you will remain in the recovery room for 3 hours.
• If you are staying overnight or more than one day, you will be transferred out of the recovery room to a room on the post-surgical floor.
• The nurses will ask you to sit up and perform deep breathing exercises using an incentive Spiro meter. You will be started on small sips of water, and be asked to stand up and walk. It is imperative that you begin walking as soon as possible to prevent blood clots.
• If you tolerate small sips of water the day of surgery, you will be advanced to stage one of your diet.
• Once your surgeon is satisfied that your digestive system is functioning properly, you will be discharged home. Any drains or catheters will be removed prior to your discharge.

ONCE HOME, IT IS IMPORTANT TO FOLLOW ALL OF THE INSTRUCTIONS YOU HAVE BEEN GIVEN. You should follow the proper diet stage as directed by the nutritionist and/or doctor. You should begin taking a daily multivitamin and any other nutritional supplements as directed by your nutritionist.

• You will be out of work for 3 days to 1week following a banding procedure and 1-2 weeks following a gastric bypass.
• You should already have made a follow-up appointment with our surgeons or physician’s assistant approximately 7-10 days following surgery. If you had not done so, please call our office to schedule your visit as soon as possible.
• We have made available to you a Daily Intake Log and Your Personal Weight Loss Log to assist you on your weight loss journey. Please click on each log to download a copy.
  
     Daily Intake Log
     Weight Log

If you should experience any of the following call our office and request to speak to Dr. Floch:

• Shortness of breath
• Persistent nausea or vomiting
• Vomiting a bright red or dark brown liquid (go to the emergency room)
• Increased redness, swelling or foul-smelling discharge at incision site
• Increased soreness or pain in your incision(s)
• Any new or unusual pain in your abdomen, chest or legs
• Temperature higher than 101^oF
• Passage of very dark stool
• Acute depression or negative emotions

Please do not hesitate to contact our office with any questions or difficulties you may be experiencing. One of our surgeons is on call at all times should the need arise.

NUTRITIONAL GUIDELINES

PURPOSE:

This diet is designed to restrict caloric intake to produce desired weight loss, to help develop appropriate eating habits and to prevent disruption or obstruction of your pouch. In addition, it is strongly recommended to pursue weight loss in preparation for surgery. Even a small amount of weight loss may contribute to a decreased surgical risk during bariatric treatment.

MAIN FOCUS:

1. Drink enough fluids to keep your body hydrated
2. Eat adequate protein
3. Take required vitamin and mineral supplements to meet Recommended Daily Allowances.

DIET PRINCIPLES:

1. Drink 6-8 cups of fluid each day or1.5 to 2.0 liters
   • Sip one cup of liquid over an hour
   • Stop drinking within 30 minutes of a meal, start drinking 30 minutes after a meal.
   • Sip allowed beverages slowly
   • Do not use a straw
2. High calorie foods, beverages, and snacks are omitted.
3. When your doctor gives you permission, vitamin/mineral and calcium supplements are required daily. Additional vitamin B12, iron, and zinc may be recommended.
4. Eat very slowly. Foods need to be thoroughly chewed to prevent blockage.
5. Stop eating as soon as you are full. Indications of fullness are:
   1. a feeling of pressure in the center just below your rib cage,
   2. a feeling of nausea,
   3. a pain in your shoulder area or upper chest. Contact your doctor if the above symptoms persist or worsen.
6. Include protein first at each meal to help maximize protein intake. As your pouch expands, you may only need to eat 3 meals and 1-2 high protein snacks each day.
7. The diet will be advanced gradually, depending on tolerance:

The first stage of the gastric bypass diet is a clear liquid diet, which begins in the hospital after your surgery. You will start with sips of water and then add fat-free broth, diet gelatin, diet Italian ice, and decaffeinated tea as tolerated.

You will continue the clear liquid diet at home for about one week, until your first post-op visit with your surgeon. At home, you can try additional clear liquids like light apple juice and no-sugar-added popsicles. All liquids should be non-carbonated, since carbonated drinks can put pressure on your small stomach pouch. Avoid chewing gum (even sugar-free) because accidentally swallowing it could cause a blockage. (See anti-blockage info in back of packet.)

Please sip liquids slowly. You may want to use a medicine cup or shot glass to measure your 1-ounce portion. By drinking every 15 minutes while you are awake (that is, 4 oz per hour for 12 to 16 hours), you will easily meet your fluid goal. Aim to drink 42-70 oz per day.

Remember to take your chewable or liquid multivitamin daily. Some popular & palatable chewable brands include Bariatric Advantage (.com), Trader Joe’s High-Potency Woman’s, GNC (pineapple chewable) & Centrum (orange or berry chewable).

Stage 1 Clear Liquids Shopping List

• unsweetened light juices: light apple juice, light white grape juice, or Light Cranberry Juice Cocktail, or dilute regular unsweetened juices with water
• sugar-free Jell-O.
• no added sugar popsicles without fruit pieces: Dole, Welch's, or Tropicana No Sugar Added Fruit Juice Bars
• fat-free chicken or beef broth, like Pacific, Trader Joe’s, Nature’s Promise, etc.
• decaffeinated tea, or herb tea
• non-carbonated no-cal flavored drink like Crystal Light or Fruit-2-O
• non-carbonated bottled water, or tap water
• Isopure Protein Zero Carb*

*Please dilute Isopure with an equal amount of water or no-cal flavored drink or freeze in an
ice cube tray and add water to glass of Isopure “cubes.”

• Isopure Protein Zero CarbFlavors: apple melon, passion fruit, alpine punch, icy orange, grape frost, and blue raspberry
• Isopure Protein powder is NOT suitable at this stage because it is not a clear liquid.
• Isopure is available at The Vitamin Shoppe (with branches in Norwalk, Danbury, Milford and Stamford), Mrs. Green’s (Fairfield & Stamford), Nature’s Way (Stratford), on line or at the surgeons office.

About one week after your gastric bypass surgery, your surgeon will advance your diet to full liquids. You will then be able to add in cow’s milk or soy milk, smooth light yogurt or plain low-fat Greek yogurt and one of the high protein drinks listed below. Please continue to avoid sugar, carbonation, caffeine, and chewing gum.

Your full liquid diet should aim for 40 - 60 grams of protein daily.
Protein-rich full liquids include:

PROTEIN GRAMS
0% or 1% milk/LactAid or unsweetened low-fat soy milk ………	8 g in 8 oz. milk
Simply Smart or Over the Moon 0% or 1% milk ………………………………	10 g in 8 oz. milk
Plain non-fat or smooth light yogurt or a light yogurt drink ……………	6-8 g in 6 oz carton
Plain low-fat Greek yogurt (Chobani, Fage, Trader Joe’s) ………………	13-18 g in 6 oz carton
Atkins Advantage Shake ……………………………………………………………………	18 g in 11 oz can
Worldwide Pure Protein Shake - 21 g protein ………………………………	21 g in 11 oz can
Myoplex Carb Control Ready-to-Drink ………………………………………………	25 g in 11 oz carton
Worldwide Pure Protein Shake - 35 g protein …………………………………	35 g in 11 oz can
Isopure Protein Zero Carb …………………………………………………………………	40 g in 20 oz bottle
Zero Carb Isopure Protein powder 1 scoop + 11 oz water …………	25 g in 11 oz drink
Designer Whey Protein powder 1 scoop + 8 oz skim milk …………	25 g in 8 oz drink
Body Tech Whey Tech whey protein 1 scoop + 8 oz skim milk …	25 g in 8 oz drink

For variety, alternate protein-rich liquids with water, juice, or no-cal flavored drinks. Continue to sip 1 oz about every ten minutes while you are awake. Aim for 42 - 70 oz liquids, including water, each day.

See below for your Full Liquids Shopping List and suggestions about purchasing high protein drinks.

Stage 2 Full Liquids Shopping List

• skim or 1% milk, or 1% Lactaid milk, or Simply Smart 0% or 1% milk;
• unsweetened low-fat soy milk
• light (nonfat, no sugar added) smooth yogurt*, like Dannon Light ‘n Fit Creamy, or plain natural nonfat yogurt, low-fat plain Greek Yogurt (Chobani, Fage, Trader Joe’s, etc.) or low carb low fat smooth yogurt like Dannon Light ‘n Fit Carb Control

  *Please avoid fruit pieces and seeds in yogurt or yogurt drinks

• Low-fat cream of chicken soup (Healthy Request, etc.)
  Make with skim milk and strain before serving.
• choice of high protein very low carb shake
  • Atkins Advantage Shake - 7 flavors, widely available at pharmacies, groceries, etc.
  • Worldwide Pure Protein Shake -21 g 5 flavors, available at Trader Joe’s, Vitamin Shoppe
  • Worldwide Pure Protein Shake -35 g 5 flavors, available at Trader Joe’s, Vitamin Shoppe
  • Myoplex Carb Control Ready-to-Drink 4 flavors, available at Vitamin Shoppe, GNC
• choice of high protein very low carb drink powder
  • Zero Carb Isopure Protein powder- 5 flavors, available at Vitamin Shoppe
    For your Stage 2 diet, mix just 1 scoop powder (25 g of protein) with 11 oz water;
  • Designer Whey Protein powder- 7 flavors, available at Vitamin Shoppe
    For your Stage 2 diet, mix just 1 scoop powder with 8 oz skim milk;
  • Myoplex Carb Control 2 flavors, available at Vitamin Shoppe
    Mix contents of 1 envelope with 11 oz water.
• no-added-sugar popsicles without fruit pieces
• no-cal flavored drink like Crystal Light, Fruit-2-O
• decaffeinated tea, or herb tea
• non-carbonated water, or tap water

Now that your diet has progressed to pureed food, you can start eating three meals a day! Eating chunks of food could block the exit from your stomach.

Start with small portions of pureed foods, and stop before you feel full. (See sample menu and portion size suggestions on the pages which follow). Remember to eat slowly - each meal should take 15- 30 minutes.

Because protein is so important to help you maintain muscle while you are losing weight, eat your protein-rich foods first at meals. Then move on to fruits and vegetables. Continue to avoid chewing gum. By now, taking your chewable or liquid multivitamin every day should be a habit.

It is still important to drink enough fluids- aim for at least 42 oz per day. Drink slowly, 1-2 oz at a time. Drink fluids between meals, so you don’t overfill your stomach: wait 30 - 45 minutes after meals before drinking, and stop drinking 30 minutes before a meal.

Choose these foods	Not these
PROTEIN-RICH FOODS:
pureed* skinless chicken and turkey	pureed beef, pork, lamb
Stage 1 baby food strained chicken or turkey	pate, liverwurst, hot dogs
pureed fish, like water-packed tuna	fried fish, canned fish in oil
very soft scrambled eggs, egg whites or Eggbeaters	fried egg, boiled egg
pureed/whipped lowfat cottage cheese (Friendship)
low fat or fat free ricotta cheese	sliced cheese
pureed tofu, silken tofu	cream cheese
light/low-fat smooth yogurt	yogurt with added sugar
plain natural nonfat Greek yogurt (Chobani, Fage)	yogurt with fruit pieces or muesli pudding, custard, ice cream

VEGETABLES:
Stage 1 baby food strained vegetables	raw vegetables
pureed cooked vegetables like carrots, spinach, tomatoes, squash, beets, peas Avoid gas-forming vegetables listed opposite	broccoli, cauliflower, cabbage onions, and dried beans are "gassy" and may cause discomfort fries, chips, gravy

FRUIT:
Stage 1 baby food strained fruits	canned fruit in syrup
Smooth unsweetened applesauce	fresh fruit
pureed no-sugar-added canned peaches, pears, apricots

COOKED CEREALS [optional]:
Cream of Wheat, farina, unflavored grits Flavor with no cal sweetener & cinnamon if you like Add protein by making cereal with milk, not water	oatmeal all dry cereals

PROTEIN- RICH BEVERAGES:
skim and 1% milk, Simply Smart milk	2% milk, whole milk,
plain soy milk	chocolate milk
protein drinks like Pure Protein Shake	flavored soy milk, cream

CALORIE-FREE BEVERAGES:
water	carbonated water like seltzer
non-carbonated no-cal drinks like like Crystal Light, Diet Snapple, Fruit-2-O	soda, diet soda fruit drinks, fruit juice
decaf coffee and tea without sugar no cal sweeteners are okay	alcohol, wine, beer

*To puree foods, use a blender or food processor to a smooth consistency. If necessary, add water, broth, tomato juice, milk or low fat mayo to make a smooth puree. To save time, you can use stage 1 strained baby food like strained chicken and no-added sugar strained fruit. Toddler foods are not suitable because they are lumpy.

HOW MUCH IS THAT? MEASURING EQUIVALENTS:
0.5 oz =	1 tablespoon =		3 teaspoons =	15 ml
1 oz =	2 tablespoons =	1/8 cup =	6 teaspoons =	30 ml
1.5 oz. =	3 tablespoons =		9 teaspoons =	45 ml
2 oz =	4 tablespoons =	1/4 cup =	12 teaspoons =	60 ml

Your new stomach holds only 1.5- 2 oz (3-4 measuring tablespoonfuls), so when planning your pureed meal, prepare a maximum of:

2 to 3 tablespoonfuls of protein-rich food, plus

1/2- 1 tablespoonful of fruit, vegetable, or cooked cereal

Initially you may manage only a few teaspoonfuls per meal. Stop eating when you begin to feel full, even if there is food left on your plate. You may want to use a baby spoon or teaspoon to help you take small bites and eat slowly.

Sample Pureed Menu
BREAKFAST:

• Soft scrambled Eggbeaters*
  Cream of Wheat made with skim milk

LUNCH

• ricotta cheese (low fat or fat free)
• unsweetened applesauce

DINNER

• pureed turkey*
  pureed squash

  *Protein foods are in highlighted as a reminder to eat them first.

BETWEEN MEAL LIQUIDS

• 11 - 22 oz protein-rich beverages
  (Ask your dietitian about suitable protein drinks and powdered protein supplements)
  +
  20 - 30 oz water and calorie-free beverages

Tender or Soft (easy to chew) foods are the next step in your diet after gastric bypass surgery. Your meals can now include tender cooked foods like fish, ground turkey, vegetables, and no-sugar-added canned fruit. To avoid dumping and to maximize your weight loss, continue to choose low fat foods without added sugar.

Now that your foods are more solid, make it a habit to chew foods well- aim for 20 to 30 chews before swallowing. Do not, however, chew gum. To remind you of your new, smaller meal size, choose smaller plates for your meals.

Protein-rich foods remain the most important part of your diet. Aim to eat these foods first. Drink liquids between meals- you should manage 4-8 oz per hour. Wait 30 to 45 minutes after meals before drinking, and stop drinking half an hour before a meal. Your fluid goal is now 42 - 60 oz/day.

Soon your surgeon will discuss the use of a vitamin B-12 supplement as tablets or injections. If you opt for tablets, buy those labeled 1000 mcg (micrograms) sublingual (under-the-tongue) vitamin B-12, available at health food stores and Trader Joe’s. The dose recommended by your surgeon is 1 tablet (1000 mcg) once a week.
Continue to take your daily chewable or liquid multivitamin.

Choose these foods	Not these
PROTEIN-RICH FOODS:
lean (90+% fat free) ground chicken or ground turkey - try it in meatloaf tender skinless poached or boiled chicken	ground beef, pork, lamb hamburger, sausage, hot dogs
baked, grilled, or poached fish	fried fish, fish in batter
canned fish in water you may want to moisten with low fat mayo/dressing	canned fish in oil
eggs, egg whites, Eggbeaters Try scrambled, poached, boiled egg, or omelet	fried eggs
cottage cheese - low fat	2%, 4% cottage cheese
cheese reduced fat; ricotta , low fat or fat free	full fat cheese and ricotta
tofu	tempeh, hummus

VEGETABLES:
peeled, well-cooked non-gassy vegetables: tender green beans, carrots, asparagus tips, mushrooms, tomatoes, squash, tiny peas, spinach zucchini	all raw vegetables corn, celery, gassy vegetables like chilies, peppers, onions, broccoli cooked dried beans/peas/lentils stringy green beans
peeled cooked potatoes, sweet potatoes	chips, fries, crackers and other snack-type foods

FRUIT:
canned, stewed, or baked peeled fruit without added sugar; apples, apricots, peaches, pears, plums, crushed pineapple;	fruit juice canned fruit in syrup citrus fruit, berries, melon
fresh ripe banana	coconut, dried fruit

CEREAL [optional):
oatmeal, farina, grits, cream of wheat	Raisin Bran, granola, muesli, Kashi
Protein Plus Special K	presweetened cereal cereal with dried fruit or nuts

SPREADS:
Olivio Spray, I Can’t Believe It’s Not Butter Spray	oils, butter, cream cheese
fat free or low fat mayonnaise or dressing	regular mayonnaise peanut butter, honey, jelly & jam

PROTEIN- RICH BEVERAGES :
skim and 1% milk, Simply Smart milk	2% milk, whole milk,
plain soymilk	chocolate milk
protein drinks like Pure Protein Shake	flavored soymilk, cream

CALORIE-FREE BEVERAGES:
water	carbonated water like seltzer
non-carbonated no-cal drinks like like Crystal Light, Diet Snapple, Fruit-2-O	soda, diet soda fruit drinks, fruit juice
decaf coffee and tea without sugar no cal sweeteners are okay	alcohol, wine, beer

Sample Soft Menu
BREAKFAST:

• low fat cottage cheese
• canned pear slices in natural juice

LUNCH:

• canned tuna mixed with low fat mayo*
  banana slices

DINNER:

• lean ground turkey in tomato sauce*
  steamed zucchini

  *Protein foods are highlighted as a reminder to eat them first.

BETWEEN-MEAL LIQUIDS:

• 11- 22 oz protein-rich liquids
• 30- 40 oz water and calorie-free beverages
  Ask your dietitian about suitable protein drinks and powdered protein supplements.

You are now ready to expand your diet. With your dietitian’s help, you can introduce foods like lean red meat, fresh fruits, and raw vegetables over the next few weeks. To avoid dumping and to maximize your weight loss, continue to choose low fat foods without added sugar.

Make time to chew foods well- your meal should take 20 to 30 minutes. Continue to choose small portions. Large bites of food could cause an intestinal blockage, as could swallowed chewing gum.

Protein-rich foods remain the most important part of your diet. Your protein goal is now 70–90 g per day. Drink liquids between meals: wait 30 to 45 minutes after meals before drinking, and stop drinking half an hour before a meal. Aim for the day is 42 - 60 oz daily.

You are now ready to use a daily chewable or liquid calcium supplement. Your dietitian can help you determine the right dose of calcium citrate. Continue to take your daily multivitamin and sublingual vitamin B-12 tablet (or schedule monthly B-12 injections).

Choose these foods	Not these
PROTEIN-RICH FOODS:
lean skinless chicken breast or leg meat lean skinless turkey Your dietitian can suggest other lean meat, poultry and fish to try.	fried chicken, poultry skin ground meat less than 90% lean sausage, hot dogs, bacon corned beef, spare ribs
fish, scallops, shrimp and crabmeat	fried fish, fish in batter
canned fish in water	canned fish in oil
beans like chickpeas, lentils, black beans	baked beans
eggs, egg whites, Eggbeaters prepared without added fat	fried eggs
cottage cheese; 0 or 1% fat	2%, 4% cottage cheese
cheese reduced fat; ricotta low fat or fat free	full fat cheese and ricotta
tofu, tofu burgers, veggie burgers	hummus, fried tofu

VEGETABLES:
cooked vegetables: tender green beans, carrots, spinach, beets, zucchini, squash, asparagus, mushrooms, tomatoes, tiny peas your dietitian can suggest salad veg to try	corn, popcorn tough broccoli stems stringy green beans
peeled cooked potatoes, sweet potatoes	chips, fries, crackers and other snack-type foods

FRUIT:
canned, stewed, or baked peeled fruit without added sugar; apples, apricots, peaches, pears, plums, pineapple	canned fruit in syrup coconut, dried fruit
peeled fresh apple, peeled ripe pear	orange & grapefruit membrane
melon without seeds; banana Ask your dietitian about other fresh fruits.	cherry pits, apricot pits

CEREAL [optional):
low sugar cold or hot cereal	granola, presweetened cereal
Prot Plus Special K and Kashi GoLean	presweetened cereal Kashi Golean Crunch, any cereal with dried fruit or nuts Cereal bars made with sugar

BREAD [optional]:
1?2 slice bread; or 1 slice light bread – toasted	pizza, rolls, bagels, croissants

SPREADS:
Olivio Spray, I Can’t Believe It’s Not Butter Spray	oils, butter, margarine
fat free or low fat mayonnaise	regular mayonnaise, cream cheese
* fat free or low fat salad dressing	regular salad dressing peanut butter, honey, jelly & jam

PROTEIN- RICH BEVERAGES :
skim and 1% milk, buttermilk, plain soy milk	2%, regular & chocolate milk
plain natural nonfat yogurt	full fat yogurt
light smooth yogurt	yogurt with added sugar

CALORIE-FREE BEVERAGES:
water	carbonated water & drinks
non-carbonated no cal drinks	soda, diet soda
coffee and tea without sugar	alcohol, wine, beer

Sample bariatric advanced menu with protein count

The protein portion sizes listed here suit most people 5- 12 weeks post-op.

Protein Grams
BREAKFAST:
Protein-rich food	1.5 oz cottage cheese, or 3 tbsp scrambled egg	5
Fruit/vegetable	peach slices	0

BETWEEN MEALS:
No-cal drinks	Coffee with	0
Protein-rich liquids	4 oz skim milk	4
	5 oz Pure Protein shake (35 g protein/can)	17-18

LUNCH:
Protein-rich food	1 - 1.5 oz tuna, or part-skim	7-10
vegetable	mozzarella
fruit	cherry tomato	0
	melon balls	0

BETWEEN MEALS:
No-cal drinks	Water or Diet Snapple	0
Protein-rich liquids	6 oz Pure Protein shake (35 g protein/can) or 11 oz Mayoplex Carb Control Ready-to-Drink	18-22

DINNER:
Protein-rich food	1.5 oz stewed chicken, or	7-10
vegetable	baked salmon Green beans, squash	0

EVENING BEVERAGES:
No-cal drinks	Celestial Seasonings Apple Cinnamon Spice tea	0
Optional protein drink	5 oz Isopure Prot Zero Carb	10
PROTEIN TOTAL		58-79 g

Questions about your protein intake?

Your dietitian can help you calculate your daily protein grams, and supply the
checklist “Where’s the Protein?” for you to use at home.

Now that you’ve completed the 5-Stage Post-Op Diet, what comes next?
Over the coming weeks, you can continue to reintroduce lean protein foods like lobster, crab, Cornish game hen, ham, beef stew, pot roast, and pork tenderloin.

• If you find plain grilled meats too dry; try baked or stewed meat with vegetables.
  • Low fat mushroom or red pepper soup (like Imagine or Trader Joe’s) make great marinades.
  • Add low-fat sauces like tomato sauce, Trader Joe’s red pepper sauce, or salsa.
  • Create a sauce using reduced-fat mayo,
• 2% fat Greek yogurt, or fat-free ricotta.
• If you enjoy well-seasoned food, you can gradually reintroduce spicy mustard, chilis, curry, and hot sauce.
• Because some people find hamburger, steak, pork chops, and ribs more difficult to digest, you may want to try these foods later rather than sooner.

Remember to include vegetables in your meals.

• Continue to try new salad vegetables, one at a time, so you can track those that suit you best.
• To start, try grating or dicing raw veggies like carrots, radishes, and cucumbers. Check out lower-calorie ways to dress your salad, like lemon, balsamic vinegar, salsa, and reduced-fat dressings.
• Make a protein and calcium dip for veggies using nonfat yogurt or fat-free ricotta blended with your favorite creamy dressing.
• You can now reintroduce cauliflower and other members of the cabbage family; make sure you trim off tough, stringy bits. Fruits are also part of your healthy new diet.
• By including fruit along with lean protein food and vegetables as part of a meal, you’ll find you have room for a modest portion.
• 1 oz (2 tablespoons) of fruit. Has only 4 g carbs, if you’re counting.
• Now that you can chew, choose fresh fruits and canned fruit without added sugar instead of applesauce.
• Ensure you chew dried fruit well-unchewed pieces could cause a blockage leaving your smaller stomach.
• Avoid swallowing indigestible bits like orange and grapefruit membranes; and large fruit seeds like cherry pits, orange seeds, apricot pits, and watermelon seeds.

You will notice that your stomach capacity increases gradually. This is normal.

• By 2-3 months post-op, your stomach will hold about 1/3 cup (about 5 tablespoons) of well-chewed food per meal.
• By 4-6 months after surgery, your stomach will reach its maximum capacity of about 1/2 cup (4 oz). 11

As your stomach capacity increases, your protein food portions can increase.

• By 4-6 months post-op, you may find you can manage 1 1/2 - 3 oz protein food per meal.
• You may be able to decrease your protein drink now that you can eat more protein at mealtimes.

To optimize your weight loss, continue to eat just 3 meals per day.
(If you prefer to use a protein shake instead of breakfast, you'll eat just 2 meals.)

• Between-meal snacks are not recommended.
• Use the time between meals to meet your fluid goal of 60- 70 oz, including protein drinks.
• Remember: you want the most protein for the least amount of calories. Supplemental protein is less than 200 calories and is appropriate for between meals, and protein drinks greater than 200 calories are intended to be a meal replacement.

You still need your daily multivitamin.

• If you haven't already, check with your doctor’s office about your calcium citrate supplement.
• Continue to take your B-12 supplement as instructed, or schedule your monthly B-12 injection.
• To ensure your supplements are being absorbed, your surgeon can schedule blood tests at 3, 6, 9, and 12 months post-op, and yearly thereafter.

DUMPING SYNDROME

Dumping syndrome is fairly common following bariatric surgery, particularly if you don’t follow all of the special dietary instructions given to you. The signs of dumping syndrome are:

• Nausea
• Vomiting
• Bloated stomach
• Diarrhea
• Excessive sweating
• Increasedbowel sounds
• Dizziness
• Emotional reactions

Bariatric surgery will make a tremendous change in your eating habits.

Rely on close family members and friends for support and encouragement, as this may be an emotional time in your life. It is important that you keep a healthy mind and body. Keep your follow-up appointments, exercise and learn to cope with emotional difficulties. Your health care team will also be there to guide you after your weight loss surgery.

Even though you may have staples or steri-strips on your incision when you are discharged, you may wash your abdomen in the shower. Avoid soap because it may burn, Do not take a tub bath or use a Jacuzzi, pool or hot tub until your incision is fully healed. It can take 1-2 weeks to make that happen. Call our office if you experience any of the following:

• Increased redness, swelling or foul-smelling discharge at incision site
• Increased soreness or pain in your incision
• Temperature higher than 101^oF
• Any new or unusual pain in your abdomen, chest or legs

Steri-strips will fall off after 7-10 days. If they do not, you may remove them yourself in the shower. Staples are rarely used but will be removed in the office after 7-10 days. If you develop a red rash on your wounds that is the shape of the bandage, it can be treated with hydrocortisone cream.

Regular follow-up visits are scheduled during the first year after weight loss surgery to check your overall physical and mental health, metabolism and nutritional status. It is crucial to your health that you keep these follow-up appointments. Many patients may decide to have plastic surgery one to two years after their weight loss to remove skin folds around the abdomen. Your first follow-up visit with your bariatric surgeon will be seven to 10 days after discharge. Subsequent visits for gastric bypass and gastric sleeve patients are scheduled for one month, three months and every three months thereafter for the first year. After the first year, follow-up visits are required every three months and then every six months after the second year. Band patients will be seen 5-10 days following surgery and then once a month for the first year. During the second year they will be seen every three months and then every six months during the following years. You also will be scheduled to see the dietitian and psychologist about one month following discharge and for regular follow-up visits to help you adjust to life after bariatric surgery.

A LIFETIME COMMITMENT TO FOLLOW UP

With a weight loss treatment, one of the most important components is the commitment to follow-up. We look forward to working with you in reaching and maintaining your health goals. Compliance to a follow-up scheduled is very important. Regular follow up visits are essential to evaluating your health and instrumental in achieving your weight loss goals. During visits, we will evaluate your compliance with lifestyle changes and validate progress.

Your required follow-up visit pattern after bypass and sleeve surgery is as follows:

• Five to seven days - initial post-operative evaluation and wound check
• One month - physician evaluation; psychological and nutritional follow up as needed
• Three months - assessment of diet, compliance with vitamins and exercise; psychological follow up as needed, blood work up
• Six months - physician evaluation and blood work
• Nine months - assessment of diet, compliance with vitamins and exercise
• Twelve months - physician evaluation and yearly blood work
• Yearly for life - physician evaluation and blood work. Missing office visits could compromise the outcomes of your weight loss surgery. Long-term follow-up care is essential for success.

Laparoscopic adjustable gastric banding patients are seen as follows:

• Five to ten days – initial wound check
• One month – first band adjustment
• Second month – band adjustment and fill
• Third month – labs and fills
• Four to five months – nutrition and exercise assessment, band adjustment and fill
• Six months – labs and fills
• Seven to eleven months – band adjustment and nutrition and exercise assessment
• Twelve months – labs and fill
• Second year – every three months – full evaluation and possible adjustment
• Third year and lifetime – every six months – full evaluation and possible adjustment

Exercising helps bariatric patients lose weight more rapidly after surgery. Establishing a gradual exercise and physical activity program
is a key to helping achieve desired weight loss. We recommend that our patients begin an exercise program as soon as our surgeon feels that it is the appropriate time to do so.

Following bariatric surgery, the patient takes in fewer calories. As a result, the body, in its search for energy, could begin to burn muscle instead of fat. Exercising alters the metabolism so the body would burn fat instead of muscle.

In addition to helping achieve desired weight loss, an exercise program will also boost your metabolism, decrease risk of cardiac disease, lower blood pressure, tone muscle and increase energy.

Daily physical activity is also instrumental in helping achieve weight loss. Walking, gardening and house cleaning are just a few of our daily activities that will burn calories and contribute to helping lose weight.

We realize the importance of an exercise and physical activity program but will only suggest it when we feel you are physically ready for it.
It will be done in graduated stages so that you will be able to do it without experiencing difficulty. Among our support groups is one that specializes in exercise. Our doctors will guide you through your exercise and physical activity program and will always be available to answer your questions and offer you support and encouragement.

As with most operations, bariatric surgery also has restrictions that are necessary to follow in order to expedite the healing process and to help achieve successful results.

Our surgeons and dieticians will provide you with specific diet guidelines to follow immediately after surgery and for long-term weight loss. Since bariatric surgery alters the way the body’s digestive track works, patients have to slowly move into a new diet that will emphasize portion size and nutrition. For the first six weeks the diet will consist of liquid/pureed foods because the digestive track needs time to heal. This includes foods that are liquid to soft in consistency. Discomfort and complications can be avoided and desired weight loss achieved by following the bariatric diet provided.

Exercise and physical activity programs help achieve desired weight loss. However we will only suggest it when we feel you are physically ready for it. The day of your bariatric surgery you will be asked to stand or walk. During your hospital stay you will be asked to take short walks. Driving should be avoided for two weeks after returning home if you continue to take postsurgical medications that can make you drowsy. Depending on the type of bariatric surgery you have, you will be home from work anywhere from one to six weeks. You should be back on your regular physical routine after six weeks. Our surgeons will provide you with an exercise and physical activity program that increases in stages following your surgery so that you will be able to handle it without difficulty. Beginning an exercise program in modulation and increasing it in time will help you speed up the weight loss results you want to achieve.

It is safe to become pregnant after gastric bypass surgery but it is recommended that the patient wait until 18 months after the surgery when weight stabilizes. The reason we ask for this delay is to prevent the mother and newborn from suffering possible malnutrition.

After band surgery you do not have to wait an extended time to become pregnant. The band can be adjusted so that you do not lose too much weight too fast.

After weight loss surgery problems could occur to the growing fetus because the body goes through potentially stressful changes with substantial nutritional upheaval. Studies have found that patients can experience deficiencies in B12, iron, calcium and vitamin D after undergoing bariatric surgery. It is also possible that patients can experience protein-calorie malnutrition and fat malabsorption. It is quite common for patients to experience nausea after bariatric surgery and it can be exacerbated by morning sickness related to pregnancy. This would increase the difficulty of getting the nutrients needed during pregnancy.