Your Complete Guide to Nutrition for Weight Loss Surgery

By Sally Johnston

Your Complete Guide to Nutrition for Weight Loss Surgery is exactly that. The essential guide for those considering, or who have had gastric band, sleeve or bypass surgeries.

Your Complete Guide combines appetising, healthy and simple recipes, the knowledge of an experienced dietitian, input from a wide range of colleagues in the industry,

• Language: English
• Publisher: Sally Johnston
• Release date: Mar 18, 2020
• ISBN: 9780992434663

Sally Johnston

Sally Johnston grew up in Maine and majored in history at Chatham College. After receiving her masters degree at the University of Pittsburgh, she taught in Pittsburgh before moving to Baltimore in 1971. Sally was director of the Star-Spangled Banner Flag House and worked at many of Baltimore’s historic sites. In 2010, she and Lois Zanow wrote and published Monuments to Heaven: Baltimore's Historic Houses of Worship. Trained as an educator, Pat Pilling has always enjoyed hunting for historical truths hidden in libraries, attics, and archives. For almost twenty years, the hunt for facts about Mary Pickersgill and her family have been alluring project. Pat and her husband, Ron, wrote Pickersgill Retirement Community: Two Centuries of Service to Baltimore 1802–2002.

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Surgery Types

The aim of weight loss (or bariatric) surgery is to allow you to feel satisfied after eating a small amount of food. This allows you to eat less food without feeling hungry, thereby reducing your food intake to promote weight loss. There are various forms of weight loss surgery and each will be discussed in detail.

A Successful Journey

Whilst technically different, what is common to all forms of weight loss surgery is that the surgery itself is just one part of the picture of weight management. Surgery alone does not guarantee you will lose weight; it is a tool that can assist you to lose weight when teamed with lifestyle change.

Colleen Cook is a successful weight loss surgery patient from 1995 and is the author of the best selling weight loss surgery book, The Success Habits of Weight Loss Surgery Patients. It is based on her research of the most successful long-term patients and the habits they have in common as they maintain their weight over time. Colleen is also the President of Bariatric Support Centers International, a company that specialises in providing education and support services for those who have had weight loss surgery and the professionals who work with them. Following is a comment from Colleen:

SUCCESSFUL PATIENTS TOOK PERSONAL RESPONSIBILITY FOR STAYING IN CONTROL. THEY WERE FOUND TO HAVE A GENERAL FEELING THAT MAINTAINING THEIR WEIGHT WAS INDEED THEIR OWN RESPONSIBILITY AND THAT SURGERY WAS A TOOL THAT THEY USED TO REACH AND MAINTAIN A HEALTHY WEIGHT.

Colleen’s words illustrate perfectly that weight loss surgery itself does not cause weight loss. Those undergoing weight loss surgery will need to take responsibility for their lifestyle choices. To achieve the best weight loss results and maintain that weight loss in the long term, you will need to choose healthy and nutritious foods, increase physical activity and maintain regular follow up with your support team.

This book is your partner in ensuring a safe preparation and recovery from surgery and developing a healthy lifestyle for long-term success.

IT IS A GREAT JOURNEY.

Dana, gastric band

I AM MORE FIT NOW THAN AT ANY OTHER TIME IN MY LIFE.

Linda, gastric bypass

IT’S BEEN LIFE CHANGING, THE BEST THING I HAVE EVER DONE.

Beth, gastric band

YOU NEED TO DO THE WORK - IT IS NOT A MIRACLE CURE.

Kristi, gastric band

THIS SURGERY HAS CHANGED MY LIFE.

Robyn, sleeve gastrectomy

IT’S CHANGED MY WHOLE LIFE!

Frances, gastric bypass

BARIATRIC SURGERY IS LIKE THE CHERRY ON TOP OF THE CAKE, OR THE TIP OF A PYRAMID. IT IS UNDERPINNED BY THE LIFESTYLE FOUNDATIONS WHICH ARE A PREREQUISITE TO LONG TERM SUCCESS.

Dr Justin Bessell, Surgeon

I HAVE CHOSEN TO LIVE A BETTER LIFE AND ALTHOUGH SURGERY IS A DRASTIC MEASURE, I WOULD DO IT AGAIN IN A HEARTBEAT.

Nina, sleeve gastrectomy

IT’S EXTREMELY HELPFUL TO HAVE OTHERS WALK BESIDE YOU BUT NO-ONE ELSE CAN DO IT FOR YOU.

Judi, gastric bypass

CHOOSING TO HAVE SURGERY IS A BIG DECISION AND ONE THAT WILL CHANGE YOUR WAY OF LIFE AS WELL AS THE QUALITY OF LIFE FOREVER. BE PREPARED TO MAKE THE CHANGES REQUIRED.

Dana, gastric band

Sleeve Gastrectomy Surgery

Sleeve Gastrectomy Surgery

HOW DOES SLEEVE GASTRECTOMY SURGERY WORK?

Sleeve gastrectomy surgery (often referred to more simply as a ‘sleeve’) reduces the size of the stomach by stapling along its length to form a long tube that looks similar to a banana. The majority of the stomach is then removed and discarded. The new banana shaped stomach is long and thin, therefore is often referred to as a ‘sleeve’.

About 80% of the stomach is removed making it much smaller, hence it holds much less food than it did previously. In practical terms, think of your stomach currently holding about five cups of food and fluid. Your surgeon takes away about four cups, leaving you with a stomach that will hold about one cup. This smaller stomach helps you feel satisfied after eating a small amount of food. In addition, the part of the stomach that is removed is the part that secretes much of the hormone called ghrelin, which is involved in stimulating your appetite. It is thought that producing less ghrelin further helps to reduce hunger after surgery. Although ghrelin levels start to rise again after surgery, they don’t seem to return to their previous levels. Hunger is therefore more easily satisfied, making it more manageable to eat small portions of healthy food long term post surgery.

Your new sleeve shaped stomach empties more quickly than your previous stomach did, meaning food and fluid passes more quickly into your intestine. This triggers more hormonal changes that again, help you feel more satisfied.

RECOVERING FROM SURGERY

Following sleeve gastrectomy surgery there will be some swelling associated with creating the new, smaller stomach. You will therefore need to follow a recovery diet to allow your sleeve to heal. Details are discussed in the Recovering From Surgery section (page 65).

Another form of discomfort during recovery that is common after laparoscopic (keyhole) surgery is shoulder tip pain. It may last anywhere from two to three days after surgery, up to five weeks or more. Several factors have been thought to contribute to shoulder tip pain including the effect of gas used to create space in the stomach cavity during surgery, irritation or damage to the diaphragm or even movement of the shoulder during surgery.

EXPECTED WEIGHT LOSS

Whilst there is a wide variation in weight loss following surgery, the average weight loss with a sleeve is about 25 - 30% of your total body weight, with the majority of this occurring in the first year following surgery. Whilst this will be discussed in more detail later, it is important to consider your expectations around weight loss. If we take for example a person starting at 130kg, losing 25 - 30% (33 - 39kg) of their excess weight will mean they could achieve a weight of around 91 - 97kg. On a typical BMI chart, this weight range at 170cm is still classified as obese. It is therefore important to realise that weight loss surgery is unlikely to take you to a perfect BMI, but to a healthier weight where you are medically, physically and emotionally in a better place.

The early years of the sleeve journey are critical. Most people will lose the majority of their excess weight in the first year after having a sleeve. By three years after surgery, a sleeve is likely to stretch. Our stomach is designed to stretch; hence a sleeve will also stretch. This is inevitable, as when a sleeve is created, so too is a high pressure environment inside the new, tube-like stomach. The sleeve will hold it’s shape for around three years, but then, due to this increased pressure, it will tend to stretch. It is worth noting that regularly eating past the point of feeling satisfied could start to stretch the sleeve earlier than this, so be mindful of eating only to the point of being comfortably satisfied. Therefore your ongoing success will depend on your effort to change your lifestyle and maintain positive habits in the first three years.

Whilst the size of the stomach changes after surgery, the type of foods that can be eaten does not. Choosing high-energy (calorie or kilojoule) foods regularly will hinder your progress. As with other types of weight loss surgery, snacking or grazing, lack of physical activity and poor food choices can lead to weight regain. Positive, lifelong changes to eating and physical activity will ensure your long term success.

Living with a Sleeve

Unlike the adjustable gastric band the sleeve gastrectomy is not reversible. The stomach may stretch, or adapt to fit a little more food, but it cannot grow back. A sleeve is therefore a commitment for life.

As you will be eating less after a sleeve, making the most of your food choices is important to help you obtain all the nutrients required for good health. Preventing nutrient deficiencies is discussed in detail in the Nutritional Impacts of Weight Loss Surgery and Supplementation chapter (page 229).

EATING WITH A SLEEVE

Immediately following surgery, your sleeve may only tolerate one quarter of a cup of food (or fluid food) at one time. Therefore, during the recovery stage, it is important to sip small amounts of fluid regularly. Over time your sleeve will get used to a little more food. At six months, you will probably manage about half a cup of food at a time. By 12 to 18 months you will manage about one cup of solid food. This is a guide only and will vary between people.

In the first three to six months following a sleeve, some people find they are simply not hungry. Even if your appetite is poor, it is important to try and include small, regular meals of high quality, nutritious foods. Longer term it is important to listen to your hunger and fullness signals to guide your eating, but in the first six months, if you have no appetite you may need to eat according to the clock, rather than your hunger.

Protein is always a priority following weight loss surgery, but even more so in the early stages of recovery. It is vital that you include protein in preference to other foods. Protein will aid wound healing and help maintain your muscle mass, which has an impact on your metabolism long term. Choose high protein options as you progress through each of the dietary stages. This is discussed in more detail later.

Once you have fully recovered from surgery, the best way to know how much to eat is to listen to the signals from your sleeve to work out how much food is right for you. Some people with a sleeve are interested in the size of their sleeve, in the hope this may guide how much they should be eating. Sleeves do come in different sizes or widths, depending on the preference of your surgeon. Over time and with experience, surgeons who perform sleeve gastrectomy surgeries have moved to smaller sleeve sizes. Sometimes a larger sleeve size will be chosen depending on your energy and fluid requirements. A smaller sleeve will generally hold less food, however the best guide on how much food to eat long term is to trust your own signals.

Eat to a point where you feel satisfied; never eat past the point of feeling full. People with a sleeve often describe a feeling where they think they could probably fit in just one more mouthful. This is usually not the case and the extra mouthful causes discomfort. The aim is to eat until you are still comfortable. You will feel uncomfortable when you have eaten too much, so try to stop eating before this feeling. To learn more about interpreting your satiety signals, see the Hunger and Satiety Scale on page 117.

The amount of food you can tolerate will also vary according to the texture of food you eat. It is likely that you will tolerate more food if it is in a liquid form, rather than a solid form. For example, you will generally tolerate more of a chicken and vegetable soup than grilled chicken and steamed vegetables. Solid food will tend to sit in the stomach longer than liquid, so once you have recovered, try to limit liquid meals. Choose solid foods most of the time to help you feel satisfied for a longer time after eating.

DRINKING WITH A SLEEVE

Keeping hydrated in the early stages of living with a sleeve can be challenging. You may not feel as thirsty as you did prior to surgery, or the swelling associated with having surgery may make it difficult to drink and keep fluids down. Try the following to increase your fluid intake:

• Water can be difficult for some people immediately after surgery as it feels heavy. Try adding a small dash of juice, diet cordial or slice of lemon.

• Some find that the commercially available Fiji Water is easier to tolerate.

• Diluting protein waters such as the Protein Perfection, Feel Good Protein or BODIE’z protein waters with plain water, or using them like a cordial is also useful, making water easier to drink and boosting your protein intake.

• Start slowly and drink small amounts. Try 40-50ml spaced out over 30 minutes and increase the amount as you feel able.

• Sit upright when drinking. If you are able, walk around between drinks.

• Try drinks at different temperatures. You may find cold or hot fluids more comfortable than those at room temperature. Herbal teas are generally tolerated well.

• Choose very thin fluids in the initial stages as these are often easier to manage. Dilute thicker fluids such as smoothies and soups with milk, water or ice.

• Freeze nourishing liquids such as smoothies, milk drinks or meal replacements (discussed in more detail from page 34 ) into ice blocks and suck on them slowly over time.

• Some people may find rehydration solutions, such as Hydralyte®, may be beneficial to increase hydration.

Carbonated or ‘fizzy’ drinks are generally not well tolerated soon after surgery, causing pain and discomfort and putting too much pressure on your new stomach. Therefore it is best to avoid them.

If you are not getting enough fluid (or as much as you did prior to surgery) you may feel lightheaded or dizzy. When this happens you should sit or lay down until you feel more comfortable.

Following surgery your new, smaller stomach or sleeve cannot fit both food and fluid at one time so try to separate food and fluid by about 30 minutes. It is also difficult to drink large amounts of fluid quickly, so you will need to drink small amounts regularly. Make it a habit to sip fluids throughout the day. Remind yourself to drink often; carry a water bottle with you, keep a jug of water on your desk at work or in a place where you walk past it often at home. If you find plain water difficult, try some of the tips above.

It is a good goal to try to drink at least 1500ml (1½L) of fluid daily. In the early stages following surgery this may be challenging, but over time it will become easier. As you recover, food will take over from fluid as the main way to get your nutrition in, however it is important to still try and get 1500ml of low energy fluid daily.

VITAMIN SUPPLEMENTS

Vitamin supplementation is essential after all forms of weight loss surgery, including sleeve surgery. It is important to view the vitamins prescribed to you following surgery like you would medications; they are an essential part of daily life. This is discussed further in the Nutritional Impacts of Weight Loss Surgery and Supplementation chapter (page 229).

Troubleshooting with a Sleeve

NAUSEA

Nausea is common in the initial stages after a sleeve. To help manage this it is important not to overfill your new, smaller stomach. However, it is important to regularly take in small amounts of nutritious fluids, particularly those containing protein, and to keep hydrated. Try to sip small amounts frequently.

If the nausea is severe, some people may require medication. If you experience ongoing nausea or vomiting you should contact your team.

DUMPING SYNDROME

Whilst it is most common after a gastric bypass, dumping syndrome can occur with a sleeve. Dumping after a sleeve occurs as food empties more quickly from the stomach into the intestine than it did previously. For more detail on dumping syndrome, see page 18.

LACTOSE INTOLERANCE

We don’t have any firm data on how common lactose intolerance is after a sleeve, however it does seem to occur. Lactose intolerance can be treated by following a low lactose diet (using lactose free products and/or calcium fortified soy products) or supplementing your diet with the lactase enzyme. These options should be discussed with a dietitian. Removing all milk products completely from the diet is often not necessary and can make you miss out on important nutrients. It is important to note that lactose intolerance may not be ongoing and often improves with time.

CONSTIPATION OR DIARRHOEA

After weight loss surgery, many people will develop a new bowel habit. For some they will need to use their bowels more often and for some they will need to use them less often. In the early post surgery stages when your diet is mainly fluid or pureed food, you may find your bowels behave differently, often to one extreme or the other. Over time, this generally does settle, however it may be some weeks after you are back eating ’normal’ food. Diarrhoea is not an expected symptom of weight loss surgery, however some people will have diarrhoea as a result of dumping syndrome. Taking control of dumping syndrome can help to prevent diarrhoea.

Constipation can occur after all forms of weight loss surgery due to a reduced intake of both fibre and/or fluid. It is particularly common in people who limit or avoid high fibre foods such as fruit, vegetables and wholegrain/ multigrain bread and cereal foods. Constipation is managed by ensuring an adequate intake of fibre, an adequate fluid intake and regular physical activity. Soluble fibre supplements are also useful.

ALCOHOL

The enzyme responsible for breaking down alcohol is reduced after surgery, meaning alcohol is absorbed more quickly in the intestines. After surgery, people reach a higher blood alcohol level and maintain it for longer. This has been linked to alcohol dependence.

As a rule of thumb, remember that one drink feels like two. If you plan to drink, plan not to drive.

INADEQUATE WEIGHT LOSS OR WEIGHT REGAIN

Whilst weight regain is discussed later in more detail, it is important to mention some of the issues here. There are a range of reasons why those with a sleeve may regain weight. As discussed, a sleeve does stretch over time, which means that larger amounts can be eaten. There can also be a return of hunger, which if not managed carefully, can lead to an increased food intake. Often people rely on the sleeve, rather than work with it, or think that a sleeve will cure them of a weight issue, rather than put it into remission. Motivation can drop and there may be inadequate physical activity. One of the big issues with increased food intake however is a maladapted, or maladaptive eating pattern.

Maladapted eating is adapting your eating to suit your sleeve, rather than making it work for you. Snacking or grazing on small portions as they are easier to get down means that it is easier to eat more than if one larger, solid meal was consumed. Slider foods are another common phenomenon; soft, slippery, crunchy, easy to chew or liquid foods are often high in fat and/or sugar and therefore high in energy (calories or kilojoules). People may also extend out their meal times, eating slowly and taking regular breaks, and by doing