Sleeve Gastrectomy Surgery Healthy Eating

Guidelines

Weight LossSurgery Service

Notes

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Sleeve Gastrectomy

2

excised stomach

pylorus

gastric‘sleeve’

3

Introduction

Sleeve gastrectomy surger y has dramatically decreased the size of your stomach. It is important to follow these instructions carefully to prevent pain on eating, vomiting or damage to your new stomach.

This operation will enable you to lose weight provided you also work on changes to your lifestyle.

The quality of food you eat is very important to ensure you get the most success from your surgery.

Your diet needs to be well balanced and healthy and you need to be active, this will strongly influence how successful your weight loss is.

Your greatest weight loss will occur in the first 6–8 months following sleeve gastrectomy surgery. Most patients will plateau after 12–18 months and after this time additional weight loss will be difficult.

Follow the dietary guidelines in this booklet for each phase of your recovery. It is important to progress with textures of food carefully to allow time for your body to recover from the surgery and adapt to food again.

You must also follow the rules below in order to attain a weight that is close to your ideal body weight and to maintain your weight loss.

‘Golden rules’ for success

• Eat slowly (put your cutlery down between bites to help slow you down)

• Chew food well

• Stop as soon as you feel full (heavy in your chest)

• Do not eat and drink at the same time—have a drink 10–15 minutes before mealtimes and wait 30 minutes after eating before drinking

• Take small mouthfuls—using smaller cutlery can be helpful

• Avoid distractions at meal times—sit at the table and turn the TV off

• Use a tea plate rather than a dinner plate

• Sit in an upright position when eating and rest afterwards

• Aim to eat 3 small meals per day with small snacks in between if needed

• Eat protein foods first

• Avoid drinks that are high in calories and avoid fizzy/carbonated drinks

• Avoid foods and fluids containing sugar or high amounts of fat such as pure fruit juice—these will slow down your weight loss

4

Importance of protein

It is important to ensure adequate protein intake after surgery. Protein is the nutrient the body uses to make new tissue. It is important to get enough protein after surgery to help with wound healing and help preserve muscle tissue, so the weight that is lost is fat mass.

To ensure you are getting adequate protein in your diet we recommend you include a protein source in each of your meals and snacks. It is important to eat the protein source first at meal times.

Good sources of protein:• Meat—including red meat/fish/chicken• Eggs• Low fat dairy products—including

skimmed milk, low fat low sugar yoghurt, low fat cottage or creamed cheese, fromage frais

• Pulses/legumes and lentils—including baked beans

• Tofu or Quorn®

We recommend you include a pint of skimmed milk and a protein shake twice a day for the first 6 weeks following surgery.

Supplementation

You will be prescribed a multivitamin and mineral supplement which needs to be taken once daily until you are weight stable and eating a balanced diet that will provide your necessary vitamins and minerals.

Dietary advancement

Phase 1Begin: Day of surgeryEnd: After gastrograffin swallow performed and no leaks detectedFood type: Nil by mouth

Phase 2 (initial phase)Begin: After gastrograffin swallow performed and no leaks detectedDuration: 1 dayFood type: Free fluidsAmount: Sips increasing as tolerated Fluid goal: 1,000–1,500ml/4–6 cups per day

Phase 3 (free fluid phase)Begin: Day 2Duration: 9 daysFood type: Free fluidsAmount: 3–6 servings per day—125–190ml/½–¾ cup maximum per servingFluid goal: 1,500ml/6 cups per day

Phase 4 (purée phase)Begin: Day 10 (~week 3)Duration: 4 weeksFood type: PuréeAmount: 3–6 servings per day—125–190ml/½–¾ cup maximum per servingFluid goal: 1,500–2,000ml/6–8 cups per day

Phase 5 (soft phase)Begin: Day 38 (~week 6)Duration: 2 weeksFood type: Soft Amount: 3 meals + 3 snacks per day— 250ml/1 cup maximum per mealFluid goal: 1,500–2,000ml/6–8 cups per day

Phase 6 (regular diet)Begin: day 53 (~week 8)Duration: ongoingFood type: solid Amount: 3 meals + 3 snacks per day— 250ml/1 cup maximum per mealFluid goal: 1,500–2,000ml/6–8 cups per day

5

Example meal plan for free fluid phaseMeal Suggested menu

Breakfast • 62ml/¼ cup skimmed milk + 62ml/¼ cup diluted apple juice

Lunch • 62ml/¼ cup thin soup + 62ml/¼ cup low fat liquid yoghurt

Supper • 62ml/¼ cup thin soup + 62ml/¼ cup skimmed milk

Snacks • 62ml/½ cup protein shake—2–3 times per day

Start date Finish date

Each meal/drink should not exceed 125ml/½ cup per serving and have no solid bits in it.

Aim for 1,500ml/6 cups per day to avoid dehydration—spread your fluids out over the day.

Examples of fluids:• Skimmed milk• High protein drink/shake—125ml/

½ cup twice a day• Water• Diluted fruit juices—no pulp • Vegetable juices—no pulp• Sugar free squash

• Milk-based drinks• Sugar free jelly• Marmite®, Bovril®, consommé,

bouillon• Thin (strained) soup• Herb/fruit teas• Tea and coffee—try to keep to a minimum

as provides almost no nutritional value and can reduce iron absorption if taken with food (use sweeteners not sugar)

Avoid fizzy/carbonated drinks as these will make you feel uncomfortable and can cause bloating. It is important you try to avoid these as much as possible for life.

Free fluid phase10 days (1–10 days) post surgery

6

The size of your meals should not exceed 125–190ml/½–¾ cup.

Puréed foods should be a similar consistency to baby food or apple sauce. There should be no lumps or stringy pieces—this is most easily achieved by using a food processor or handheld blender.

Put some of the water used to boil the vegetables or consommé in the blender to get the right consistency for puréed meat, fish and poultry. Remove skin, bone and gristle from meat or fish before blending.

Liquidise dishes separately—for example, separate liquidised potatoes from liquidised meats—to keep a better appearance and

taste. Liquidise in bulk and freeze—ice cube holders are useful to portion out dishes. Use herbs and spices to flavour dishes.

Examples of puréed foods: • Low fat yoghurt/low fat fromage frais/

custard• Blended soup• Puréed chicken, white fish or turkey (red

meat is harder to purée)• Puréed legumes or lentils• Puréed potato• Puréed fruit• Soft cereals (Weetabix®, Ready Brek®)

with lots of skimmed milk• Sugar-free puddings

Start date Finish date

Purée phase4 weeks (11–38 days) post surgery

Example meal plan for purée phaseMeal Suggested menu

Breakfast• 1 Weetabix® with skimmed milk or• 1 pot of low fat low sugar yoghurt or fromage frais or• 45ml/3 tbsp porridge or Ready Brek® with skimmed milk

Lunch • 250ml/1 cup smooth soup or• 1 egg (scrambled)

Supper• 45–60ml/3–4 tbsp puréed chicken + 10ml/2 tsp puréed

potato and cheese + 10ml/2 tsp puréed vegetables

Snacks• Low fat and sugar custard with apple purée or• Skimmed milk putting (such as rice or sago) or • Low fat and sugar yoghurt/fromage frais

7

Example meal plan for soft phaseMeal Suggested menu

Breakfast

• 1 ½ Weetabix® with skimmed milk or• 1 slice toast + low fat cheese or ham or 1 egg or• 1 pot of low fat yoghurt or fromage frais or• 45ml/3 tbsp porridge/Ready Brek® with skimmed milk

Lunch

• 1 cup soup made with skimmed milk/meat/beans/lentils or• 1 egg (scrambled) or• 50g cooked fish/minced chicken or turkey/ground beef/pulses or• 30ml/2 tbsp risotto/mashed potato/winter squash

Supper

• Shepherd’s pie or• Fish pie or• 50g fish/minced chicken or turkey/ground beef or• 40g low fat mild cheese or• 125ml/½ cup mashed potato/sweet potato/winter squash or • 4–6 crackers/1 slice toast

Snacks (aim for 3 per day)

• Custard with puréed apple or• Milk pudding (such as rice or sago) or• Low fat and sugar yoghurt or fromage frais

Fluids

• Water • Skimmed milk• Protein drink (see page 5 for recipe)• Diluted fruit juice or diet squash• Tea, coffee (sweetener, no sugar)

Start date Finish date

The size of your meals should not exceed 190–250ml/½–¾ cup.

Continue eating the same sort of food you were for the purée phase, but it does not need to be blended—mashing will make it the consistency of toddler food. It should be still soft, or able to be broken up with a fork. Keep to the same quantities and eat 4–6 times per day.

Cook all meat for longer than you would normally and use moist methods of cooking as this will help to make the meat more tender and easier to chew.

Include protein in every meal (see protein sheet for guideline amounts).

Examples of soft foods:• Well cooked/mashed vegetables • Soft minced meat with gravy• Flaky fish • Puréed fruits, moving on to tinned fruit

gradually • Soft cereals such as Weetabix®• Scrambled eg gs/omelet te/eg g

custard (hard boiled eggs are not well tolerated)

• Baked beans (mashed initially)

Soft phase2 weeks (39–52 days) post surgery

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You can start to reintroduce more solid foods into your diet 8 weeks after surgery. It is important to focus on the quality of your diet at this stage to get the most benefit from your weight loss surgery.

Successful patients who have had a sleeve gastrectomy have 2 things in common:

1. They follow their dietary recommen-dations closely (see ‘golden rules’ at beginning of booklet).

2. They initiate a regular exercise programme 40–60 minutes 4 times per week.

Caution foods

There are some foods which are more likely to make you sick if you introduce them too early. It is important to learn about the new restriction your pouch is providing before you progress to the tougher, firmer foods.

The following foods some people find more challenging—we do not recommend you avoid them but that you should take care when you introduce them back into your diet.

If you do have trouble with any foods we recommend you remove them from your diet for 2–3 weeks and then retry them.

Examples of caution foods:• Fibrous foods—string beans, pineapple,

celery, sweet corn, fruit segments, those with pips and seeds

• Foods with a skin—tomatoes, grapes, some fruits

• Over-cooked pasta

• Dried fruit

• Firmer, chewier meats—steak, pork or chicken if roasted or barbecued (casseroles, minced meat or pot roasts, which tenderise meat, are easiest to eat)

• Bread—particularly white, soft bread (Weight Watchers® and Nimble brand bread may be better tolerated. Toast is also more manageable)

• Rice

• Nuts

The meal plan on page 10 is a guide to what sorts of foods and amounts you should be eating on a regular diet.

Start date

Regular diet phasefrom week 8 (day 53) post surgery—ongoing

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Side effects

Dumping syndrome

Dumping syndrome occurs when sugars go directly from your stomach to your small intestine or when undigested contents of your stomach are transported or “dumped” into your small intestine too rapidly.

You may experience the following unpleasant symptoms if you consume food or fluids high in fat, sugar or alcohol:

• Nausea• Rapid heart rate• Sweating• Stomach cramps• Diarrhoea• Sweating• Dizziness• Pallor• Feeling faint• Weakness

What to doAvoid the food that is causing the problem. It can be helpful to keep a food and symptom diary to look for trends.

It can help to stick to 3–6 small meals per day that include some protein and low glycemic index (GI) carbohydrate (ask your dietitian for examples).

Avoid ‘testing the limits’. Some people like to test different foods that are high in fat or sugar, to see how much they can get away with eating before they get symptoms of dumping syndrome.

This is not advisable as the more your body is exposed to these foods, the sooner your intestines will adapt to absorbing them without getting symptoms, and the less weight you will lose. Also, everyone is individual and what affects one person may not affect the next.

Vomiting

This should not occur. If it does, ask yourself:

• Did I eat too quickly?• Did I eat too much?• Did I chew it well enough?• Did allow enough time between eating

and drinking?• Did I eat the right texture?

If you are still vomiting after you have addressed all of the above consider how soon it is after surgery. If it is within the first 2 months, try returning to a liquid or purée diet and see if symptoms resolve. You may just need to take longer to progress through the phases.

If you experience daily vomiting for more than 3 days even on fluids, contact a member of the team for further advice. We may need to admit you for IV hydration, thiamine supplementation and an X-ray to check for any surgical complications.

Hair loss

In the early stages after surgery, weight loss can be very rapid and some people notice that their hair is beginning to thin. However, providing the rate of weight loss slows down and the diet is balanced, hair will return to its normal condition. Ensuring you have an adequate protein intake is essential.

Constipation

To prevent constipation, make sure you drink sufficient fluids (1,500–2,000ml/6–8 cups per day) and eat foods high in fibre such as wholegrain cereals, fruit and vegetables. If you continue to get constipated you could take a non-bulking agent such as Benefiber®, Movicol®, Senna®, glycerine suppositories or milk of magnesia. See your doctor or pharmacist for advice or contact your team at Chelsea and Westminster.

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11

Dietitian appointments

You will be followed up regularly to monitor your progress and wellbeing.

We will monitor your weight loss and discuss any problems or difficulties you may be experiencing and help to prevent any problems becoming complications.

We will expect you to attend appointments every 3 months for the first year, every 6 months for the second year, and annually thereafter.

If you have any queries or questions regarding the dietary guidelines or if you have started feeling unwell after following it, please contact us.

Specialist Dietitians in Weight Loss SurgeryT: 020 3315 8161/8178E: obesity@chelwest.nhs.uk

Patient support group

We would also encourage you to join our patient support group.

This is held at Chelsea and Westminster Hospital, every third Tuesday of the month from 6–8pm.

Visit www.chelwest.nhs.uk/weightloss and choose ‘Getting Support’ from the sidebar to find out topics, venues and dates of these meetings.

The British Obesity Surgery Patient Association (www.bospa.org) also has a number of support groups within England.

Weight Loss Surgery Service

369 Fulham RoadLondonSW10 9NH

Main Switchboard020 8746 8000

Websitewww.chelwest.nhs.uk

August 2012