Nutritional Deficiency After Gastric Bypass Surgery

Nutritional Deficiencies in Obesity & After Bariatric Surgery

Obesity is defined as Body Mass Index (BMI) greater than 30 and is further classified as grade 1 (BMI 30 to 34.9), grade 2 (BMI 35 to 39.9) and grade 3 (BMI ≥40). It is one of the leading medical issues facing developed countries in modern medicine. Obesity increases the risk for cardiovascular disease, diabetes, hypertension and dyslipidaemia, (high cholesterol). In 1987, Manson et al proved that being overweight (BMI >25) was associated with increased risk of death. In the same year, Donahue et al.  found an association between coronary heart disease and central obesity. In addition to the physical toll, mental health disorders are also more prevalent in obesity. A study (n=662) showed that obesity was more common among subjects suffering from depression when compared to subjects with normal BMI. However it is worth noting that most medications used by psychiatrists leads to weight gain.

 

In terms of US dollars the cost of obesity is high and will continue to increase. In 2008 the US spent an estimated 147 billion dollars on the medical costs of obesity. Bariatric surgery is shown to be effective in reducing weight and modifying the risk factors associated with cardiovascular morbidity. Based on current NIH guidelines, bariatric surgery should be considered for grade 3 obesity or grade 2 obesity with two or more comorbidities that are related to obesity (e.g. diabetes and hypertension). Compared with usual care, bariatric surgery is associated with decreased number of cardiovascular deaths and lower incidence of cardiovascular events in obese adults. Surgery also decreased the risk of developing diabetes when compared to usual care in obese persons. The most dramatic effect of bariatric surgery is weight loss and bariatric surgery has shown to either normalize blood pressure or reduce the need for antihypertensive therapy and the effect seems to correlate with the degree of weight loss. A meta-analysis of 29,000 patients undergoing bariatric surgery, showed that bariatric surgery patients had 50% reduction in mortality, compared to non-surgical controls.

 

Types of Bariatric Procedures

Bariatric procedures can be divided into two broad categories: restrictive and malabsorptive. Restrictive procedures include the laparoscopically placed adjustable gastric band that forms a small gastric reservoir of about 15ml.  The sleeve gastrectomy is a restrictive procedure, which leaves a narrow gastric pouch of about 100 ml, and the Roux-en-Y Gastric Bypass (RYGB) is a combined restrictive and malabsorptive procedure, in which the stomach is divided into a small pouch of about 30 ml. This procedure leaves the majority of the stomach excluded and bypassed by ingested food particles. The gastric pouch connects to a Roux limb of jejunum and this results in food particles bypassing some of the small intestine and decreasing the surface area for digestion and absorption.

 

Nutritional Deficiency and Obesity

The obesity epidemic in the United States may be viewed as a form of malnutrition with an obvious excess of calories, often supplied in the form of fat and sweetened beverages, but with a limited use of healthy foods. Prior studies clearly demonstrated a link between poverty rates, high fast food restaurant density and difficult access to supermarkets or other sources for fruits and vegetables. Another hypothesis is that obesity is associated with an inflammatory state that results in lower levels of specific nutrients. Studies have been done that may explain the apparent paradox that obese people may already present with micronutrient deficiencies. Vitamin B12 is a common deficiency in obese patients and pre-operative nutritional assessments have found Vitamin B12 deficiencies that vary between 3-11%. Vitamin D deficiency is common in temperate zones and has been seen in obesity, with a reported prevalence ranging up to 60%. BMI can lead to increased or decreased risk of fracture depending on the type of bone. There is some evidence of the association of iron deficiency with obesity and pre-operative assessments have found obese subjects to be iron deficient up to 18 %.

 

Nutritional Deficiencies after Gastric Bypass

surgery

Nutritional deficiencies after bariatric surgery are multifactorial. Patients that are assessed for bariatric procedures are strongly encouraged to lose as much weight as possible prior to their procedure. Hence patients go on low calorie diets to lose weight and therefore are more susceptible to deficiencies of iron, B12 and calcium. Bariatric surgery causes drastic anatomical changes of the digestive tract that alters the normal process of digestion. The capacity of the stomach to hold food and secrete juices that facilitate digestion is reduced. So after RYGB, the capacity of the remnant gastric pouch is only 20 ml and similarly, the surface area for digestion and absorption of food in the small intestine is markedly reduced, depending upon the amount of intestine resected. It is reasonable to presume that such alterations in the gut anatomy will adversely affect nutrient metabolism.

 

This makes bariatric surgery patients more vulnerable to micronutrient deficiencies and protein energy malnutrition. After surgery the patient is on a liquid only diet for period of 2-4 weeks then this diet is gradually advanced to pureed diet over the next few months. Patients cannot tolerate large quantities of food after surgery and their daily caloric intake during the initial postoperative period typically ranges between 500-900 kcal/day. It is difficult to maintain adequate micronutrient intake on such low caloric diets. Furthermore, postoperative complications like vomiting, obstruction, fistula formation, ulcers and dumping can also prevent adequate nutrition. Small bowel obstruction is a late postoperative complication that can occur following RYGB. The risk is higher with laparoscopic RYGB and the obstruction is usually due to internal hernias. Fistula formation is a common complication of sleeve gastrectomy. A meta-analysis showed that fistula rates in sleeve gastrectomies were up to 2.2% and other studies showed fistula rates ranging from 0 to 20%.

vitamins, pills and tablets

Considering the potential for nutritional deficiencies, patients are routinely asked to take multivitamins, supplemental calcium and iron. Supplementation is especially important for patients undergoing the gastric bypass bariatric procedure. However studies have shown that patient compliance with these supplements is low and therefore it is difficult to maintain adequate nutrition. A study showed that over a 10-year period only 33% of patients were compliant with nutritional supplements. These high rates of non-compliance with supplementation make it even more difficult to treat micronutrient deficiencies.

Thiamine B1

Thiamine deficiencies after gastric bypass can result in weakness, polyneuropathies (a disease affecting peripheral nerves), beriberi, Wernicke’s Encephalopathy (WE), nystagmus and hearing loss. The most serious manifestation of thiamine deficiency is Wernicke’s encephalopathy and the main risk factor identified was persistent vomiting and intravenous administration of glucose without thiamine. Wernicke’s encephalopathy leaves residual neurological defects in the majority of the affected. The prevalence of thiamine deficiency in a study following 318 subjects for 2 years was 18%. In a review of subjects who underwent bariatric surgery and developed Wernicke’s encephalopathy, 95% of the affected patients underwent the gastric bypass.

Vitamin B12

The reported prevalence of B12 deficiency widely varies. Studiesyringes report a prevalence that ranges from 11% to 70% after the bariatric surgery. It is worth mentioning that B12 deficiency is prevalent prior to surgery and can be as high as 18%. B12 is mostly bound to protein in our diet and the prevalence of B12 deficiency increases after surgery for all patients, but it is found to be greatest with RYGB procedures and least with restrictive procedures. Supplementation is recommended, as even with supplementation, vitamin B12 levels in a study were found to be in the lower thirds of the reference range. Supplementation can be oral, intranasal, sublingual or intra muscular. The best evidence of efficacy is for the intramuscular route (regular B12 injections).

 

Vitamin D

Vitamin D deficiency is quite common in bariatric patients being assessed for surgery. Post operatively it is very difficult to assess the impact of bariatric surgery on vitamin D metabolism. In most studies vitamin D levels increase with aggressive supplemental regimens. However despite improvements in serum levels the prevalence of vitamin D deficiency remains high. In a study of a group of patients’ status post LAGB (Laparoscopic Adjustable Gastric Banding), vitamin D deficiency decreased from 58% to 33% but this was not significant. Gastric bypass leads to bone loss, high PTH and 25(OH) D levels. This can be seen despite supplementation with calcium. Vitamin D deficiency increases risk of hypocalcaemia, bone loss with resulting fractures and even osteomalacia. Acutely hypocalcaemia can be associated with cramps and changes in sensory function, which have been reported after bariatric procedures.

Iron

Iron deficiency after gastric bypass is common. A retrospective analysis of 959 subjects status post RYGB found that 51% were deficient in iron. Almost half of the iron deficient subjects (40%) were severely deficient. Meat intolerance is common post gastric bypass and results in the absence of an important source of iron in the diet. The overall low parietal cell mass of the pouch results in hypochlorydia and is thought to be one of the mechanisms that lead to decreased absorption of iron in the gut. Iron is absorbed in the duodenum and thus its removal compromises iron absorption. It has been shown using radiolabelled isotopes that iron absorption worsens after gastric bypass. Iron absorption was measured before and after gastric bypass and was found to be decreased in the latter.

Conclusion

Obesity is a common disease in the USA and globally. The incidence and prevalence of obesity is rapidly increasing. Obesity increases the risk of cardiovascular diseases, diabetes and dyslipidemia. Obesity also leads to poor self-esteem and lack of self-confidence as obese individuals consider or are considered as unattractive. Obesity and its associated health risks have a huge financial burden with the estimated cost around 147 billion dollars in 2008. Obesity is a paradoxical state of malnutrition that consists of excessive caloric intake and micronutrient deficiencies. This state can be partially explained by poor dietary choices and poor access to food rich in nutrients. It is also hypothesized that obesity is a state of inflammation and abnormal micronutrient metabolism that results in deficiencies of iron, b12 and vitamin D. The fact that obese people can have micronutrient deficiencies needs to be recognized. This will allow for increased screening, diagnosis and treatment of micronutrient deficiencies in obese people.

 

Bariatric surgery is indicated for obese individuals with BMI > 40 or BMI > 35 and two or more co-morbidities that are obesity related. Bariatric surgery has shown to help obese patients lose up to 20-35 % of baseline weight and decrease mortality, incidence of diabetes and adverse cardiovascular events. Post bariatric surgery patients have also been found to have micronutrient deficiencies including iron, b12 and vitamin D. The cause of micronutrient deficiencies in patients who have undergone bariatric surgery is multifactorial. Micronutrient deficiencies after bariatric surgery is a result of pre-existing micronutrient deficiencies severely decreased caloric intakes, surgical complications and perhaps altered post-surgical digestive anatomy.

 

Micronutrient metabolism in obesity is complex and not completely elucidated. As our understanding of the complex physiology of micronutrient digestion in obesity develops, so will our ability to treat micronutrient deficiencies. Further research needs to be done to address questions like Recommended Dietary Intake (RDI) of micronutrients for obese subject and RDI of micronutrients for post bariatric surgery patients. Also supplementation for micronutrient deficiencies for obese patients and bariatric surgery patients is not evidence based. Currently supplementation for bariatric surgery subjects is higher than RDI but there is little evidence of benefit. One could argue that even higher dose supplementation might still be inadequate. Nutrition in bariatric surgery is challenging. The importance of identifying and treating micronutrient deficiencies prior to surgery is reiterated. After bariatric surgery it is important to maintain close follow up for nutritional status as deficiencies can result in devastating consequences including Wernicke’s encephalopathy, neuropathies and heart failure.

 

Title: Nutritional Deficiencies in Obesity & After Weight Reduction

Published: Annals of Nutritional Disorders and Therapy 2(2):id1024 (2015)

Authors: Owais Bhatti, Klaus Bielefeldt and Salman Nusrat

 

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How Obesity Negatively Affects The Joints

 What’s the link between obesity and skeletal health?

 

At least 2 studies have now shown the negative impact that obesity can have on one’s skeletal health, thereby highlighting the importance of losing weight, especially through bariatric surgery when necessary.

 

The first of the studies found a correlational link between obesity “and a higher risk for surgery in orthopaedic trauma patients”. Furthermore, what was particularly fascinating about the study was that the researches discovered that those patients who were obese spent longer in the hospital and therefore had greater treatment costs. On top of this “there were also more likely to be discharged to a care facility, rather than to home”.

 

Essentially, the study discovered the following:

 

  • “Obesity increased the risk of surgery: 72% of the obese patients required surgical treatment”.
  • “Patients with a lower BMI had shorter hospital stays”
  • “Mean hospital costs were $160,606 for non-obese patients and $234,863 for obese patients”.

 

But what has all of this got to do with skeletal health?

 

In another study, involving animals, researchers at the University of Missouri “examined how the development of obesity and insulin resistance contributes to bone-fracture risk”. The study concluded that the obesity and Type 2 diabetes negatively affected bone; the bone quality was not very good as once thought, meaning that they have an increased risk of fractures.

 

What is more concerning and alarming about the study is that a link was found between bone mass and obesity; i.e. those that were obese did not accumulate “as much bone mass relative to their body weight”. The researchers concluded that “decreased bone formation, loss of bone mass and decreased bone strength were present in the obese animals”.

 

The important of losing weight can therefore be seen as vital. One’s bone strength, quality and mass is impacted by obesity and therefore losing weight is necessary to increase skeletal health. Moreover, by losing weight there is a decrease in the risk of orthopaedic trauma.

Obese Men Do Not Seek Surgery As Soon As They Should?

Major Gender Disparity Among Bariatric Patients

Researchers at the University of California, San Diego School of Medicine, have identified demographic, socioeconomic and cultural factors that contribute to a major gender disparity among men and women undergoing weight loss surgery. The study, “Benefits of Bariatric Surgery Do Not Reach Obese Men” reported that 80% percent of patients who undergo bariatric surgery are female, despite equal rates of obesity among American men and women.

 

In the study it was interesting to note that patients were more likely to be female if from a lower income group or if African American or Hispanic. Patients were less likely to be female with increasing age, more comorbidities, or private insurance. Another factor driving more women to have surgery could also be cultural and men have a skewed male body perception which hinders the likelihood of seeking health-care advice.

 

The results of this study should raise awareness in men about the complications that obesity brings to their health. Men only begin to seek the surgery as they age and become sicker as they generally seem more satisfied with their health even when they were classed as overweight or obese compared to women. Women also seem to be more aware of the problems obesity brings to health. They are more willing to look at surgical weight loss earlier in life, whereas men tend to wait until they develop obesity related complications.

 

Men need to be educated about the need to treat obesity earlier so that they don’t develop complications in the future. Weight loss surgery contributes to improving medical conditions associated with obesity such as, diabetes, high blood pressure, high cholesterol, sleep apnea and arthritis. Men need to wake up to the need to control their obesity and invest in their future health and quality if life.

 

Reference: Journal of Laparoendoscopic & Advanced Surgical Techniques March 2015, 25(3): 196-201. Doi10.1089/lap.2014.0639

 

Authors: Fuchs Hans F, Broderick Ryan C, Harnsberger Cristina R, Chang David c, Sandler Bryan J, Jacobsen Garth R & Horgan Santiago.

 

Physicians Endorse Weight Loss Surgery

New Joint Scientific Statement Issued on Use of Bariatric Surgery to Improve Cholesterol Levels and Reduce Risk of Heart Disease

Dr

JACKSONVILLE,
FLORIDA, US (Market wired – February 16, 2016)

Bariatric surgery is effective in improving cholesterol and lipid levels, important risk factors for heart disease, according to a new joint scientific statement by the National Lipid Association (NLA), American Society for Metabolic and Bariatric Surgery (ASMBS), and Obesity Medicine Association (OMA). The statement was published in the January/February issue of the Journal of Clinical Lipidology, the official journal of the NLA.
“Patients who have excess weight or obesity may store over 50 percent of their body cholesterol in body fat,” said Carl Orringer, MD, president of the NLA and associate professor of medicine at the University of Miami Miller School of Medicine. “Bariatric procedures that promote body fat loss can reduce cholesterol blood levels, especially bariatric surgeries that result in the greatest amount of weight loss.”

According to the statement, a reduction in body fat, as well as favourable alterations in endocrine and inflammatory homeostasis are among the mechanisms by which bariatric procedures may improve dyslipidemia. Bariatric procedures may also have favourable effects on bile acid metabolism and the intestinal microbiome, which may also improve dyslipidemia.

The first part of the statement published this month, focuses on the mechanism by which bariatric surgery affects cholesterol and lipid levels. The second part of the statement, which focuses on risk factors and surgical outcomes, will be published in the March/April edition of Surgery for Obesity and Related Diseases (SOARD), the official journal of the ASMBS.

“Bariatric surgery is well known to improve diabetes mellitus in patients with obesity,” said Harold Bays, MD, an executive officer of the NLA and lead author. “But what is less well recognized is the beneficial effect bariatric surgery may have on cholesterol levels, which is one of the most important risk factors for heart disease. In fact, it is sometimes forgotten that decades ago, gastrointestinal surgery was proven effective as a treatment for high cholesterol,” said Dr Bays.

“Disease-reversing weight loss of 10-25 percent of body weight can occur using both medical and surgical means. While as little as 10 percent weight loss may not return an individual with obesity to a normal body mass index (BMI), the beneficial health impacts are well documented and include a profound improvement in lipid profile and reduction in other cardiac risk factors, including blood pressure and fasting glucose levels,” said Wendy Scinta, MD, MS, president-elect of the OMA and medical director of Medical Weight Loss of NY.

“We believe this important scientific statement will assist clinicians in better engaging with patients on the treatment of obesity and the consideration of bariatric surgery as an important option for those with risk factors for heart disease,” said Raul Rosenthal, MD, president, ASMBS.

 

Title: Lipids and bariatric procedures part 1 of 2: Scientific statement from the National Lipid Association, American Society for Metabolic and Bariatric Surgery, and Obesity Medicine Association

Authors: Harold E Bays, Peter H Jones; Terry A Jacobson; David E Cohen; Carl E Orringer; Dan E Azagury; John Morton; Ninh T Nguyen; Deborah B Horn; Wendy Scinta and Craig Primack

DOI: http://dx.doi.org/10.10/j,jacl.2015.12.003

 

How Well Do Weightloss Pills REALLY Work?

Weight Loss Dietary Supplements Need To Be Regulated

 

Approximately 30% of adults in the US report using dietary supplements for weight loss, contributing to nearly US$2 billion a year on these products. However, many supplements have no evidence to support weight loss claims made on labels and in advertising.

 

Four leading obesity research, treatment and prevention groups have issued a joint scientific statement recommending dietary supplements for weight loss claiming curative or medicinal qualities be subject to review and approval by the FDA. In order to protect the public from false claims of safety and efficacy of dietary supplements the groups are calling for the reform of the 1994 Dietary Supplement Health and Education Act (DSHEA) to provide the FDA and the Federal Trade Commission (FTC) with increased regulatory and funding.

 

The statement reads: “All publicly available dietary supplements sold or advertised for weight loss should have randomised, double blinded, placebo-controlled studies of sufficient duration to support both safety and claimed efficacy. These randomised controlled trials should be of appropriate magnitude and rigor. If a dietary supplement is marked as curative or medicinal it should be categorised as a drug and subject to enforcement by the FDA”.

 

“While we acknowledge that there may be effective dietary supplements on the market, there is a clear need for long-term data showing the benefits, safety and effectiveness for these unregulated treatments claiming weight management,” said Dr Steven R Smith, The Obesity Society (TOS) past-president and Chief Scientific Officer at Florida Hospital, Orlando, FL.

 

According to the statement, the harm can go beyond financial losses, including:

 

 

  • exposure to unsafe ingredients including drugs removed from the market or compounds not adequately studied in humans;
  • exposure to products tainted with prescription drugs, and;
  • deleterious response to products that may include increased blood pressure, cardiac arrhythmias, stroke, seizure and even death

 

While weight loss is recognised as a treatment for obesity, according to the FDA, dietary supplements should not make claims that their products will “diagnose, treat, cure or prevent any disease”. Legally only FDA-approved drugs can make those claims. Currently under the DSHEA, dietary supplement companies are not required to provide pre-market data for the safety and claimed efficacy, or evidence that label claims are not false or misleading to consumers.

 

Consumers struggling with their weight who do not experience direct harm from the purchase of dietary supplements, the groups say, “misleading and unsubstantiated claims detract consumers from evidence-based interventions and treatments, such as FDA-approved medications, metabolic and bariatric surgery and commercial intensive lifestyle intervention programmes with proven safety and efficacy”.

 

In addition to the regulatory recommendations, the groups proposed steps to help healthcare providers address the dangers with patients:

 

  • Be aware of the lack of credible evidence for efficacy and safety of many supplements promoted for the purpose of weight loss.
  • Query patients who desire to accomplish weight loss regarding their use of dietary supplements for this purpose.
  • Advise patients who desire to accomplish weight loss of the limited evidence supporting the efficacy and safety of many supplements and the lack of oversight by government agencies regarding the claims made about such supplements.
  • Be educated on the DSHEA and the roles of FDA and FTC in safety and claims monitoring of supplements promoted for the purpose of weight loss.
  • Avoid engaging in entrepreneurial activities in which they may directly profit from the prescribing of non-FDA approved weight-loss remedies where both safety and efficacy have not been proven.

 

TOS’s Advocacy and Public Affairs Committees led the development of the statement over a six month period, adhering to a rigorous, scientific process and review of existing peer-reviewed research. In addition to TOS, signatories include the Obesity Action Coalition, the Obesity Medicine Association, and the Academy of Nutrition and Dietetics.

 

Source: The Bariatric News Wednesday 21st October 2015

 

Weight Loss Surgery Appropriate for Recently Diagnosed Diabetics

Obese Type 2 Diabetics Should Be Prioritised For Weight Loss Surgery

 

Obese patients with type 2 diabetes and especially those diagnosed with recent diabetes should be prioritised for weight loss surgery over those patients with a higher BMI and diabetes. When taking healthcare costs into consideration many patients see a reversal of diabetes after surgery which means fewer expensive diabetes medication or treatment for diabetic related complications in future.

 

These are claims made by Swedish and Australian researchers in their paper, “Health-care costs over 15 years after bariatric surgery for patients with different baseline glucose status: results from the Swedish Obese Subjects Study”, published in The Lancet Diabetes & Endocrinology.

 

Current Situation

 

Most healthcare systems prioritise access to weight loss surgery based on a person’s BMI which generally means that high BMI patients get priority. Patients with lower BMI’s and obesity related health problems like type 2 diabetes should also be considered for surgery but guidelines around the world differ greatly. It has been recommended that the status of the patient’s diabetes rather than BMI alone be used to select patients to receive weight loss surgery. The long term effect of weight loss surgery relative to conventional therapy on the costs in obese patients according to their diabetes status has not been assessed using real world data. Therefore, the authors of this paper wanted to look at the healthcare costs over 15 years for this group of patients treated medically and surgically.

 

Method

 

The study included 2,010 patients who had weight loss surgery and were matched with a control group of 2,037 patients who were treated medically. The patients came from 25 surgical departments and 480 primary health-care centres. The researchers retrieved the prescription drug costs for the patients via questionnaires and the nationwide prescribed drug register. They followed up the sample linked to register data for up to 15 years.

 

Outcome

 

The authors state that previous studies have assessed the entire eligible obese population and have likely underestimated the cost benefits of weight loss surgery for patients with type 2 diabetes while overestimating them for patients without type 2 diabetes. This study demonstrated that for obese patients with type 2 diabetes, the upfront costs of weight loss surgery seems to be largely offset by prevention of future health-care and drug use. This finding of cost neutrality is seldom noted for health-care interventions, nor is it a requirement of funding in most settings. Usually, buying of health benefits at an acceptable cost (eg £20 000 per quality adjusted life year in the UK) is the economic benchmark adopted by payers when new interventions are assessed. Weight loss surgery should be held to the same economic standards as other medical interventions.

 

In conclusion weight loss surgery should be an option for patients with type 2 diabetes regardless of the BMI.

 

Reference: DOI: http://dx.doi.org/10.1016/S2213-8587(15)00290-9

 

Authors: C. Keating, M.Neovius, K. Sjoholm, M. Peltonen, K. Narbro, J. Eriksson, L. Sjostrom & L. Carlsson

Eating with a BioRing Gastric Band

A PRACTICAL GUIDE TO EATING AND DRINKING AFTER YOU’VE HAD A GASTRIC BAND

 

The gastric band is an effective way of losing weight, however, the band is only going to work properly and help one lose weight if one follows a healthy diet. In essence, the diet needs to be low fat, low calorie and portion controlled. What will be written over the course of these next few paragraphs will serve as a basic guide on what to expect after the first few weeks of having the surgery and then how to maintain an appropriate diet (what foods can be eaten and what foods should be avoided).

Patient

Immediately after having the surgery and for the first 4 weeks following the operation no solid foods should be taken. Instead a liquid diet should be followed for 2 weeks followed by a soft moist diet for another 2 weeks, after which one can slowly start to add solid food back into the diet. The importance of why one should not eat solid food is because solid food “can create pressure on your stitches and stretch your new stomach pouch. This may lead to vomiting and discomfort”.

 

Thus, we can see that there are 3 basic steps to the diet following surgery:

 

  1. Liquid diet for 2 weeks
  2. Soft moist diet for 2 weeks
  3. Start to introduce solid food and aim to follow a “protein rich, low calorie healthy diet

 

NB: “it is natural to expect some change in the frequency of your bowel habits; this is because the quantity of food you are now eating is considerably smaller than before the operation”. If one is concerned about bowel habits, some foods that may help include: whole-wheat breakfast cereals, fruit and vegetables, pulses (lentils and kidney beans)

 

 

 

Weeks 1 and 2 – The Liquid Diet

 

Milk

 

It is important for the purposes of the intake of protein and calcium that the liquid diet be based on milk (ideally low fat). One should aim for at least 2 pints of milk or a milk alternative a day.

What other fluids are allowed?

  • Slimming drinks
  • Yoghurt drinks and smoothies
  • Still mineral water
  • Smooth soups
  • Tea and coffee without sugar
  • Unsweetened pure fruit juice

 

NB: stop drinking as soon as you feel full

 

Weeks 3 and 4 – The Soft-Moist Diet

 Omelette

Now one can start introducing foods with a soft moist texture. “Foods should be broken into pieces or mashed with a fork”. At the beginning you may only be able manage a few mouthfuls, but this will increase gradually. Stick to small portions and eat from a side plate.

Suitable foods include:

 

  • Minced meat
  • Fish in white sauce
  • Mashed potato
  • Soft omelette
  • Tender meat casseroles
  • Carrot, broccoli, cauliflower, swede
  • Mashed banana
  • Low calorie yoghurt
  • Low calorie mousse
  • Low calorie custard

 

Week 5 onwards – The Protein Rich, low calorie diet

 Protein

From this point onwards it becomes appropriate to start experimenting with different textured solid foods. Food will still need to be tender and chewed well (aim to chew at least 20 times per mouthful).

 

It is important to eat 3 meals a day with suitable small snacks in between, even if you do not feel hungry.

 

Due to the difference in portion sizes, it can become difficult to ensure that you have the right protein intake; a lack of protein can lead you to feeling weak. Some food protein sources include: dairy, egg, meat, fish, protein shakes, pulses.

 

 

 

SOURCE: North London Obesity Surgery Service (NLOSS)