Patient Education :

PATIENT INFORMATION AND INSTRUCTIONS POST OBESITY SURGERY
We are glad that you have recognized the gravity of your weight problem and take a huge step towards dealing with it. Let us join hand and work towards that goal. Bariatric surgery is currently the best available alternative for patient with morbid obesity. It is important to understand that surgery is not a one-time solution for your obesity. It is a means to provide assistance to help control your weight and hence rid you of your co-morbidities by enabling you to make healthy nutrition choices and lifestyle changes.

Progress Report
Name: ________________ Height (cms) : ________
MRN: _________________ Ideal wt (kg): ________

ANTHROPOMETRIC DETAILS

Visit	Preop**	4-Weeks	2-Mth	3-Mths	4-Mths	5-Mths	6-Mths	9-Mths	1 Year
Date
Weight (kgs)
BMI (kg/m2)
Waist C (cms)
Hip C (cms)
WHR
Excess Wt(kgs)
% EWL

* Total Protein, Serum Albumin, Iron (Haemoglobin, S.Fe, TSI and TIBC) Folic Acid and Vitamin B12 Tests.
** CBC, Liver function tests, Lipid Profile, Glucose Estimations, Thyroid Estimations, Vitamin and Mineral Tests.

Diet Post RYGB
We have bypassed 90% of your stomach, the entire duodenum and a small part of the proximal jejunum which will have a combined effect of restriction and mal-absorption. The smaller gastric capacity and a narrow anastomotic gastrointestinal stoma will call for dietary modifications especially in the early post-operative phase. You must adhere to these changes for optimum weight loss. In general, you will advance through the following Diet phases, and at each phase you have to avoid foods high in sugar and fat -

Phase 1	Clear liquid Diet	Initiated about 48 hours post surgery
Phase 2	Full liquid Diet	Initiated about 3-4 days post surgery
Phase 3	Semi-solid Diet	Initiated about 15 days after surgery
Phase 4	Low-fat solid Diet	Initiated about 4 weeks after surgery

RESUMING DRINKING and EATING AFTER RYGBP
DAY 0 AND 1 :
You will consume nothing orally, not even water on the day of operation as well as the next day till your con-ray test is performed. All fluids will be provided through an intravenous drip.

PHASE 1 - CLEAR LIQUID DIET
On the 2^nd day after your operation, we will do a con-ray test to affirm that there is no leak through the staples. After this, your IV will be removed and you can commence drinking clear fluids.
You will be discharged the next morning.
For your clear liquids, choose from the following list (LIST 1) -
 Clear fruit juices without added sugar and diluted by half with water: apple or grape juice.(Avoid citrus juices for the first two days).
 Sugar-free powdered drink mixes made with sugar-substitute
 Tea Coffee,
 Kanji/Broth/clear soups
 Water In Plenty (The more the water in take, better the weight loss!!)
When initiating intake, consume only a small amount each time, about 15-30 ml. Sip slowly and be alert to realize your feeling of fullness. After a few sips, pause to check if you are comfortable enough to consume more. You constantly have to be cautious not to distend the small pouch or else it would cause vomiting.
If you can abide by the clear liquid diet, you can step up to the next phase within 2-3 days.

DAY 3 & DAY 15 :
PHASE 2 - FULL LIQUID DIET
It is essential during this initial phase you stick to only liquids for about the next 12 days or so as chunks of food could block the opening leaving your stomach and resulting in vomiting and pain. Start with small amount of afore mentioned foods as you will feel full quickly. Use Skim milk powder freely to increase protein intake.
The appropriate fluid choices during the phase are as follows (LIST 2) -
Keep your fluid thin for the first 2 weeks -
 Milk shakes using skim milk
 Milk based Kanjis, thin porridges, Rice kanji, Broken wheat Kanji, Yoghurt/Curds,Lassi,Fruit, Yoghurt.
 Low fat, strained cream soups (Use Skim milk instead of water or whole milk for the soup base). Use of vegetable purees is permitted. However, avoid any vegetable pieces in soup e.g. Cream of tomato soup, Cream of spinach Soup, Cream of mushroom soup.
 Sugar-free instant breakfast like corn Flakes, rolled oats (Thinned with milk blenderized)
 Sugar Free Protein drinks
 Baby Food
 Egg nogs
Initially you will have to drink small amounts frequently (15 - 30 ml at a time). After a few days, your daily intake of the above mentioned liquid s (list 2) should be atleast 3 cups, not exceeding 1 cupful for many meal. In addition, keep sipping 4 cups of low calorie liquids from list 1 throughout the day to prevent dehydration.

DAY 15 TO DAY 30 :
PHASE 3-SEMI SOLID DIET
We will initiate this step after the third week of surgery. This is the transition phase from a liquid to a regular diet and we will progress through this slowly. Begin to gently thicken up the liquids that you are consuming for the first 15 days, for instance, the porridges can now have a lower volume of milk to make them thicker and solid by the end of this month, the soups can became thicker, the fruits and vegetables less pureed. We can also begin the consumption of soft foods like egg whites; mashed potatoes and paneer. Raw bread, red meat and rice are generally the most difficult to digest and hence would be avoided.
Remember to add one new food at a time and guage your body's response/tolerance to it. Aim at 4 - 6 small meals and no meal should exceed the volume of the measuring cup. Take your time to eat, take small bites and chew thoroughly. Continue to sip on low calorie liquids in between mealtimes. However, avoid any liquids 30 minutes prior to and 90 minutes post a meal.
Avoid skin of raw vegetables and fruits at the step of your diet. The intake of liquid calories has to now be slowly reduced. Try to moisten meats and vegetables with broth or low fat gravy as moist foods are better tolerated.
Your diet can now include (LIST 3) -
 Mashed potatoes made with milk
 Cooked Egg white, any form except fried
 Milk based Dalia/Porridges
 Chopped lean meat, fishes pieces
 Cottage cheese
 Peeled and Deseeded soft textured fruits (Avoid Dry Fruits/Nuts and hard fresh fruits).
 Well cooked vegetables without seeds or skins
 Low fat pudding or custard, soft jellies-In Small Amounts
 Pureed meat-Lean chicken or fish, vegetables or fruit (Cooked really soft, blenderized and sieved, use them even in soups)
If you still experience discomfort while eating soft textured food -
 Slow down on the speed of your eating
 Use smaller portion sizes
Remember you are re-educating your stomach. If you eat too much, too fast or don't chew enough you are bound to feel uneasy.

PHASE 4 - REGULAR DIET :
Transition back to solid foods can begin from the 5th week after surgery. It is most likely that one month post bypass you may experience some vomiting or diarrhea. If either of these persists, you are advised to contact us. The first couple of months post bypass may be a period of loss of appetite. This is due to change in certain stomach hormones as well as reduced stomach capacity. This should pass by in a few months.
Once you have established diet based on solid food you will stay with that permanently. Continue adding one new food at a time to help determine what foods are tolerated. Keep breads and red meat last on your list. To make things easier, we have provided a detailed food guide below, which will enable you to select your food wisely. As a general rule you will maintain a low fat, low sugar diet with a high intake of proteins and complex carbohydrates. Besides this, you also have to keep a check on your eating habits. Remember to chew your food completely. You will experience discomfort if you eat too fast or don't chew well. You have to adapt to this new way of eating to stay healthy and successfully loss excess weight.... keep it off.

FOOD GUIDE
Aim at incorporating the food listed under the following categories each day. Our efforts should not only be aimed at weight loss towards a healthy weight loss.

CEREALS
Key - Whole grains/complex carbohydrates
Options - (select any 2 options each day)
 1 roti (minus the oil/ghee)
 2 heaped tablespoons of cooked cereal like rawa, dalia, rice flakes (poha)
 2 slices whole wheat bread
 2 tablespoons of Wholemeal Breakfast cereals (cornflakes, rolled oats)

PULSE
This food group is an important source of protein for vegetarians.
Key - For Vegetarians, 2 tablespoon of cooked thick dal/pulse for lunch and dinner; Non Vegetarians can replace this group with chicken/fish for one meal.
Remember -
Avoid legumes and whole pulses in the night. Dals are the best options for dinner.
Try and incorporate at least 1 tablespoon of sprouts each day, in some form or the other. Sprouting not only increases the nutritive value of pulses but also improves digestibility.
Make use of soy in your daily diet. Replace a part of wheat flour with soy flour while making roti's and make use of soy chunks/nuggets in vegetable and even rice preparations.

NON VEGETARIAN GROUP:
Key - 35 to 45g of fish, poultry or 1egg white every day.
Remember -
No red meat
Trim all visible fat
Remove skin from poultry
Grill, bake or boil/steam. Avoid deep frying.

DAIRY PRODUCTS
Although milk and curds are essentially liquid form of calories, they cannot be avoided due to calcium they provide.
Key - 3 measuring cups (or 600ml) of skim milk/curds to about 2 cups and use 30-45 g paneer (cottage cheese) or 25 g cheese 3 times a week.

FRUITS AND VEGETABLES
Now you can do away with the juices and soups. Start with peeled and deseeded soft fruits and vegetables.
Key - 2-3 different vegetables and 2 pieces of seasonal fresh or stewed fruit daily.
Remember - To include a portion of dark green or orange vegetable daily.

FATS AND SUGAR
Limit your daily intake to 1-2 teaspoons of sugar and 3-4 teaspoons of oil/ghee/butter.

FLUIDS
The more the water intake, the better the weight loss as it will keep your pouch full. Optimum intake of fluids is also essential to prevent dehydration.
Key - 2.5 liters of water/day
Remember - Do not mix solid food with fluids. Liquids will make you feel full before you have consumed enough food. Low calorie, non-carbonated liquids should not be consumed 30 minutes prior to or 90 minutes after a meal.

FOODS TO BE RESTRICTED
Sugar, honey and jaggery are 'empty calorie' foods that provide no other nutrient except for calories and thus should be avoided. Products containing large amounts of sugar should be omitted. e.g. jam, marmalades, preserves, drinks, cordials, desserts, and other items that have sugar listed as one of the first three ingredients. These foods have practically no nutritive value and thus should be excluded from the diet.
High fat foods such as chips, chocolates, puffs, pastries, pies and carbonated drinks should be avoided.
Alcoholic beverages like whisky, beer, wine, port, champagne etc are also empty calorie and thus we recommend you to stay away from them.
A few Guidelines....
Eat three meals and two proteins snacks per day, not more than a cupful for any meal.
No munching in between meals. The stomach pouch is created to hold the amount of food that can fit into the cup. If you consume more than your pouch size on a single occasion, you are likely to feel sick and vomit. It is therefore essential for you to learn how much your stomach can accept at one time and not exceed that.
Aim at a balanced diet and prioritize proteins.
A well balanced diet is very essential. Now that you have a smaller capacity to eat, you must eat the right foods and avoid eating your stomach pouch with nutritionally poor foods. Protein rich foods and complex carbohydrates are most suitable whereas foods high in fats and simple sugars should be avoided.
We have to prioritize proteins when resuming diet. Protein is important wound healing, sparing loss of muscle mass, minimizing hair loss and preventing protein malnutrition. Foods high in protein include dairy products, egg fish, poultry, tofu, dried beans and legumes.
During the month or so you might need to use a protein supplement until you can take in adequate protein from the foods you consume.
Eat slowly, sense your satiety signals and stop.
Satiety stands for the feeling of fullness. The nerve ending in our stomach connect to the satiety centers in our brain. When the stomach is sufficiently full, these signals tell us that we should stop eating. However, it takes a good 30 minutes for this feedback mechanism. If you eat too fast, you would have eaten too much before even your body is able to signal you to stop eating. Thus we advise you to eat as slowly as possible, observe any feeling of discomfort and if not, then proceed with more. As a guideline, you should consume only 2-3 tbsp of food over a 10-15 minutes period, pause to sense fullness and if not then proceed.
Chew your food well
Chew food until it is almost liquid in your mouth. Well-chewed food will place less stress on your gastric pouch.
Sip on plenty of zero calorie liquids and no liquids with meals. As mentioned earlier, fluid intake is very crucial after surgery. It is essential to sip slowly and constantly throughout the day. Fluid intake is important for weight loss, to prevent dehydration and also to help minimize constipation. Fluid intake should be at least 1 liter to begin with. Our ultimate target should be to consume at least 2.5 liters everyday.
The timing of fluid intake is also an important consideration. Always adhere to the following - Take no liquids with meals.
Do not drink liquids 30 minutes before or 90 minutes after meals. Drinking liquids with meals, too close to mealtime, or too fast, may cause bloating or vomiting.
Drink plenty of water.
Do not gulp liquids. A sipper is a convenient way to get small sips and to avoid gulping.
The longer you wait before drinking is better. This avoid flushing out the stomach, and therefore avoids rapid hunger.
Do not use a straw. This can cause your stomach pouch to fill with air.
Avoid regular soda, sweetened beverages and alcoholic beverages. These have no nutritional value and could cause weight gain.
Most fluids should be non caloric such as water, diet soda, coffee, unsweetened tea.
Reserve at least 30 minutes of your time for exercise each day.
With your excess weight earlier, exercise was indeed troublesome. But now that you are on a weight loss spree, it will be easier for your body to execute physical activity. Exercise is important not only from a weight loss perspective, but also to keep you healthier and fitter for life.
Set aside at least 30 minutes of your day for moderate intensity exercise. Begin with simple options like walking, swimming and slowly step up to aerobics, jogging etc. Besides, try to be as active as possible and incorporate physical activity in your lifestyles, for instance, use the stairs, instead of sitting idly in front of the T.V / Computer, engage in some house hold chore, walk a street extra and so on.
As you shed weight, your stamina for physical activity will improve and you have to further make use of this improved state of well being for your own good.

ADDITIONAL CONCERNS
Supplements
You are required to take vitamin and mineral supplements for the rest of your life.
Taking a vitamin and mineral supplement is vital to maintain your nutritional health and prevent vitamin and mineral deficiencies. You are now at greater risk for decreased absorption of vitamins and minerals because:
You are eating a significantly smaller amount of food in a day.
Absorption of vitamins and minerals occurs in the stomach and small intestine. Following surgery, there is less area for absorption to occur.
Recommendations
After gastric bypass surgery, there is a risk of vitamin and mineral deficiencies without supplementation. There is a greater risk for iron, folic acid, vitamin B12 and calcium deficiency. Therefore, additional amount of these nutrients are required. Menstruating females and people with low iron levels prior to surgery are at risk for iron deficiency anemia; therefore, prophylactic iron supplementation is required. After surgery, the multivitamin/mineral supplement and calcium is recommended in a syrup form. Eventually, you will be able to take supplements in a pill form as long the pill is no larger than the size of a little fingernail. If the pill is larger, be sure to break it into small pieces, cut it or crash.
Remember
 Do not take calcium and iron supplements at the same time. The calcium with interfere with iron absorption. Calcium supplements are better absorbed if taken at several intervals during the day.
 If the supplements make you nauseous (especially iron), do not take it on an empty stomach or try taking it at night.
 Coffee, tea and colas sodas (decaffeinated or caffeinated) can interfere with iron absorption. Some patients can develop deficiency of fat soluble vitamin i.e. vitamin A, D, E and K. It is thus essential to check blood levels of these vitamins once in every six months.
Dumping Syndrome
Alcohol, Fats & Sugar and foods high in these should be avoided for two reasons -
To avoid high caloric intake and subsequent weight gain,
Dumping syndrome.
Dumping syndrome involves a series of signs and symptoms like abdominal cramps, sweating and diarrhea which is caused because of rapid intake of calories into your gastrointestinal tract hence creating tract hence creating increasing secretion of certain gastrointestinal hormones.
Lastly, we would like to reiterate that surgery is NOT a ONE-TIME solution or your obesity. It is a means to provide assistance to help control your weight. It is very crucial to emphasize that you take your multivitamin, calcium and iron tablets for life. There is no substitute for that. Further, any period of continuous vomiting for more than a week needs to be brought to our notice immediately.
Remember, your pouch is a tool to help control weight loss by enabling you to make
 Healthy nutrition choices  
 Lifestyles changes  

What is Obesity ?

Nutrition and Weight Management Centre