Pre-Op Nutrition Class

Talk about information overload. A lot of it was review for me, but I took Mr. Salted and I thought the poor man's head would explode. We both felt he needed to be there, though. I'll hit the highlights:

1) I have to limit sugar to 5 grams or less per serving to prevent dumping. In milk and yogurt, sugar must be limited to 12 grams or less per serving. I asked why this varied, and the nutritionist said the sugar was different--natural--and was processed differently by the body.

2) I am now in low-carb hell until my surgery date (August 3), when I just don't eat at all for a few days, they give me IV nutrition, and I drink a lot of fluids. Today's forecast: abject terror with scattered feelings of panic. If I go over my allotted 40g of carbs per day for the next two weeks--which I don't think even a beetle can live on for any length of time--I am to do it in the nonstarchy vegetables category. Nonstarchy vegetables include green beans, beets, broccoli, carrots, cauliflower, mushrooms, spinach, zucchini and tomatoes.

3) I can only have one serving of fruit per day because it has so many carbs. (One serving of fruit = at least 15 carbs. Sigh. I already had a banana this morning, so that's it for today.)

4) Clear liquids start the day of surgery and the following day. At first, I will probably only be given water in a medicine cup. This gives the stomach time to recover from surgery. The best fluids are liquid at room temperature and do not contain residue, sugar, caffeine or carbonation--sometimes room temperature is just easier to take than cold. I will need to sip continuously, but slowly, and not use a straw. Hydration is extremely important, and my post-op liquid intake goal is to drink one ounce over a 15-minute time span, and the equivalent of 48 ounces or six cups per day. I can have water, ice chips, broth, sugar-free Jello and popsicles, and beverages like Crystal Light, Diet Snapple, and Diet V-8 Splash as long as they are caffeine-free and non-carbonated.

5) Full/liquids will be the week following surgery. All of these timelines will vary depending on doctor's orders. The goal of full/liquids is to transition between clear liquids and pureed diet. I will need to take 2 Bariatric Advantage multivitamins and one sublingual (dissolves under the tongue) B12, which aids the intrinsic factor and promotes proper digestion. If there is any numbness or tingling in the feet and hands, I'm supposed to let everyone know ASAP. My recommended daily allowances (RDAs) are 60-80 grams MINIMUM protein, low fat, sugar free or reduced carbs, and 48-64 ounces, or 6 to 8 cups of fluid per day. The foods I am allowed during this period include protein drinks such as Zero Carb Isopure (GNC carries them), Atkins shakes, Pure Protein shakes (they sell these in cans at Trader Joe's), Matrix, Nectar (available at bariatriceating.com) and Unjury (unjury.com), which also carries a high-protein chicken broth. I can have fat-free or 1% milk, Lactaid milk, and soy milk such as Soy Slender (available at Albertson's). I can have reduced-fat cream soups except for tomato and should add nonfat dry milk powder or unflavored protein powder to them. I can also have light, low-carb or plain yogurt if it has no fruit pieces or sugar-free pudding if it has been thinned with a little extra milk. I need to blend and/or strain any soups so they do not contain particles.

6) Some people develop lactose intolerance after this surgery. In this case, I should choose soy protein, spirulina types of protein, or whey protein ISOLATE. Whey protein CONCENTRATE contains lactose and should be avoided. I went ahead and bought a big can of protein powder made with whey protein ISOLATE at Trader Joe's yesterday, and the price wasn't bad--$12.99.
Protein drinks need to be low in sugar, calories and fat.

7) Getting protein and fluids in are my two main goals. I won't know what I can tolerate until after surgery, so I have to roll with it in many cases. Things I like now might be disgusting to me afterward. I also learned that I might have hair loss (the good news keeps on coming), so pushing the protein can help with that.

8) About 10 days after surgery, the pureed diet begins. The goal of the pureed diet is to transition between full liquid diet and the mechanical soft diet. Calcium and magnesium becomes very important and I will need to take in 500/600 mg three times per day. Tropical and Lifetime are two of the brands she showed me for liquid supplements of this nature, and Bariatric Advantage has some chocolate calcium citrate chews that I like. All food should have the consistency of baby food, and the suggested portion size to start with is 1/4 cup. The fluid intake goal rises to 8 cups per day during this phase, and the RDA of protein remains at 60 to 80 grams per day. (Now that I've heard about that hair loss thing, I'll be doubling it, fear not.) This is also where I need to keep beverages separate from food--no liquids 20-30 minutes before or after solid foods.

The nutritionist discourages scrambled eggs during the pureed phase; meat can be pureed with broth or gravy and added to soups, though red meat should be avoided. Small-curd cottage cheese is okay or yogurt without fruit pieces. Nothing should contain nuts or seeds. Strained or pureed vegetables are fine, but peas and corn should be avoided as they do not puree completely and may get caught in the pouch. Malt O' Meal, Cream of Wheat, or Cream of Rice is okay, as is baby cereal, but no oatmeal, rice, or pasta. Mashed potatoes should be okay. Recommended foods include: pates, hummus, refried beans thinned with broth, pureed chili with melted cheese, pureed sloppy Joe mixture over mashed potatoes, unsweetened applesauce, or fruit smoothies with protein powder. Bariatriceating.com has many good recipes, including pureed foods.

9) The mechanical soft/mushy diet starts two weeks or so after surgery and continues until the end of the August. This phase includes foods that are tender and easy to chew. They don't need to be pureed, and may include such things as ground meats, moist tuna salad, egg salad, chicken salad, bananas, and steamed fruits. Sugar and fats should still be avoided, and protein needs to be eaten first. Stringy foods like broccoli, celery and asparagus stalks need to be avoided, as does red meat. Texture examples include eggs scrambled with milk, soft ripe fruits without skin or seeds, and crackers. A meal is somewhere between 1/4 cup and 1/2 cup of food and should take 20 to 45 minutes to finish.

10) About a month out from surgery, many of the same guidelines apply. I can begin to eat salad, but need to continue to keep liquids and solids separate and eat protein first to ensure I have room for them. I also need to start with softer raw vegetables and work up to crisper ones. I need to avoid crisp or sharp edges on meat, and teriyaki or barbecue sauces, as they contain sugar. It may be hard to tolerate fruits with stringy membranes such as oranges, and juice and sweetened beverages will need to be avoided for the rest of my life. When choosing grains and cereals, I need to steer toward whole-grain carbs (wheat crackers, brown rice). Saturated fats will need to be limited, and simple sugars are always to be avoided. Carbonated drinks should be avoided permanently as well. They cause bloating and studies have shown that people who continue to drink them tend to lose less weight.

11) I will need to take something like Prilosec for the first couple of months. Taking vitamins with coffee or tea interferes with their absorption.

The basic guidelines to follow are:

Slow down, chew everything to the texture of applesauce
Eat protein foods first
Separate beverages from food 30 minutes before and after eating
Take all vitamins and supplements

12) Regular bone density scans are suggested if possible.

13) Dumping syndrome is a reaction to sugar, sugar alcohols, high fat foods, or alcohol after gastric bypass surgery. The symptoms may include abdominal cramping, sweating, nausea, dizziness, headaches, diarrhea and weakness, "Early" dumping syndrome may occur within 15 minutes after eating and is often associated with diarrhea. "Late" dumping syndrome can occur up to 4 hours after eating and feels more like having low blood sugar. Acceptable sugar substitutes include Splenda, Equal, Sweet 'n Low, aspartame, saccharin, and Nutrasweet.

14) Food intolerances vary from one person to another, and what tastes good before surgery is often different from one tastes good afterward. Using the baby utensils can help with remembering to take small bites and chew them well. If vomiting occurs, it may help to return to clear liquids for a couple of days. Don't avoid healthy foods that cause vomiting--wait a week and try the food again. (Oh joy!) Try food at different temperatures, and add a meat tenderizer to meat or poultry if it is not being tolerated well. Constipation may occur, and no fiber supplements are allowed until six weeks out from surgery. Milk of magnesia, stool softener, or Probiotic pills (available at Walgreen's) can be helpful. Beano and Gas-X can be used for gas. Bad breath can occur from the body being in a state of ketosis post-op, and if this happens, gum should be avoided (in case it is swallowed accidentally). Bad breath typically improves over time as the diet becomes more varied.

15) Don't drink with a straw. Stop eating when you feel full. Don't lift anything heavier than a grocery bag, and no swimming for 4-6 weeks when the incisions heal.

Now that I have summarized all that, I think I need to go lie down. No wonder Mr. Salted's eyes glazed over...damn! I have my final pre-surgery consultation with the surgeons today.