Section 8: Follow-up and general guidelines on healthy eating and living with a gastric bypass or sleeve

The key to a positive outcome with weight loss surgery is to work closely with your specialist dietitian. Follow the advice given, and be honest if you are having any problems with sticking to the regime. They will work with you to achieve the best result possible.

The key areas are:

1. Modifying your diet, eating patterns and eating habits
2. Altering your relationship with food
3. Gradually increasing your activity and fitness levels

Aftercare is fundamental to your success, and your specialist dietitian will work with you to help you achieve your goals safely and efficiently.

How does the follow-up work?

• You will receive an email confirming the date and time of your first dietitian appointment, which will take place within a week of surgery.

• Your dietitian will then arrange further follow-up appointments, as required, for the remainder of your aftercare package. We sometimes request that you call in to arrange further appointments, or this may be your preference.

• At 3 months post-surgery, your dietitian will offer a review with your surgeon (also available as a telephone appointment).

Please note that appointments may change from time to time, and you will always receive a new email confirming the new appointment. If you ever need to check or change an appointment, please call us.

Some patients opt for telephone or email consultations instead of having  them face to face. If you have telephone consultations, we strongly encourage you to ensure you are in a suitable environment. Avoid speaking whilst driving (even on hands-free), out shopping, or distracted by children or work colleagues. Let us know when it is suitable for you to have your appointments, and we will make a note of it so that we can avoid arranging times that are not suitable.

Your progress will be monitored by checking your weight, BMI, and changes to your medication and other health conditions, assessing your dietary intake, and tracking your activity levels.

It is important to be honest, even if you have had bad days! Sometimes you may be asked to keep a food/activity diary. Our specialist team has a wealth of experience with patients who have undergone weight loss surgery, and are extremely focused on providing a useful, non-judgmental and supportive service. This will be very different to any kind of weight loss advice you may have received before – it is geared to weight loss surgery specifically, so try to leave any preconceptions about dietitians behind you!

IMPORTANT: Attend all your follow-up appointments (phone call or face-to-face). If a proposed date is not convenient for you, then contact us and we can reschedule it to a more convenient time. Also, when you cancel/reschedule in advance, your appointment can then be offered to another patient who may need our help. Tell us if you are struggling with any part of your band journey - we are here to support you, but can only do so you if you tell us about any difficulties you are experiencing.  Evidence shows that patients who attend regular follow-up appointments are more likely to achieve weight loss.

• Remember that you have access to advice on urgent problems, 24 hours a day, if required.
• Stay positive! Everyone loses weight at a different rate – this is especially important to remember when you come into contact with other patients, when attending the clinic or using internet forums.

If your surgery took place after August 2019, you also have access to a year's free membership to BandBoozled.co.uk. This is an online support centre specifically for patients following weight loss surgery. If you haven't been offered this, please contact [email protected].

The first few weeks after surgery

It takes a minimum of 4-6 weeks, on average, to get used to the feeling of having a gastric bypass or sleeve gastrectomy.

You should adopt a staged approach to eating after surgery to ensure the stomach can heal. Eating solid food too soon may cause you to vomit and, more importantly, put pressure on the staple line (gastric sleeve) or joins between the stomach and small intestine (gastric bypass).

• Weeks 1 and 2: liquid diet
• Week 3: puree diet
• Week 4: soft/sloppy diet
• Weeks 5: post-operation onwards - gradually incorporating solid food

General guidelines on eating and drinking

How to eat

Changing the way you eat is just as important as changing what you eat if you are to avoid discomfort and/or regurgitation when eating.

• Take small bites of food, chew well and eat slowly. Smartphone apps such as "Bariatric Meal Timer" (Apple), "20 Minute Eating - Eat Slower" (Apple) and "Time Your Bites" (Android) can help. We sometimes refer to a concept called the ’20, 20, 20, 20 rule’, which we use with gastric band patients and can be helpful:

1. Take a bite of food the size of a 20 pence piece. Chew it for 20 seconds, and then swallow.
2. Wait 20 seconds before taking your next mouthful. This will mean there is at least 40 seconds for each mouthful to settle in the stomach.
3. Repeat 1) and 2) for a period of 20 minutes, and then stop. This is to avoid overloading the stomach, and also to avoid ‘grazing’.

• Serve yourself small portions – using a small 6-inch plate is about right.
• Switch to children's sized cutlery to help ensure you take small mouthfuls. Or try a small dessert fork or teaspoon.
• Sit down to eat, savour your meals, and avoid eating on the move.
• Start the day with a drink, ideally hot - this can help ‘warm up’ the muscles in the pipe that leads from your mouth to your stomach, which in turns reduces the chances of problems eating.

• Eat your first meal as soon as you start to get hungry. This might not be for 3-4 hours after waking, so use this time to have plenty of fluids. Try to avoid waiting until you are very hungry, as this can lead you to not follow the 20/20/20/20 rule and then encounter problems.

• Avoid leaving a gap of longer than 4-5 hours between meals. This can also cause you to feel uncomfortable when eating, or lead you to experience regurgitation (see Common Problems for more information on problem-solving).

• The concept of Mindful Eating can be really helpful – see later in this section.

Drinks

Everyone has slightly different fluid requirements which depend on factors such as gender, activity levels and body weight. 2 litres of fluid every day is sufficient for most people, but you will need to increase this the more physically active you are or when the weather is warmer. Remember, the best way of checking if you are drinking enough fluid is monitoring the colour of your urine – it should be pale straw-coloured from 4-5 hours after waking onwards.

 Suitable drinks include:

• Still water or still no added sugar / sugar-free flavoured water
• No added sugar / sugar-free cordial/squash
• Tea, coffee, fruit teas (with no sugar added; artificial sweeteners are fine; limit milk to 1 pint per day once you have completed the liquid only stage (weeks 1 & 2) and choose skimmed, 1% fat, semi-skimmed (or lactose-free equivalents) or calcium-enriched, unsweetened soya milk)

Drink slowly - take small sips, not big gulps.

Avoid drinking with meals and for 30 minutes after meals. This can help to avoid discomfort and reduces the risk of Dumping Syndrome.

Fizzy drinks

We advise that you completely avoid fizzy drinks for the first six weeks following your surgery, or until you have been back on a solid/chewable diet for two weeks. This is to avoid unnecessary pressure on the staple line (sleeve gastrectomy) or newly created joins (gastric bypass) which, if put under too much pressure, could rupture and lead to serious complications.

Once you have been back on a diet of solid food for at least two weeks (minimum six weeks after surgery), we consider there to be minimal risk to you trying a fizzy drink.  We would suggest that you choose diet / sugar-free versions only. However, many patients find it very uncomfortable to drink fizzy drinks after surgery and it causes heartburn; if you experience either of these symptoms, fizzy drinks are best avoided.

Completely avoid for life

Chewing gum - this can create trapped wind, which can be very uncomfortable.  More importantly, accidentally swallowing gum could cause problems.

Non-steroidal anti-inflammatory drugs (NSAIDs) - these can increase the risk of abnormal narrowing of the gap between the new stomach pouch and the small intestine (stenosis – see Bypass / Sleeve risks of surgery, potential complications, side effects).  Examples of NSAIDs include:

• Ibuprofen
• Diclofenac
• Naproxen
• Aspirin – unless in a low dose and dispersible

Healthy eating and balanced meals

Eating a wide variety of foods ensures you are consuming a range of nutrients and is important for general health. It can reduce the risk of certain cancers, heart disease, diabetes and osteoporosis. Eating a healthy balanced diet also helps you to lose weight, whether you have had weight loss surgery or not! Smartphone apps such as "My Fitness Pal" can be useful in monitoring your intake.

The image below shows the ideal way to balance each of your meals:

½ protein-based foods

¼ carbohydrate - based foods.

¼ vegetables / salad (fruit can also be included here)

Protein-based foods should form half of each meal

Examples of protein-based foods include meat, fish, eggs, beans, lentils, Quorn, tofu and other soya-based products. Milk and dairy foods are also a great source of protein.  Aim to include 3 portions per day to provide calcium.  A portion is:

• A small individual pot of yogurt, ideally 0% fat and low sugar options or cottage cheese
• A third of a pint (~200ml) of milk, ideally skimmed, semi-skimmed, 1% fat (or lactose-free equivalents) or calcium-enriched, unsweetened soya milk (avoid nut-based milks as these lack protein)
• A small matchbox sized piece of cheese, ideally reduced fat.

Protein is essential for the body, both in a structural and a metabolic role. Around 50% of body protein is present in muscle, skin and other structural tissues. Protein is also important for enzymes, hormones, the immune system, and for transporting substances around the body. Proteins are made up of chains of amino acids.

Ensuring you have adequate protein in your diet after surgery will maximise the healing process, whilst ensuring your nutritional intake is complete to optimise your health and wellbeing.

Evidence suggests that gastric bypass and sleeve patients need a minimum of 60g protein per day, up to 1.5g per kg of ideal body weight (your weight at a BMI of 25kg/m²). Speak to your dietitian about your individual requirements.

Interesting fact - foods from an animal source such as meat, eggs and milk provide all of the essential amino acids, and are called “complete proteins”. “Incomplete proteins” lack some essential amino acids and include grains, seeds, nuts, fruits and vegetables. Soya is one of the only plant foods which is a complete protein. It is therefore important to eat a variety of different protein sources.

Following the advice above should mean you are consuming enough protein.  However, you will find a table in each of the post-operative dietary stages showing the protein content of various foods.

Vegetables / salad should form a quarter of each meal

They provide vitamins, minerals and fibre. Choose a variety of different coloured fruits and vegetables - this ensures the best range of vitamins and minerals as well as powerful antioxidants. Fruit can be included as a snack or dessert.

Carbohydrate-based foods / starchy foods should form a quarter of each meal

They contain fibre, B vitamins, calcium and iron, and are a great source of energy.

There are a lot of misconceptions about carbohydrates, specifically that they are fattening. This is not the case!

Why is carbohydrate important?

Carbohydrate-rich foods are the primary source of fuel for all your bodily functions. Your body breaks down carbohydrates (or "carbs"), into glucose (energy) for your cells and muscles to use - that's why eating a moderate amount of carbohydrates is very important.

There are two types of carbohydrate:

o Simple carbohydrates - often listed on food labels as 'Carbohydrates (of which

sugars)'. This usually refers to table sugar (added sugars), but it also includes the

natural sugars found in fruit and milk.

o Complex carbohydrates - also called 'starchy' foods. Starchy foods include bread,

cereals, rice, pasta and potatoes. An important factor to remember is that complex

carbohydrates, especially wholegrain varieties, include dietary fibre, which increases satiety of food, helps prevent constipation and can also help to lower cholesterol levels.

Here are some examples of different carbohydrates:

Following gastric bypass and sleeve gastrectomy surgery, you need to be careful of including too many simple carbohydrates in your diet due to the risk of Dumping Syndrome. Choose complex carbohydrates instead and always try to go for the wholegrain varieties rather than white, as this can also help in reducing the risk of Dumping Syndrome.

Aren't carbohydrates fattening?

No. If we take in more calories than we burn up, no matter what the source, the excess will be converted into body fat. Since sugary foods taste good and are high in calories, it can be easy to consume too many of these, resulting in a higher calorie intake and thus weight gain. Sometimes, people mistakenly think starchy carbohydrates such as bread and potatoes are fattening. However, weight for weight, carbohydrate contains less than half the calories of fat and studies show they are much better at satisfying our hunger.

o 1g carbohydrate contains 3.75 calories

o 1g protein contains 4 calories

o 1g fat contains 9 calories

o 1g alcohol contains 7 calories

Can low carbohydrate diets help with weight loss?

Low carbohydrate diets, which cut out most starchy foods, are sometimes used for weight loss. In the short term they can lead to side effects such as constipation, headaches, mood swings, bad breath and nausea. In the longer term, cutting out any food group can be bad for health because you risk missing out on vital nutrients.

It is also important to note that the weight lost from low-carbohydrate diets is mainly muscle and water, rather than fat mass. When trying to lose weight permanently, losing lean muscle tissue is detrimental as muscle is metabolically active and burns calories even when you are at rest. Therefore, a decrease in the amount of muscle you have will lead to a decrease in the number of calories you need each day to maintain your weight. This makes it much harder to keep your weight under control when you stop following the low carbohydrate diet.

Low carbohydrate diets also tend to be higher in fat, and eating a high fat diet (especially one rich in saturated fat from foods such as meat, cheese, cream and butter) could increase the chances of developing heart disease. Low carbohydrate diets may also restrict the amount of fruit, vegetables and fibre, all of which are vital for good health including reducing cancer risk. Overall, there does not seem to be any advantage in following a low carbohydrate diet which cuts out most starchy foods, as any weight loss is usually not sustainable.

Low-carbohydrate diets (defined as diets containing between 50g and 130g carbohydrate) can be effective in managing weight, improving glycaemic control and cardiovascular risk in people with Type 2 diabetes in the short term i.e. less than 12 months (Diabetes UK 2018). This is probably due to the accompanying reduction in energy (calorie) intake and subsequent weight loss (Diabetes UK 2018).

So, how much carbohydrate should I be eating?

As mentioned earlier in this section, about a quarter of the food on your plate at each meal as a source of starchy carbohydrate is a good way to ensure you are getting the balance right when you have had a gastric bypass or sleeve gastrectomy.

The type of carbohydrate is particularly important following gastric bypass and sleeve gastrectomy, due to the risk of dumping syndrome. Sugary foods such as table sugar, soft drinks and sweets generally contain few other nutrients and are recommended only on a more occasional basis. These are often called "empty calories" due to their lack of other nutrients.

Further points to remember

• Try to reduce sugar, sugary drinks, refined (white) grains, trans fats (found in cakes, biscuits, pastries, fast food, coffee creamer, palm oil and processed foods in general) and saturated fats (found in butter, ghee, lard and coconut oil).
• Remember that all fats contain a lot of calories and should be limited, although not completely avoided.
• Instead of trans fats, saturated fats or processed fatty foods, choose small amounts of polyunsaturated or monounsaturated fats, which are better for heart health, hormone production and the immune system. Sources of these healthier fats include:
• Oils which are liquid at room temperature e.g. olive oil, rapeseed oil
• Unsalted nuts and seeds
• Linseeds / flaxseeds
• Oily fish such as mackerel, salmon, fresh tuna, pilchards or sardines

Further guidance on ensuring balanced meals can be found in Further Reading and Resources.

Vitamins and minerals

Vitamins and minerals are an important part of your diet, especially after gastric bypass or sleeve gastrectomy surgery. Since the diet allows only small amounts of a limited variety of foods, it may be difficult to get enough vitamins and minerals from food alone. Deficiencies can develop in a matter of months. Iron, folate (folic acid), vitamin B12, vitamin D and calcium are the nutrients most affected. Work with your dietitian to ensure that you have a good intake of the following vitamin and mineral rich, as well as taking the supplements described in Supplements and Blood Tests:

• Iron – fortified breakfast cereals, eggs, bread, red meat and chicken (N.B. ‘caution’ foods – see Section 12), salmon, pilchards, sardines, peas, beans, lentils, chickpeas, spinach, dark green vegetables, nuts, dried fruit, oatcakes, seafood, dried apricots, dried figs, yeast extract (e.g. Marmite, Vegemite). The iron in meat and fish is most easily absorbed, but if you are vegetarian, try to eat a food rich in vitamin C with plant sources of iron, as this will help absorption. Examples include berries with breakfast cereal, peppers in an omelette, beans with tomatoes.

• Folate – Fortified breakfast cereals, green leafy vegetables, wholemeal bread (N.B. ‘caution’ food – see Section 12), oranges, bananas, eggs, sprouts, chickpeas, milk, yeast extract, soya beans, cheese, nuts, lentils, salmon

• Vitamin B12 – Whilst you can ensure your diet includes vitamin B12-rich foods such as meat (although this is a ‘caution’ food – see Section 12), fish, eggs, milk, cheese, yeast extract and fortified breakfast cereal, vitamin B12 deficiency occurs following gastric bypass and sleeve surgery in some patients because it is not able to be absorbed as well as prior to the operation. Generally, dietary modification can’t treat the deficiency and so injections or high dose oral supplements will be required (see Supplements and Blood Tests).

• Calcium – Cheese, milk, yogurt, fortified unsweetened milk alternatives, seeds, tofu, almonds, fish with bones (e.g. tinned mackerel/sardines), prunes, green leafy vegetables, dried cooked beans. Choose low fat dairy foods whenever possible.

Vitamin and mineral supplements are discussed in Supplements and Blood Tests.

Foods/drinks you should limit

If you want to get the best results from your surgery, it is crucial that you eat healthily. Consuming more calories than your body needs will always result in weight gain, so it’s important you limit your consumption of certain foods and drinks, listed below. These will not only be easy to eat, but also add ‘empty calories’ to your diet.  Furthermore, sugary foods can result in ‘Dumping Syndrome’ and fatty foods can give unpleasant side effects (see Dumping Syndrome).

• Hard cheese – try reduced fat varieties instead such as Quark, Ricotta, cottage cheese or reduced fat cheese spread.
• Skin on chicken/poultry and fat on meat – remove these prior to cooking.
• Chocolate and sweets.
• Cakes and pastries.
• Ice-cream.
• Nuts - plain (not salted) nuts eaten occasionally in small amounts as a snack are a good source of protein and minerals. However, as they are high in fat, be careful to keep portions small.
• Desserts & puddings – try low fat, low sugar yogurts/mousses or sugar-free jelly instead.
• Milky coffees such as lattes/cappuccinos.
• Hot chocolate / milky malted drinks (e.g Horlicks, Ovaltine) – try lower calorie varieties g. Highlights/Options, although these can still be quite high in sugar, so take care.
• Fruit juice – limit to 1 small glass (100ml) per day.
• Spreads – all fat spreads are high in calories and should be used sparingly. Choose a reduced fat or ‘light’ variety and try to avoid those which have ‘hydrogenated vegetable oil’ on the ingredients list, as this is a source of harmful ‘trans fats’.
• Oil – if you are cooking with oil, choose olive or rapeseed oil and use sparingly, as they still contain as many calories as other types of oil. Try a spray oil instead, which will help you to use less.

Alcohol

We recommend you avoid alcohol for the first 4 weeks after your surgery and until you are tolerating a normal, textured diet.

If you drink alcohol, make sure it is in moderation. The government guidelines recommend that you do not regularly drink more than 14 units per week. This is the same for both men and women.

This is equivalent to:

• 6 pints of 4% ABV beer
• 6 x 175ml glasses of 13% ABV wine
• 14 x 25ml shots of 40% ABV plain spirit e.g. vodka, rum, whisky, brandy, gin.

It is best to spread these evenly through the week.

Did you know?

o A glass of wine has similar calories to a slice of cake

o A pint of bitter has similar calories to a slice of pizza

o A spirit & cola has similar calories to half a doughnut

o Alcohol contains 7 calories (kcal) for every gram, almost as much as pure fat

o Alcohol contains no nutritional value

o Alcohol can slow down the number of calories you're able to burn through exercise

o Drinking alcohol increases the temptation to eat high calorie snacks

o Exercise won't reverse the damage regular drinking does to your body

Tips:

• Choose lower ABV wines/beers
• Invest in a measure for spirits to avoid free-pouring
• Opt for smaller measures, e.g. buy smaller wine glasses
• Add less alcohol but extra low-calorie mixers to your drinks
• Find an alternative to alcohol to relieve stress - yoga, walking, reading etc
• Set yourself a limit before you start drinking and stick to it
• Offer to be the designated driver sometimes, so you aren't drinking
• Have at least 3 alcohol-free days each week
• Drink more slowly, alternating alcoholic drinks with water and/or food

Remember: Alcohol adds calories to your diet, and ultimately increases your appetite. It can also reduce your willpower, so you may be tempted to come off your healthy eating regime whilst drinking

Use the below table as a rough guide to how many calories you are consuming per drink:

                                    Source: NHS/Cancer Research UK

Fizzy drinks should be avoided until at least six weeks after surgery, or until you have been established on a solid diet for at least two weeks. Thereafter, they could cause discomfort and/or heartburn, so either use lots of ice and stir to remove some of the fizz or choose diluted fruit juice or still mineral water with 'no added sugar'/'sugar-free' squash/cordial as a mixer instead of lemonade / cola / tonic /soda water.

Mindful Eating

Mindful eating is based on the Buddhist concept of mindfulness, which involves being fully aware of what is happening within and around you at a moment in time.

Applied to eating, mindfulness includes noticing the colours, smells, flavours, and textures of your food; chewing slowly; getting rid of distractions like TV or reading; and learning to cope with guilt and anxiety about food. Practicing mindful eating can be a really useful weight loss tool, as it makes you think about and question your hunger a lot more than you usually would, often reducing the amount of food you would eat even further.

Do these habits sound familiar?

o Eating until you are too full and then feeling guilty

o Emotional eating - eating when you are bored, stressed, upset or anxious, rather than hungry

o Eating food without really tasting it

o Mindlessly eating when watching TV/reading/ on the computer

o Eating a meal at the same time every day, whether you are hungry or not

o Skipping meals, not paying attention to your hunger signals

If so, try the following:

1. Check-in mindfully

o How hungry am I on a scale of 1-10?

o Each time you go to eat something, ask: 'Am I physically hungry? Do I really need

to be eating this?'

o Aim to eat until you are satisfied (80% full), leaving yourself neither stuffed nor starving.

1. Take mindful mouthfuls

o Have you ever eaten a whole meal and not really tasted it? Slow down; bring all of your senses to the table.

o Think about the smell, taste and texture of the food you are eating. Really chew your food and experience each mouthful.

(This works in line with the 20, 20, 20, 20 rule)

1. Attentive eating

o It is not always easy to give eating your full attention if you have a busy lifestyle, but it is important to do so.

o Try not to multitask whilst you eat. Allow yourself 20 minutes to stop, check-in mindfully and really enjoy eating your meal.

o Concentrating on one thing at a time is key to eating mindfully.

A common mindless eating habit to get into is emotional eating - eating when you are bored, stressed, upset or anxious. The reasons for this will vary from person to person, but recognising the triggers for this kind of eating is the first step to overcoming it.

Your dietitian can work with you to help you recognise what your triggers for eating are and help you overcome these. However, many can be avoided by following the 3 mindful eating rules above and making practical tools for you to use on a day-to-day basis.

For example, see the hunger scale printed below. You can use this to question your hunger when you are thinking about having a snack or meal. If you find this useful, speak to your dietitian and they may be able to suggest some further ideas for your individual needs.

Head Hunger vs Stomach Hunger

There are two different types of hunger:

• Head Hunger: This is when you aren’t actually hungry as such, but you ‘fancy’ something specific to eat. Usually only something high in sugar and/or fat will satisfy you, and if you are offered a less “exciting” snack, you may not want it.

• Stomach Hunger: This is when you are physically hungry; your stomach could be rumbling as a result. If this is the case, you would eat anything to satisfy your craving, not just something you would regard as a ‘treat’ or a ‘nice’ snack

When measuring your hunger, it is important to measure stomach hunger, not head hunger.