Bariatric Nutrition Guide: Phase 3 and 4

The inHealth bariatric program offers a multidisciplinary approach to obesity treatment. Making good food choices and eating a balanced diet will help you shed and maintain your weight loss after bariatric surgery and maintain a healthy lifestyle for life. Your bariatric surgeon will advance you through each phase of the post bariatric surgery diet plan — beginning right after surgery — until you're ready for the final, lifelong phase. Eating after bariatric surgery will become easier over time, as you progress through the post-surgery nutrition plan.

Nutrition at a glance

Food serves as an important vehicle for transporting nutrients into the body. A crucial step to being successful during these final stages post bariatric surgery and forever is making significant changes to your eating habits and your relationship with food. No, you don't have to say goodbye to enjoying normal foods, but you do need to adjust the way you think, and ultimately feel, about food to lose weight and keep it off. Weight loss and maintenance is an ongoing effort and working with your health coach will provide you with the insight and tools you need to live a healthy life.

BASIC Bariatric principles

1. PROTEIN FIRST: You must eat protein at every meal. If there are other items on your plate, use the 3:1 eating rule (3 bites protein, 1 bite other).

2. WATER: Drink a minimum of 64 ounces every day for hydration and good health. Also, remember the 30-20-30 rule; stop drinking 30 minutes before a meal, don't drink during the meal and wait at least 30 minutes after a meal before drinking again.

3. EXERCISE : Thirty (30) minutes every day. Start with ten (10) minutes each day and increase over time.

4. MEALS : Three (3) meals a day and one to two (1-2) protein snacks as needed; no skipping any meals.

Goal of Phase 3:

Start weighing food: 4-6 ounces of food in total per meal. 20 grams (3oz.) of that will always be protein. Remember, Protein first!

Chew all your food to applesauce consistency. If you don't follow these precautions, you may experience vomiting, stomach irritation, and swelling.

As part of your new life, STOP drinking 30 minutes before a meal and wait to drink until 30 minutes after a meal.

Phase 3 – Soft Foods Diet – 15 to 21 Days

Track food and fluids with a food tracker.

Caloric goal: Up to 800 calories. (Varies from patient to patient)

Things to Note:

It is important to only eat until you feel satisfied and no more!

Never eat and drink at the same time.

Never eat more than 4 ounces of food at once.

Chew your food thoroughly.

Never eat before bed.

Avoid any spicy food.

Always check your labels before consumption and avoid foods with high fat, sugar or carbohydrates levels.

Scrambled eggs (soft, boiled, poached)

Chicken, salmon- moistened with mayo

Pureed Vegetables

Meats pressure-cooked to tenderize

Tuna salad moistened well with mayo

Tofu

Recommended Clear Liquids

Smooth almond or peanut butter

Cottage cheese, thinned plain oatmeal

Pureed fruit

Refried beans

Low fat cottage cheese or Greek Yogurt

Sample Menu: Pureed/soft food

Breakfast:

7 a.m. - ¼ cup scrambled egg or egg substitute, 4 Tbsp. (2 oz.) Plain oatmeal made with skim milk (very thin or milk-like consistency)

8 a.m. - Protein drink made with 8 oz. skim milk or milk alternative

10 a.m. - 8 oz. water

Lunch:

Noon - 4 Tbsp. (2 oz.) pureed turkey, 2 Tbsp. (1 oz.) pureed carrots, 2 Tbsp. (1 oz.) mashed potatoes

1 p.m. - 4 oz. herbal tea

2 p.m. - Protein drink made with 8 oz. skim milk or milk alternative

4 p.m. - 4-8 oz. water

Dinner:

5 p.m. - 4 Tbsp. (2 oz.) pureed chicken, 2 Tbsp. (1 oz.) pureed carrots, 2 Tbsp. (1 oz.) mashed potatoes

6 p.m. - Protein drink with 8 oz. skim milk or milk alternative

7 p.m. - 8 oz. water

Instructions for pureeing foods:

Consider purchasing or borrowing a blender or food processor for this stage if one isn't already available.

1. Cut food into small pieces about the size of a thumbnail.

2. Place food in the blender or food processor.

3. Add enough liquid (ex: fat free chicken broth, fat free gravy, milk, or yogurt) to cover the blades.

4. Blend until smooth like applesauce.

5. Strain out any lumps, seeds, or whole pieces of food.

6. Use herbs and spices to flavor food (avoid spicy and high sodium flavorings).

7. Use ice cube trays to freeze pureed foods and pop out into Ziploc bags to avoid wasting any. This helps with portion control as each cube is about 2 oz. (4 Tbsp.).

Phase 4 – Solid Foods Diet – 21 Days and Beyond

By this stage, your stomach should be in better shape to handle solid foods. From now on, these foods are the foods you're going to be eating for the rest of your life. Ultimately, you can consume a healthy, well-balanced diet in small portions.

At each meal, you want to have at least three ounces of protein. You may wish to get a digital pocket scale to weigh your food, so you know what three ounces of protein looks like. You will find it is easier for non-protein foods to go down, so you may gravitate to choosing non-protein foods. You want to train yourself to eat protein first. Eat three bites of protein to every one bite of something else (three to one rule).

It is easy to get certain foods stuck, so from this phase forward, it will be essential for you to slow down and chew your food thoroughly, pausing between bites.

All foods from previous phases

Beans: navy, pinto, kidney, black

Steamed/soft vegetables- Avoid stalks of broccoli, asparagus, celery & limit white potatoes, green peas, and corn.

Low fat ground beef or turkey

String cheese / low-fat cheese

Recommended Solid Foods

Fruits: (peeled) apple, pear, peach, nectarine

Salad (as tolerated)

Deli meats

Seeds and nuts (as tolerated)

Steps for Adding Solid Foods:

Try only 1 small bite of the new food and chew well. Wait awhile and if there are no problems, take another bite.

If at any time you feel too full, nauseated or vomit, stop eating and rest. Take only clear liquids at the next meal and add blended foods and liquids at the following meal. Try one solid food again the next day.

Did I chew to a paste consistency?

Did I eat too fast?

Did I eat too much volume?

Also, ask yourself the following questions:

Rice, pasta and doughy bread may not be tolerated for six months or more.

Try fresh fruits without the skin first. If tolerated, the skin can be tried the next time. Salads are generally well-tolerated if chewed well.

Avoid high sugar and high fat foods to avoid a high calorie intake.

Solid foods will fill your stomach pouch more than liquids, so you will be eating smaller quantities of foods versus liquids.

You may find that you tolerate a certain food one day and not the next. This is normal.

Please Avoid:

Hard /crunchy foods may always be poorly tolerated.

Fried foods/greasy foods are hard to digest and are very high in calories.

Corn chips, potato chips, tortilla chips, hard taco shells

Meal Planning

As you move into phase 4 this will be your forever diet. The focus should be on real, whole foods that will nourish your body with healthy fats, proteins, fiber, and other vital nutrients.

2+

+1-2

3-6

1

Vegetables, servings (non-starchy)

Fat, servings (oils/nuts/seeds)

Protein, oz.

Carbs/Starch, servings
(fruit, grains, beans)

Note: Everyone has a different carbohydrate tolerance. To achieve and maintain a healthy weight, there are varying amounts of carbohydrates a person thrives on. Work with your health coach to find the amount that makes you feel best.

Low carb = 30-75 g/day
Moderate carb = 75-150 g/day

Portions & Food Choices

Products

Chicken

Lean beef

Lamb

Duck

Buffalo

Turkey

Fish (wild)

Seafood

Bison

One Portion Size and Nutrients:

3 oz. meat = deck of cards or palm of hand. 2 eggs= 2oz.

Protein

Fruit

Look for fresh or frozen and avoid canned

Berries: 1 cup

Apple, orange, grapefruit, pear, peaches, nectarine 1 medium = baseball size

Сherries, grapes 12

½ cup melon, watermelon or pineapple

One small banana or ½ large

Starchy grains

Portions: ½ cup grain/rice/starchy vegetables/ beans

1 cup winter squash

Medium potato = small computer mouse

1 oz = 1 slice regular bread, 2 slices low carb bread, 1 6-inch tortilla

1/2-1 cup dry cereal

Fat

Portions: 1 tsp. = 1 dice, 1 Tbsp. = 3 dice, 2 Tbsp. = ping pong ball

1 oz nuts = small closed fistful

All raw unsalted nuts and seeds (almonds, walnuts, brazil nuts, cashews, flax, chia, pumpkin, hemp, sesame)

Low/medium heat: extra virgin olive oil, sesame oil

Medium/high heat: coconut oil, ghee, avocado oil

No heat: flaxseed oil, hemp oil

Olives (5)

Avocado (1/4 large or ½ small)

Successful Eating Behaviors

When you have endured bariatric surgery, you may experience nausea or become ill if you overeat.

Avoid starches like white rice, pasta, and bread.

Eat wholesome fresh foods that come from the earth. Avoid processed foods.

Protein Needs: 60-90 grams

Average caloric range is typically between 1000-1500 calories.

In between meals, drink at least six to eight cups of water and any other non-calorie, non-carbonated beverages.

Stop drinking thirty minutes before eating and DO NOT drink until thirty minutes after a meal.

CONTINUE to take your multiple vitamins, calcium supplements, iron and B12 supplement as directed.

REMEMBER; avoid using a straw or chewing gum.

Never eat out of a box or bag. Measure out portions.

Never eat in front of a TV or computer. Be mindful and practice intuitive eating.

Dehydration Risk

After bariatric surgery you are at risk for dehydration because you cannot consume large quantities of fluid quickly. Instead you will have to sip on fluids during the day. This may be a challenge for some and a new habit to create. Your fluid goal is 6-8 cups per day or 48-64 oz. You can achieve this goal by sipping on 1 oz. of fluid every 15 minutes or 4 oz. every hour.

Symptoms of dehydration include increased thirst, dry mouth, dizziness, confusion, headache, decreased urine output, or dark urine.

Importance of Protein Supplements

After bariatric surgery you are at risk for dehydration because you cannot consume large quantities of fluid quickly, instead you will have to sip on fluids during the day. This may be a challenge for some and a new habit to create. Your fluid goal is 6-8 cups per day or 48-64 oz.

You can mistake thirst for hunger. Keeping up with hydration is key.

Importance of Supplements

Because of the limited volume capacity of the stomach, it will be nearly impossible to meet your nutritional needs with diet alone.

Supplement RX

Patients are required vitamin and mineral supplements for the rest of their life. Taking vitamin and mineral supplements is vital to maintain nutritional health and prevent deficiencies. Patients are now at greater risk for decreased absorption of vitamins and minerals because they are eating a significantly smaller amount of food in a day.

After surgery, starting the first day you get home from the hospital.

Take multivitamins with minerals daily. (Bariatric specific vitamins)

1-2/day

Multivitamin

Dose dependent on brand purchased—take at 1st meal of the day

2-3x/day (take one 500 mg tablet, 2-3x/day on an empty stomach, in between meals

Calcium Citrate

1200-1500 mg/day (total provided by food intake and in supplemental form in divided doses)

1/day (Take with 2nd meal of the day. DO NOT TAKE IRON AND CALCIUM AT THE SAME TIME – wait at least one hour.)

Iron

Men: 30-45 mg/day
Women: 45-60 mg/day

3,000 mcg/week sublingual (under the tongue) OR 500 mcg nasally once per week

B12

Take anytime during the day.

How to choose the correct protein shake:

Calories ranging from 120-160 calorie serving

At least 20 grams of protein/serving

Low fat (Ideally less than 3 grams/serving)

3 grams of sugar or less/serving

Some options: Bariatric Advantage/Bariatric Fusion Meal Replacements, Truvani, Garden of Life

30

3

90

carbs, g

sugars, g

calories

Potential Challenges:

Plateaus:

Surgical weight loss causes rapid weight loss that is not your body's natural way to lose weight. As you begin to lose weight your body is rapidly depleting itself. Your food intake and vitamin recommendations are provided to help you lose weight safely and effectively. However, it is very unusual for your body to lose all the weight consistently. You may go through a period of rest called a plateau to help your body regain balance. Plateaus may last 3-4 weeks and are necessary. It is understandable that hitting a plateau can be frustrating, especially since you have put so much energy and effort into your program.

DO NOT think that you are doing anything wrong.

DO NOT cut back on your food volume.

DO contact the dietitian/health coach to ensure that your current diet and exercise is appropriate.

Weight Gain:

Weight gain can occur after surgical weight loss if you are:

Consuming too many calories

Inactive – exercise is 50% of weight loss and 100% of maintenance

Snacking inappropriately

Keys to keeping weight off:

STAY ACTIVE.

Do not skip meals.

Meet protein goal for the day.

Follow healthy eating guidelines. Meet your fluid goals daily.

Take your vitamins and supplements daily.

Develop a healthy relationship with food.

Lifestyle Adjustments

It is very important to start adopting good eating habits not just before but after surgery.
They include:

Eat mindfully and limit distractions.

Do not eat while driving.

Do not eat while watching television or in front of a computer.

Avoid eating standing up - take the time to sit and eat a meal or snack.

Do not skip meals: start-planning meals.

Eat slowly.

Chew food thoroughly.

Use a small plate and small utensils to help keep portions small.

Measure food (food scale, measuring cups, measuring spoons, don't eat out of the bag or package).

Avoid grazing. Eat only at designated meal and snack times.

Avoid eating fast foods. There are limited healthy options at fast food restaurants.

Avoid drinking high caloric beverages such as sweetened teas, lemonade, fruit juices, regular soda, sugar sweetened coffee drinks, energy drinks.

Be in tune with your hunger. Eating when you are stressed, angry or happy doesn't mean you are hungry.

Dining Out at Restaurants

Eating out with family and friends is an important social experience and you should not be afraid of it. Use the following guidelines to help make dining out a relaxing and enjoyable experience.

Think about what you will eat before you go out. Planning ahead will make you more likely to select appropriate foods. Select "safe" foods you know you can tolerate. Sometimes it is hard to tell what is in an item on a menu by its name. Do not be afraid to ask. It is wise to stick with foods you know when dining out.

Order child-size portions if possible, however do not order from the child's menu. You may have to give a simple explanation of your dietary needs.

Avoid fried foods. If it is fried, ask if it can be baked or steamed instead.

Share a meal.

Avoid alcohol as it contains a large amount of calories and the surgery itself significantly lowers your tolerance.

Complications

Even though change to the size of the stomach is a useful tool, it can cause serious problems if you don't follow healthy eating habits and meal planning. Complications can happen at any time after surgery. Following the diet guidelines for portion size, specific foods and supplements will help prevent complications. Common complications and ways to prevent them are listed below.

Complication

Possible Causes

Ways to Prevent Complication

Dehydration

Not drinking enough fluid

Vomiting

Drink at least 6-8 cups of fluid daily. (48-64 oz.) Always sip, never gulp fluids.

See ways to prevent below.

Complication: Dehydration

Nausea and vomiting, and heartburn

Eating too much food

Eating too fast, or not chewing thoroughly

Follow portion control guidelines above. Always stop eating when you feel satisfied.

Eat slowly and chew food well. Avoid eating when rushed or under stress.

Complication:
Nausea, vomiting or heartburn

Blockage

Meals should last 20-30 minutes. If you vomit more than 1-2 times/day, or after every meal, call your doctor immediately.

Constipation

Not enough fiber

Add in more fruits, vegetables and whole grains. However, limit whole grain bread, bran and raw fruits and vegetables immediately following surgery. Add these foods in slowly so your pouch can adjust.

Complication:
Constipation

Dehydration

Do not take any fiber supplements or laxatives without getting approval from your doctor first.

Diarrhea

Lactose intolerance

Try a lactose-free or dairy alternative milk.

Complication: Diarrhea

Dumping syndrome

Avoid simple sugars, sweets. Drink liquids away from meals (at least 30 minutes). Reduce fat intake.

Blockage of stomach opening

Not chewing food well

Chew food 15-30 times before swallowing. Call your doctor if nausea, vomiting or pain persists.

Complication: Blockage of stomach opening

Stretching of stomach pouch

Eating past the point of fullness

Avoid large quantities of food. Eat mindfully. Initially only 2-3 tablespoons of food per meal.

Complication: Stretching of stomach pouch

Adapted from: https://www.mercy.net/content/dam/mercy/en/pdf/quick-nutrition-guide-for-bariatric-surgery.pdf

Good luck in this new adventure! Remember, your motivation and compliance with these nutritional guidelines will help you maximize the benefits of your bariatric surgery!

References:

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