1. BMI of Lancaster’s PRE SURGICAL NUTRITION CLASS Kevin Thomas, RD, LDN

2. PRINCIPLES OF SUCCESS HYDRATION NUTRITION GUIDELINES PROTEIN VITAMINS AND MINERALS PERSONAL ACCOUNTABLITY

3. HYDRATION Your goal as soon as you get home!! SIP Non-carbonated, no calorie fluid … at least 64 ounces each day!

4. 6/10/2016 DUMPING SYNDROME (Gastric bypass only)

5. 6/10/2016 WHAT CAUSES DUMPING??? 1.Too much sugar 2.Too much fat 3.Too much protein 4.Eating too fast 5.Drinking with meals

6. 6/10/2016 LOOK FOR ADDED SUGAR Look for foods with 2 grams or less of sugar per meal Remember: your serving may be smaller than that listed on the nutrition label!!! If a food is a fruit or milk product and it has a lot of sugar, check the source of sugar —Natural sugar OK —Avoid added sugar or processed sugar

7. 6/10/2016 COMMON NAMES FOR ADDED SUGAR: INGREDIENTS: CULTURED PASTEURIZED GRADE A NONFAT MILK, WHEY PROTEIN CONCENTRATE, PECTIN, CARRAGEENAN. Plain Yogurt: INGREDIENTS: CULTURED PASTEURIZED GRADE A REDUCED FAT MILK, APPLES, HIGH FRUCTOSE CORN SYRUP, CINNAMON, NUTMEG, NATURAL FLAVORS, AND PECTIN. CONTAINS ACTIVE YOGURT AND L. ACIDOPHILUS CULTURES. Fruit-flavored Yogurt: Brown sugar Corn syrup Dextrose Glucose Syrup Honey Invert sugar Maltose Sucrose Corn sweetener Malt syrup Maple syrup Fruit juice concentrates Molasses Raw sugar Sugar High fructose corn syrup Check the ingredients…

8. 6/10/2016 LOOK FOR PROTEIN Choose high-protein foods - Refer to list in packet Keep track of your protein intakes - Food journal, log, etc. Remember: your serving may be smaller than that listed on the nutrition label!!! For example: if you eat only 1 ounce of lean ground beef, how many grams of protein are you getting??? (refer to “High Protein List”)

9. 6/10/2016 HOW MANY GRAMS OF SUGAR ARE YOU LOOKING FOR ON LABELS??? 2 grams or less!!!

10. 6/10/2016 WHICH FOODS HAVE NATURAL SUGARS??? 1.Fruit 2.Dairy products - Milk, yogurt, pudding, etc.

11. DIET PROGRESSION PHASES

12. SUMMARY OF THE DIET PHASES Phase 1: Full liquids Phase 2: Pureed (blenderized) foods Phase 3: Soft foods (moist and mushy) Phase 4: Solid food - Maintenance

13. PHASE 1 RECOVERY: FULL LIQUIDS Skim milk, 1% milk, plain soy milk High protein drinks (such as Isopure) No sugar added Carnation Instant Breakfast Low fat/fat free, sugar-free yogurt Sugar-free pudding Low fat cream soups (strained) Vegetable juice Make your own high protein shake!

14. FULL LIQUID GUIDELINES Begins when you arrive home Sip 4 ounces of something with protein every 2-3 hours (drink water in between!) - gradually increase to 8 ounces (week 2) Avoid extreme hot or cold temperatures Stop sipping as soon as you feel full or nauseated

15. 6/10/2016 TRUE OR FALSE: I have to follow the “no liquids with meals” guideline in the full liquid stage. FALSE!!!

16. PHASE 2 RECOVERY: PUREED FOODS Fat free or 1% cottage or ricotta cheeses Scrambled or poached eggs Baby food (Stage 1 or Stage 2) Well-mashed squash, yams, potatoes Pureed fruit/vegetables without seeds Sugar free applesauce Pureed soups

17. PUREED GUIDELINES All foods must be baby food consistency Eat 4 ounces (1/2 cup or 8 Tbsp) for Breakfast, Lunch, and Dinner Take 10-20 minutes to finish a meal No fluid with meals, 15 minutes before, or 1 hr after meals Drink high protein supplements between meals to meet protein/fluid goals

18. 6/10/2016 TRUE OR FALSE: Any food is OK to puree if it is low fat and sugar free. TRUE!!!

19. PHASE 3 RECOVERY: SOFT FOODS Over-cooked vegetables Cooked or refried beans (fat free!) Baked or canned fish Soft meats (pureed, marinated, stewed, poached) Crockpot meals Low sugar cereal (soggy in milk) Hard-boiled eggs, scrambled, or poached Bananas or pureed fruit

20. SOFT FOOD GUIDELINES All foods must be “moist and mushy” Eat 4 ounces (1/2 cup or 8 Tbsp) for Breakfast, Lunch, and Dinner Take 10-20 minutes to finish a meal No fluid with meals, 15 minutes before, or 1 hr after meals Take tiny bites and chew well Drink high protein supplements between meals to meet protein/fluid goals

21. 6/10/2016 TRUE OR FALSE: If a food isn’t “moist and mushy” or “fork tender”, I can’t have it. TRUE!!!

22. PHASE 4 RECOVERY: SOLID FOODS z Add chopped meats as tolerated -Beef, chicken, fish, pork, etc. z Raw fruits and vegetables as tolerated -Softer may be best, especially in the beginning z Add new foods slowly (try only 1 new food per day) -Protein, fruit, and veggies mainly! -Limit complex carbohydrates (bread, rice, pasta, potatoes)

23. SOLID FOOD GUIDELINES Eat 4-8 ounce (1/2-1 cup) meals 3 times per day - Aim for 2-3 ounces of protein each meal - Protein is always eaten first Take 20 minutes to finish a meal - Take tiny bites and chew, chew, chew!!! No fluid with meals, 15 minutes before, or 1 hr after meals 10 grams of fat or less and sugar to 2 grams or less Drink high protein supplements between meals to meet protein/fluid goals

24. PROTEIN SUPPLEMENTS! Do not exceed 25 grams of protein at any one time!

25. WHY SUPPLEMENT VITAMINS AND MINERALS? z Bypassing main absorption site for some vitamins and minerals (gastric bypass) z Not eating as much food z Essential for baseline health z Must be taken everyday!

26. VITAMINS AND MINERALS Must be chewable, liquid, or crushable (dissolvable) Multivitamin Calcium Citrate - Better absorbed than calcium carbonate Iron Vitamin B12 *See your “Vitamin Recommendations” sheet*

27. SAMPLE VITAMIN SCHEDULE Celebrate Brand -Breakfast: Multivitamin, B12, and Calcium Citrate -Lunch: Iron -Dinner: Multivitamin and Calcium Citrate - Bedtime: Calcium Citrate Bariatric Fusion -Breakfast: Bariatric Fusion -Lunch: Bariatric Fusion -Dinner: Bariatric Fusion - Bedtime: Bariatric Fusion

29. “If you don’t take your vitamins, they’re guaranteed not to work!” - Carry them with you EVERYWHERE - Set timers on your phone or computer - Tell friends and family to remind you

30. HOMEWORK Create a vitamin schedule specific to your lifestyle Go shopping!!!! - (buy your vitamins, protein, etc. ahead of time) Keep track of your progress after surgery - Write EVERYTHING down in Daily Progress log Bring manual to hospital! - Write down any questions you have about the diets, etc.

31. EXERCISE For the first two weeks after surgery: - Focus on walking and doing light chores around the house (no re-arranging of furniture for instance) -Exercise is a great predictor of long-term weight maintenance -Most of your weight change, especially just after surgery, will be reflected by dietary change

32. PERSONAL ACCOUNTABILITY z Keep track of your progress z Take responsibility for your actions z Staying involved!! z Follow-up with your support groups

33. Remembering a Journey that Doesn’t Stop 6/10/2016

34. Congrats!