Dietary advice following bariatric surgery

What can I eat and drink after surgery?

After surgery, you will need to change the texture (feel and look) of your food to allow your digestive system to heal. This will reduce the likelihood of any complications following your surgery.

You should start with sips of water, progressing through the 4 stages as follows:

The timescales for each stage is a guide. Most people are back onto solid foods by 6 to 8 weeks after surgery.

It may take you longer to progress through each stage depending on how your body is recovering. If you progress faster than recommended, you increase the risk of damaging your pouch or causing a leak which can be dangerous or even life-threatening.

The advice will help you get the nutrients your body needs, helping you to recover and stay well following your surgery.

Stage 1: Liquids only

Your nursing team will advise you when you can go from sipping water to ‘free fluids’, which is usually within the first 24 hours after the surgery.

‘Free fluids’ include water, cooled tea and coffee, milk, low-sugar squash/cordial, sugar-free still flavoured water and small amounts of fruit juices. You are also allowed to include think soup and jelly.

You should aim to drink a minimum of 1.5 to 2 litres of fluid each day once your drip is removed. Using a sports cap or straw sometimes reminds people to sip rather than gulp larger volumes which may cause discomfort.

It is advised you avoid any fizzy drinks, alcohol or any liquids with bits/lumps in.

Before you leave hospital, you will be given some food from Stage 2 to try, to make sure that you can manage this without any issues.

Specific examples are given below.

Stage 2: Puree/smooth texture

During the first few weeks following surgery, your stomach will be very swollen and tight. It is important not to eat any solid foods which may get stuck or be forced through which could cause problems.

When you begin to reintroduce food during your hospital stay, the texture needs to be extremely smooth and runny. Some puree food can be thick in consistency (texture) which may cause discomfort, therefore the following is recommended during your hospital stay:

• Weetabix – soaked with plenty of milk (no porridge please).
• Jelly.
• Build-up mousse.
• Smooth yoghurt – no bits.
• Soup – blended (no lumps) or build-up soup.
• Think custard.
• Milk.
• Fruit juice.
• Ice cream.

The food provided by the hospital comes in a set portion size. You do not have to at the full portion.

Listen to your body and stop as soon as you feel full.

Try not to worry too much about the calories in foods at this stage; the quantities you will be able to eat will be limited anyway. The aim at this stage will be to check your tolerance and to make sure any food eaten is nutritious as possible.

Puree meals provided by the hospital should be avoided, due to their thick consistency. Once at home however, you can blend food to an appropriate (right) consistency depending on your tolerance.

Portion sizes are likely to be very small to start with due to swelling caused by the operation. As the swelling reduces, you will be able to manage slightly bigger portions. A few teaspoons are likely to make you feel full to start with, however, you are likely to manage a few tablespoons (no more than 4 tablespoons per meal) by the end of this stage.

Over the first 2 to 3 weeks at home, you can start to experiment with slightly thicker consistencies, starting to introduce soft lumps when you feel able.

You may still decide to make use of the foods and fluids listed above, but it is important that you introduce puree meals as soon as you can in order to include protein-rich foods such as meat, fish and lentils.

Please see the separate leaflet for ideas, ‘Pureed meal ideas following bariatric surgery’.

It is not encouraged to use pre-prepared puree baby food. They are not suitable for meeting adult nutritional needs.

Tips:

You should:

• Aim to eat 6 times a day, choosing nourishing foods.
• Eat slowly and leave 20 seconds between mouthfuls.
• Use a liquidiser/food blender to get the correct consistency.
• Use a sauce or gravy to help blend foods.
• Avoid eating seeds, nuts and pips.
• Avoid gulping and talking while eating if you suffer with discomfort from trapped air.
• Consider serving food on a tea plate or ramekin dish and adapt cutlery where appropriate, for example, use a teaspoon to eat soup.

Stage 3: Soft/crispy texture

During this stage you can make use of foods that are naturally soft and can be mashed with a fork.

You can also introduce crispy foods at this point if you manage them well. These may include foods such as crackers, crisp breads, breadsticks or melba toast. You should continue to avoid seeds, nuts and pips.

As you move onto this stage, introduce foods gradually into your diet. You may notice that you can eat a slightly bigger portion at meal times. If this is the case, you may reduce the number of meals to 4 a day.

Suitable meals could include:

• Eggs (poached/scrambled/boiled or used to make an omelette).
• Minced meat or meat alternative such as Quorn^TM/soya/tofu in a tomato based sauce with soft pasta.
• Fish in parsley or white sauce with well cooked vegetables and mashed potato.
• Tinned meat or fish (in sauce/brine/spring water or low-fat dressing) with mashed potato/crackers or with soft vegetables.
• Shepherd’s/Cottage/Fish pie with soft vegetables.
• Crackers with cottage cheese or soft spreadable cheese.
• Potato (inside of small jacket potato) with baked beans and sprinkle of grated cheese.
• 100g rice pudding with small mashed ripe banana.

Stage 4: Normal textures to include solids

It is recommended that you re-introduce solid foods into your diet gradually. By stage 4, you should be able to eat a good variety of foods that allows you to have a healthy and well balanced diet.

Your portion sizes may continue to increase slightly over the first few weeks of being on this stage however, they should be smaller than what you had before the operation.

If you serve food on a side plate, aim to eat 3 meals a day. If they are smaller than this, aim to eat 4 to 6 meals per day.

If you are really struggling with food at meal times, include a glass of milk or yoghurt between meals to help increase your protein intake.

Tips:

• Try new foods and consistencies in small amounts, until you are confident that you are able to tolerate them.
• Chew your food well and take your time eating.
• Include some protein rich food with each meal and snack and focus on eating this food first.
• Aim for a healthy balanced diet (for further guidance, speak to your Dietician).

Sample meal plan

Why is protein important?

Protein is really important in the early stages after surgery to promote wound healing and to minimise muscle loss.

Some high protein foods such as dry, tough meat can often be hard to manage. Try to include alternative foods that are good sources of protein, such as fish, dairy, eggs, beans and pulses/lentils.

You should include some protein at each meal and focus on eating this first.

Another way to increase your protein intake is to add milk powder to the milk you drink. (Add 2 to 4 tablespoons of milk powder per pint of milk and whisk in).

It is rarely needed to take extra protein from formulated drinks. If you are worried about your protein intake, discuss this with your Dietician.

Why is fluid important?

Drinking 8 to 10 cups/glasses (2 to 2.5 liters or 3.5 to 4 pints) of fluid each day is recommended to help you stay hydrated and to help prevent constipation.

Try to sip fluids slowly throughout the day as it may feel uncomfortable if you try to drink too much too quickly.

Carry a water bottle with a sports cap with you or use a straw if this helps to stop you gulping large volumes of fluids.

It is recommended that you keep fluid separate from meals due to the following reasons:

• If you fill up on fluids, you will be unable to fit in enough food to stay nourished.
• If you drink too soon after food, this could cause vomiting.
• Drinking whilst eating or just after can lead to dumping syndrome (see later explanation).

Fluids are absorbed in the same way as they were before the surgery, so you should continue to avoid high calorie fluids such as milkshakes and sugary drinks.

If you prefer your hot drinks to taste sweet, try adding sweeteners instead of sugar. Try to have no added sugar or diet drinks rather than full sugar options. Fizzy drinks are likely to cause discomfort so should be avoided.

How do I eat to avoid complications?

Getting the right eating technique can reduce side effects such as vomiting, bloating and discomfort. You can use the ’20:20:20 rule’ to help you with this:

• 20 chews for each mouthful.
• 20 seconds between each mouthful.
• 20 minutes for the meal.

Take small mouthfuls of food and stop when you feel full. Taking longer with food will allow time for your brain to recognise when your stomach is full.

If a food or fluid causes discomfort or pain, remove this food from your diet and retry this at a later date.

Introduce new foods in a place where you are comfortable and relaxed, and avoid lying down after eating.

It is recommended that you get rid of any leftover food so you are not tempted to return to it shortly after. To save wasting food, consider putting leftovers in the fridge of freezer (as appropriate).

Some people find that after surgery, they may feel differently following food or drink. This is normal, but you should not feel any pain or discomfort and you should not need to vomit. Most people find that how they vomit can also be different. It is usually described as regurgitation of food and sometimes white phlegm is also brought up.

If you vomit or regurgitate food, ask yourself the following questions:

• Did I eat too much?
• Did I eat too quickly?
• Did I chew this food well?
• Was the food I ate the wrong texture for my stage after surgery?
• Did I keep food and fluid separate?

You may need to re-visit the advice given in this booklet to adjust your eating technique. Some people take longer to adjust their eating technique. However, if you feel that your technique is correct and you continue to vomit, please contact your Bariatric Team.

Will there be changes to my hunger and appetite after surgery?

It is very common to not feel hungry in the first couple of months following surgery. It may be tempting to skip a meal when you are not feeling hungry however, your body still needs nourishment to stay well and enough fluids to hydrated.

It is important to keep a regular eating pattern and to sip fluids regularly throughout the day.

Will having bariatric surgery mean I need to avoid certain foods?

Not necessarily. In the long term, you should be able to have a varied and balanced diet. Some people may find some foods are more difficult to consume than others.

This is different for everyone however, the more commons foods include:

• Doughy white bread.
• Stringy vegetables.
• Overcooked pasta and rice.
• Pips, seeds and skins or piths.
• Dry roasted peanuts.

If you do have problems, avoid this food for a few days to a week before retrying it.

When you are trying a food for the first time since your surgery, ensure you are somewhere comfortable in case you struggle.

Generally speaking, if a year has passed and you continue to struggle with a particular food, it is unlikely that you will manage it in the future.

What are the common problems following surgery?

Constipation

Constipation is a common issue in the initial stages following surgery. To try and prevent this, ensure you are reaching the recommended volume of fluid each day.

Reintroduce foods with fibre such as fruits and vegetables, wholegrain cereals and bread when it is appropriate to do so.

Moderate intensity exercise can also help to get the bowels moving, so increase you activity levels as appropriate. If this does not help, consider taking a non-bulking agent such as Senna, Lactulose or Benefibre.

Dumping Syndrome

Dumping syndrome is a set of symptoms that can be caused when food or drink high in sugar or starch moves suddenly into your small bowel.

This causes water to move into your small bowel to help break down the food. This can occur within 30 minutes of eating/drinking, and symptoms include abdominal bloating, cramps and pain, sweating, nausea and vomiting, heart palpitations, dizziness/fainting and diarrhoea.

‘Late’ dumping syndrome can occur 1 to 3 hours after a meal. This is where your body releases a surge of insulin in response to this overload of sugar/starch, causing your blood sugar level to drop too low. This can lead to heart palpitations, sweating, fainting, fatigue, confusion, hunger and tremors.

Some examples of foods that may lead to dumping syndrome include chocolate, sweets, sweet puddings/desserts, full-sugar drinks, cakes and sweet biscuits.

Tolerance levels vary form person to person, however, these foods should be kept to a minimum due to their overall calorie content.

Dumping syndrome can also occur if fluids are taken too soon following a meal, so we recommend leaving 30 minutes before taking a drink. If you start to experience any of these symptoms, it is recommended to sit or lie down as this can help.

If you experience any symptoms that cannot be explained by the above, including feeling faint/dizzy or weak, you should contact your Bariatric Team, especially if you experience these symptoms regularly.

Diarrhoea

Diarrhoea is less common after surgery however, can be a symptom of dumping syndrome, or caused by eating foods high in fat.

If you have persistent diarrhoea following surgery, talk to the Bariatric Team.

Hair loss

Hair loss is a natural occurrence for everyone. It is common to find that this degree of hair loss can increase significantly due to the physiological stress created not only by the surgery and anaesthetic but the rapid weight loss that follows. Hair loss tends to peak after roughly 6 months.

There is not enough evidence to recommend taking additional supplements such as zinc and selenium in order to prevent or treat the hair loss after surgery. You can reduce the degree of hair loss by having a well-balanced diet with enough protein, in addition to taking the recommended vitamin and mineral supplements advised by your Dietitian.

Can I drink alcohol?

After you recover from your surgery, you may wish to drink alcohol which can be enjoyed as part of a healthy balanced diet.

The Chief Medical Officers (CMO) recommend for both men and women no more than 14 units of alcohol per week should be consumed. If you do drink on a regular basis, consider having alcohol free days throughout the week.¹

Following surgery, you should carefully consider the following before reintroducing it into your lifestyle.

• Alcoholic drinks often contain sugar which may cause dumping syndrome.
• Alcohol is high in energy and its nutritional value is low. It can increase appetite, making you want to eat high-calorie snack foods.
• Fizzy alcoholic drinks can cause you discomfort.
• Because you tend to absorb much quicker following surgery, a small amount of alcohol may cause a significant effect.
• Drinking more than the recommended amounts of alcohol can contribute to weight gain.

Do I need to take vitamin and mineral supplements?

Following bariatric surgery, you are at an increased risk of not absorbing enough nutrients to keep you healthy.

To help you stay well in the long term, in addition to having a healthy balanced diet, you should take:

• An A-Z multivitamin and mineral supplement daily.
• A calcium and vitamin D supplement daily.
• A vitamin B₁₂ injection every 3 months.

Recommended A-Z vitamin and mineral tablets that contain the correct copper-zinc ratio include the following:

• Forceval (once daily if you receive a prescription).
• Holland and Barrett ABC to Z (Twice daily).
• Aldi everyday health (Twice daily).
• Asda A-Z (Twice daily).
• Lloyds Pharmacy A-Z (Twice daily).
• Morrisons A-Z (Twice daily).
• Sainsburys A-Z (Twice daily).
• Sanatogen A-Z (Twice daily).
• Superdrug A-Z (Twice daily).
• Tesco A-Z (Twice daily).
• Wilko A-Z (Twice daily).

Additional supplements may be needed, but are not started routinely. We will monitor your nutritional status by doing blood tests at each appointment 3 months onwards. We will monitor you for 2 years after your surgery. Following this, your GP should take over this life-long and monitor your bloods on a yearly basis.

When will I see the Dietician after my operation?

A dietitian will call you 1 week after your operation to review your progress and to answer any questions. You will then see the Dietitian at each appointment at the hospital for your 2 year follow-up period. If further support is needed, do not hesitate to call the Dietetic Department (see contact numbers).

Contact numbers

If you need further help or advice please contact:

North Tees and Hartlepool NHS Foundation Trust

Specialist Services Admin Hub

Telephone: 01429 522 471

Monday to Friday, 8:30am to 4:30pm (excluding Bank Holidays)

Further information is available from

There is a wealth of information accessible on the internet. The resources below will provide accurate and appropriate information for those who have had Bariatric surgery in the UK.

Weight loss surgery Info
WLS info
54 St James Street
Liverpool. L1 0AB
Telephone: 0151 222 4737
www.wlsinfo.org.uk

Weight Concern
Brook House
2-16 Torrington Pl
London. WC1E 7HB
Telephone: 020 7679 1853
www.weightconcern.org.uk

British Heart Foundation
180 Hampstead Road
Greater London House
London. NW1 7AW
Telephone: 01268 525320
Healthy recipeshttps://www.bhf.org.uk/heart-matters/healthy-eating-toolkit/recipefinder
Activityhttps://www.bhf.org.uk/publications/being-active/get-active-stayactive

Alcohol
Drink Aware
Salisbury House
3
rd Floor (Room 519)
London. EC2M 5QQ
Telephone: 020 7766 9900
https://www.drinkaware.co.uk/alcohol-facts/alcoholic-drinksunits/latest-uk-alcohol-unit-guidance/

Reference

1. Department of Health (August 2016) UK Chief Medical
   Officers’ Low Risk Drinking Guidelines.

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