00:00
- Hi, I'm Jessica [Crandall] Snyder, registered dietician [CDE]
00:03
and outpatient and nutrition director.
00:05
Welcome to your first week after surgery
00:08
post-operative pre-select diet class.
00:15
Our agenda today is to discuss your questions and concerns,
00:19
really bringing in the full picture of
00:21
if your experiences are normal.
00:23
We want to bring this all together,
00:25
so that you know how to effectively use your tool.
00:28
We need to address what you'll be eating and drinking
00:31
during the pre-select phase and what your food choices are.
00:34
We'll also be discussing supplements, exercise,
00:38
wound care, medications, expectations and warning signs,
00:43
as well as upcoming events.
00:47
It's important we discuss your diet [defined as usual food and drink of a person or animal; food and drink considered in terms of
its qualities, composition, and effects on health; regulated selection of foods]
00:48
and lifestyle after surgery 
[following a specific diet after surgery is crucial as part of an overall and durable lifestyle change towards improved health].
00:51
Following a precise diet progression after surgery
00:53
is an important piece to ensure proper healing.
00:57
There's a modified texture of this diet during this process
01:01
to help decrease inflammation during
01:03
the post-surgical process.
01:05
Liquids move through rather easily [quickly],
01:08
and soft foods do as well. [Soft and solids stay in pouch longer (think about a funnel)].
01:11
However, staying away from solid foods
01:13
or foods that are coarse in nature or stringy
01:16
during this time frame.
01:19
Your portion size may be based on your tool [pouch size] after surgery.
01:24
For bypass, that's typically about one to two ounces
01:27
at this point.
01:28
For a sleeve, it's between two to three ounces,
01:32
and for a duodenal switch between two to four ounces.
01:36
Your food should be measured in a measuring cup
01:38
during this timeframe to ensure accuracy.
01:42
During this presentation today, we'll be addressing
01:44
your pouch as your new stomach
01:47
and your remnant as your old stomach,
01:49
and this is for bypass procedures only.
01:52
So, once again, listen to your pouch
01:54
and your volumes may be dependent on
01:57
the surgical procedure you chose and the healing process.
02:01
Dumping syndrome occurs for gastric bypass patients [only]
02:05
when they consume too many carbohydrates at a meal.[Dumping occurs when food/drinks move quickly through the pouch into
the small intestine. If high in carbohydrates and sugar -- which are digested quickly, food can "dump" into small intestine.
Correlated with rapid movement of water]
02:08
This causes food to rapidly empty
02:11
into their small intestines, causing symptoms
02:14
such as diarrhea, sweatiness, dizziness, lightheadedness,
02:18
fainting, nausea, or vomiting. [Tip: Limit diluted juice (diluted with water in a 1:4 ratio), skim milk, etc.]
02:21
So be cautious about the carbohydrates you're consuming
02:24
and make sure you're focusing on protein.
02:28
Your pre-select [soft] food choices will start on day seven [for 1-2 weeks before gradual transition to soft diet at 3 weeks]
02:33
and these foods are typically tolerated
02:35
for bypasses at one ounce every two hours,
02:39
and for a sleeve or duodenal switch
02:41
at one to two ounces every two hours.
02:45
Small, frequent protein rich meals
02:47
is our focus during this timeframe [protein first],
02:50
and your pre-select diet will be from day seven to day 21.
02:56
The pre-select diet foods include things
02:59
such as low-carb [light or Greek] yogurt, low-fat refried beans [or any pureed beans],
03:05
egg whites [no yolks: too high in fat and generally not well tolerated] or Egg Beaters 
[plain Egg Beaters, nothing flavored at this point], fat-free cottage cheese,
03:10
as well as sugar-free pudding [add protein powder or PB2] and tofu.
03:13
These are appropriate during this pre-select diet phase
03:17
from day seven to day 21.
03:20
Protein shakes and powders can be continued
03:23
during this phase to help you meet your protein goals.
03:28
Protein drinks are used to help supplement
03:31
your nutrient needs [until you are able to reach your protein goal with food alone].
03:34
You can consume between one to eight ounces
03:37
of protein drinks every two hours.[Drink protein shakes between meals as a protein supplement.]
03:40
It's important that you keep track of a food log [with protein intake],
03:43
to help ensure you're meeting your protein needs [minimum and goal amounts]
03:46
throughout the day.
03:48
Additional protein powder [flavored or unflavored] can be used
03:50
in [pre-selected] soft foods that you're consuming [to increase protein concentration in meals].
03:53
This can help enhance the protein quality
03:56
of the food you're eating and better help you
03:58
to meet your protein needs throughout the day.
04:02
The number one reason for readmission into the hospital
04:05
is dehydration, so sip, sip, sip, throughout the day
04:08
and stay hydrated.[Minimum of 48 ounces per day is crucial to prevent dehydration]
04:10
This may feel like a full time job,
04:12
but getting a minimum of 48 ounces of fluid per day
04:16
and a goal of 64 should feel like something
04:20
that you're working towards. [Start with one to two ounces at a time to prevent overfilling pouch. Sip, sip, sip-- 
it's OK to drink more if tolerated well.]
04:22
[Fluid "rules" to keep you safe:] Also, avoiding any straws [easy too drink too quickly which can cause discomfort],
carbonation [irritates pouch and takes up space],
04:25
caffeinated beverages [irritates pouch (ulcers)], as well as calorie beverages
04:29
during this phase [Enjoy low calorie beverages to prevent dumping syndrome as well as weight gain (fluids do not = satiety).
Water (best choice), decaf tea, crystal light (sugar free drink), sugar free gelatin or popsicles, broth, etc.]
04:31
Water is your best choice during this phase,
04:33
and making sure you stay on top of fluids,
04:36
but you do not need to separate your meals
04:39
from your fluids at this point.
04:41
That doesn't begin until six weeks.
04:43
Vitamin supplementation is a lifelong requirement
04:47
to prevent deficiencies.
04:49
Your food path has been rerouted [Bypassing main absorption site for some vitamins and minerals] and absorption
04:52
has been decreased, as well as you're not eating
04:55
as much food as you once did,
04:57
so supplementation is crucially important. 
05:00
Liquid and chewable options are your best form
05:03
of multivitamin supplementation.[Crush or cut pills (when appropriate and approved by medical team).]
05:06
You can talk with your doctor about switching
05:08
to a pill-sized tablet after about three to six months.
05:12
You'll just wanna make sure
05:13
that they're smaller than the size of a pea,
05:15
to avoid them getting stuck, and you may, at that point,
05:19
address if you can cut your pills with a knife cutter,
05:23
and absorb them appropriately. [Can remain on liquid or chewable if preferred. Sleeve and DS may tolerate tablet form.]
05:24
Once again, talk to your doctor,
05:26
if this is a modification you want to address.
05:29
Taking a multivitamin after surgery
05:31
is something that you've already started.
05:33
You will need to make sure you're maintaining that regimen
05:36
of taking two doses per day,
05:38
depending on the surgical procedure you've had. [1 adult pill 2x/day for bypass and DS, 1x/day for sleeve]
05:42
For B12, it needs to be taken at 1000 micrograms per day,
05:46
sublingually, which means under your tongue
05:48
and melting completely [OTC], or that nasal spray [prescription],
05:52
or the once a month injections with your physician's office [may also be self-injected].
05:57
Additional vitamins and minerals may be recommended
06:00
based off of your labs,
06:01
and doses may be changed based off of your lab values.
06:05
So work with your dietician [RD] and doctor [MD]
06:07
to make sure you're up to date
06:09
with the appropriate vitamins and minerals
06:11
you should be taking.
06:13
Calcium and fiber supplementation
06:15
does not start until six weeks, or the solid food plan,
06:18
so you can hold on that for now.
06:20
This is your vitamin and mineral chart. 
[Multivitamin: All procedures start immediately following surgery; 1 for sleeve; 2x for DS and RYG;
Vitamin B12: all procedures start immediately following surgery; 500-1000mgs (sublingual, nasal or injection);
Calcium Citrate: All procedures start 6 weeks post op; 1000- 1500mg (2-3 doses of 500mg);
Vitamin D: All procedures start immediately following surgery at 3000 IU;
Fiber: All procedures start six weeks post-op; 2-3 doses/day of 3-5g from fiber supplement; 25-35g/day total from food and supplement; 
Fat Soluble ADEK for DS only starts immediately following surgery;
A- 10,000 IU; D- 3,000+ IU; E - 50 IU; K - 300 mcg.]
06:23
So review your current supplementation,
06:26
and the timeline in which
06:27
you should be progressing these vitamins.
06:30
At this point, you should be at minimum
06:32
taking your multivitamin, as well as your B12.
06:36
And for the duodenal switch patients,
06:38
making sure you take your fat soluble vitamins
06:41
A, D, E and K. [Iron: DS or if needed at 30-60mg, do not take with calcium; Biotin: No required, dose at 5000 mcg,
to help with hair regrowth after surgery, may experience "shedding" 3 months post-op; Omega 3 Fatty Acids: not required,
2000 mg for anti-inflammatory benefits, recommended; Thiamin: if needed at 1-2mg; Zinc: if needed at 10-20 mg or 100% RDA, DS- 200% of RDA
multivitamin; Copper: if needed at 1-2 mg or 100% RDA, DS- 200% of RDA in multivitamin.]
06:51
Exercise is as important as water and protein,
06:55
and it must be used together to ensure success.
06:58
It helps with healing, and promotes circulation,
07:01
it improves your mood and energy,
07:03
increases your metabolism,
07:05
and is a part of your lifestyle change.
07:08
So start a routine today, if you haven't already.
07:12
You should be walking four to six times a week at first,
07:16
and working on increasing that over time.
07:20
Work towards getting 30 minutes a day,
07:22
and you can split it up if needed.
07:24
Set obtainable goals, and start working
07:27
on progressing towards those goals throughout the day.
07:31
You may get fatigued, but remember,
07:33
you can break up your activity [try to continue to move].
07:35
Still, no heavy lifting,
07:37
such as pushing or pulling or straining [greater than 15 pounds].
07:39
No more than 15 pounds at this point.
07:42
So focus on activities you can do,
07:44
instead of the ones you can't.
07:46
In regards to your wound care, if your incisions are oozing,
07:50
you can dress and gauze those with paper tape.
07:53
Change the dressings daily.
07:55
Daily checks for incisional infection are important,
07:58
so make sure you're taking care of your incision,
08:00
and assessing how they're healing.
08:03
No soaking in baths,
08:05
as that does increase the risk of infection.
08:07
You should be waiting at least three to four weeks
08:09
for wounds to heal before you start soaking in a bath,
08:13
swimming, or going in a hot tub.
08:15
Although baths and bathing are not appropriate,
08:18
showering is always okay.
08:21
After surgery, we want to make sure
08:23
that you have your follow-up appointment
08:25
scheduled with your primary care physician.
08:27
This should be completed
08:28
within one to two weeks of your surgery,
08:31
especially if there's medication changes that are needed.
08:34
Many of our patients experience medication changes
08:38
due to their change in blood pressure, blood sugar,
08:42
as well as other challenges they may be having
08:44
that need medication adjustments.
08:47
A small amount of weight loss can make a big difference
08:50
in these medication changes. [Do not change dosage based on how you "feel" -- work with PCP to address medication regimen]
08:52
Monitor your blood sugars frequently if you're diabetic,
08:55
as well as monitor your blood pressure daily,
08:57
if you have blood pressure challenges
08:59
such as hypertension.
09:01
We wanna set you up for success with your expectations.
09:05
Many of our patients will ask,
09:06
"Are these aches and pains normal?"
09:09
It is more common to have left-sided abdominal pain,
09:12
as there was a lot of manipulation
09:13
during the surgical process on this side of your body.
09:17
Make sure your pain is not accompanied
09:20
by unexplained nausea, vomiting, a fever greater than 101,
09:25
unresolved diarrhea or constipation.
09:28
If these concerns are happening,
09:30
please reach out to your surgeon.
09:33
Mild nausea can be a normal symptom
09:35
of your recovery and healing process.
09:38
Make sure when you're eating,
09:39
that you're not overfilling your pouch. [You may or may not feel fluid coming back up to the back of your throat. Listen to your pouch!]
09:42
Also, make sure that you're staying on top
09:45
of your fluid requirements [so as not to become dehydrated], as well as your protein goals.
09:48
This will help to reduce hunger,
09:50
and improve your overall energy and healing
09:53
as well as recovery.
09:55
Your bowel habits may change after surgery,
09:57
and it's normal to experience these changes.
10:00
Looser stools are common on the liquid diet.
10:03
Less frequent stools are also common [on solid diet],
10:06
as you're eating less food and less fiber.
10:09
You will be adding fiber back in
10:11
at the six week post-op phase.
10:16
If you're having diarrhea [frequent loose stools],
10:18
it can increase your risk of dehydration.
10:20
If your urine is dark
10:21
and you're starting to feel tired and dizzy [nausea, dry mouth],
10:24
you may need to have an IV placed
10:25
to get your hydration back up to par.
10:28
So stay on top of your hydration,
10:30
and if you're unable to do so,
10:31
please reach out to your surgeon's office.
10:34
Constipation is also something
10:37
that some of our patients struggle with.
10:39
If you've had no bowel movement for three days,
10:41
please reach out to your surgeon's office,
10:43
as they may prescribe a stool softener.
10:46
Minor symptoms require a call to your surgeon's office,
10:49
especially if symptoms persist.
10:52
A fever of less than 101, a seroma,
10:55
which is that blister-like appearance around your incision,
10:58
temporary numbness in extremities,
11:00
incisional abscess along your [stitch or] suture lines,
11:03
fluid retention [mild edema/swelling], loose knot or suture [stitch],
11:06
constipation or diarrhea,
11:08
mild nausea, or an oral yeast infection [thrush]
11:11
can be minor symptoms after surgery.
11:14
Once again, reach out to your surgeon's office
11:17
if these persist.
11:19
Major symptoms that require a 911 call, emergency room visit
11:24
as well as a call to your surgeon include:
11:27
Fever greater than 101, leg [or arm] pain or swelling,
11:31
shortness of breath, severe nausea with protracted vomiting,
11:35
dizziness, as well as chest pain.
11:38
Our upcoming events include our soft food class,
11:41
which is at three weeks,
11:43
our solid food class at six weeks,
11:46
the three and six month office visits
11:48
that you'll need to schedule with labs,
11:50
the six to nine month back to basics review class,
11:53
and our monthly support groups
11:55
for all of our patients including bypass,
11:58
band, duodenal switch, and sleeve.
[Thank you to the Denver Center for Bariatric Surgery for helping develop this education.]