00:00
- Hi, I'm Jessica [Crandall] Snyder, registered dietitian [CDE]
00:03
and outpatient nutrition director.
00:06
Today, we'll be discussing your nutrition preoperatively
00:09
so that you can be better prepared
00:11
for your bariatric surgery.
00:14
[Pre-operative class goals] We'll be talking about your anatomy and your new tool
00:17
and how that's going to function.
00:20
Our goals also incorporate anticipating common pitfalls
00:23
after surgery and learning about the preoperative process.
00:27
We want to make sure you establish good habits
00:30
to ensure long-term success.
00:32
We call these habits the rules of the tool.
00:36
We also want you to make sure you learn
00:37
which foods will best serve you
00:39
and your specific needs and goals.
00:42
So you may ask what is different about me after surgery?
00:45
Well, there are several different types of surgery
00:48
and based off of the surgery that you
00:49
and your surgeon have selected,
00:51
your procedure may look a little bit different.
00:54
So we'll be discussing that more in depth today.
00:56
For the gastric sleeve, bypass, duodenal switch and band,
01:00
the stomach size will be significantly reduced
01:03
from 40 to 60 ounces which is
01:05
about the size of the football,
01:07
just down to about one to four ounces
01:09
which is about the size of a hard-boiled egg.
01:11
With the bypass only, the outlet of your stomach
01:14
will be changed from [pliable] two centimeters
01:16
to a rigid one centimeter and this is key
01:18
for your pouch working as it slows digestion of the food,
01:21
leaving you feeling fuller, longer.
01:25
The bypass and duodenal switch also reroutes your [small intestine] food path,
01:30
shortening it to reduce nutrient and calorie absorption.
01:34
The next several images is
01:36
how your anatomy will be altered based
01:38
off of the surgery that you selected.
01:40
The gastric bypass, the gastric sleeve, the duodenal switch
01:44
as well as the mini gastric bypass.
01:46
If you have questions about any of these procedures
01:48
and your new anatomy. Please discuss them with your surgeon.
01:52
We also have the gastric banding procedure.
01:55
This is your pre-surgery shopping list.
01:57
These are items that you'll need to purchase ahead of time
02:00
and some of these items you can actually start taking
02:02
ahead of time, so that you can be set up
02:04
for success after surgery.
02:06
We want you to go ahead and get a multivitamin
02:08
that is chewable or liquid.
02:10
No gummies or patches.
02:12
You also need to get a B12.
02:14
It needs to stay on the bottle sublingual or nasal spray
02:18
or you'll do an injection with your doctor once a month.
02:21
You'll need four by four inch gauze pads and paper tape
02:24
and this is going to be required for the bypass,
02:27
sleeve and duodenal switch and these are really
02:30
to go over your incisions after surgery.
02:33
You will be on a clear liquid diet before surgery
02:35
so you will want to make sure
02:37
that you have clear liquid products available in your house.
02:40
Things that are appropriate on the clear liquid diet
02:42
for 48 hours prior to surgery include broth,
02:46
decaf coffee, herbal teas, diet lemonade or other beverages
02:51
that are non-calorie, non-carbonated, non-caffeinated.
02:55
You also can do sugar-free popsicles and sugar-free Jell-o
02:59
and clear liquid protein drinks such as Isopure,
03:02
Premier Clear or Trusource protein drinks.
03:06
Protein powders and shakes are something
03:08
that you also want to purchase ahead of time.
03:10
These protein [powders and] shakes need to be low in carbohydrates,
03:13
less than five grams of carbohydrates per serving
03:17
and high in protein.
03:18
These are not to be smoothies.
03:20
They're really supposed to be protein drinks
03:22
that you mix with water or a low-calorie milk alternative
03:26
to help meet your nutritional needs.
03:29
When choosing protein supplements,
03:31
we want to make sure you choose powder or pre-mixed liquids.
03:34
Those are both acceptable.
03:35
The key is to try several brands and find
03:37
which one you like before surgery.
03:40
So don't stock up,
03:41
because you may not like them after surgery,
03:43
but do make sure you trial them and find one
03:45
that you do like.
03:47
Look for at least 20 grams of protein on the serving label
03:50
and less than five grams of carbs.
03:52
This is really going to be key
03:53
for fueling your body after surgery
03:56
as you will be consuming protein drinks
03:58
for about six weeks after surgery.
04:01
Mixers such as water, non-fat milk, one percent milk,
04:05
unsweetened soy or almond milk
04:07
and ultra filtered milk are also appropriate
04:09
to utilize with your protein drinks.
04:12
If you don't like flavored protein drinks,
04:14
there are unflavored protein powder options that you can use
04:17
to help increase your goal
04:19
and meet your nutrient needs better.
04:21
[Critical fluid management and hydration] It is critical that you maintain hydration after surgery.
04:25
Not getting enough fluid [minimum 48 ounces] can actually end you back up
04:27
in the hospital and it's the number one reason
04:30
for readmission back into the hospital is dehydration. 
04:33
It's hard to stay on top of that goal.
04:35
So really, set a timer,
04:37
make sure you're keeping track of it,
04:38
keep your favorite water bottle nearby and sip, sip, sip.
04:42
Get used to this habit even now, pre-surgery
04:45
so that after surgery you can be successful.
04:48
The goal is to get about 64 ounces of fluid
04:51
every single day, forever.
04:53
This also is something that you really want to look
04:56
at making sure there are no calories in your beverages
04:58
that you're consuming.[Low or no calorie (15 calories or less)]
05:00
So after the solid food plan begins after six weeks,
05:03
we really don't want you having liquids with meals
05:06
and that means no liquids at the same time as you're eating.
05:09
You can't sit down to dinner and have a cup of water
05:11
as well as your dinner.
05:12
We really want you to separate that time out.
05:14
You can drink [10-]15 minutes before you eat
05:16
and 45 to 60 minutes after you eat,
05:19
but once again, not with your food.
05:21
So start working on this habit now
05:23
so that when you get to that six week mark post-surgery,
05:26
you can be successful with this habit.
05:28
As far as your vitamins go, it is really important
05:31
that you start this regiment pre-surgery
05:33
so that you don't go into surgery with any deficiencies.
[Vitamins 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.]

05:36
You want to make sure you get a multivitamin
05:38
and this will also be started immediately following surgery.
05:42
This is one time the dose for a sleeve,
05:44
but if you are a duodenal switch or RYG patient,
05:47
gastric bypass, you will need to take two times the dose
05:50
than what is typically recommended.
05:53
You can also opt in for bariatric specific vitamins.
05:57
Vitamin B12 is something we want you to take
05:59
immediately following surgery.
06:01
We recommend a thousand micrograms per day.
06:03
This can be taken sublingually,
06:05
which means under your tongue and dissolve completely,
06:08
through a nasal spray or an muscle injection
06:11
done in your primary care doctor's office.
06:15
Calcium citrate is another vitamin that we want you taking.
06:17
This will actually start six weeks post-op.
06:20
So mark your calendars for that six week date
06:23
to start taking calcium citrate.
06:25
There's a lot of different types of calcium on the market
06:27
and calcium citrate is the most appropriate one
06:29
for you to be taking.
06:31
We recommend between a thousand to 1,500 milligrams a day
06:35
and it's best absorbed if you break it up
06:37
throughout the day.
06:38
So 500 milligrams in the morning, 500 milligrams at lunch
06:41
and 500 milligrams at dinner.
06:44
For vitamin D, we recommend this
06:46
to be taken immediately following surgery, 3,000 IUs a day.
06:52
Your fiber supplementation should start
06:54
at six weeks post-op.
06:56
we recommend because you're eating less food substance,
07:00
your digestive habits will change
07:01
and so we do recommend a fiber supplementation.
07:04
You can start with one to two doses and work your way up
07:07
to three doses per day.
07:09
This can be added to your normal daily intake
07:12
to help you have normal digestion.
07:15
For your fat soluble vitamins, those are your A, D, E and K,
07:20
these are required immediately
07:22
following your duodenal switch surgery.
07:24
If you've had duodenal switch, you'll need
07:26
to make sure you're getting 10 thousand international units
07:29
of vitamin A, 3,000 international units of vitamin D,
07:33
50 IU's of vitamin E and 300 micrograms of vitamin K.
07:39
All of these vitamins are very important for you
07:41
to make sure you prevent deficiencies
07:43
and if you have any questions, you can ask your surgeon
07:46
as well as your registered dietitian.
07:48
So make sure you're taking these vitamins
07:50
and make sure you purchase them ahead of time
07:52
so that you can be prepared afterwards.
07:55
[Minerals chart: [Iron: DS patients or if needed; 30-60mg; do not take with calcium]
[Biotin: Not required; 5000mcg; to help with hair regrowth after surgery, may experience "shedding" 3 months post op]
[Omega 3 Fatty Acids: Not required; 2000mg; for anti-inflammatory benefits, recommended]
[Thiamin: If needed; 1-2 mg]
[Zinc: If needed; 10-20mg or 100% RDA; DS- 200% of RDA in multivitamin]
[Copper: If needed, 1-2 mg or 100% RDA; DS- 200% of RDA in multivitamin]]
For minerals, you may need to take these in addition
07:57
based off of which procedure you've had
07:59
or if you've had a deficiency present.
08:01
Iron is one of those labs that we check frequently
08:04
and if you've had a duodenal switch, you'll need
08:06
between 30 to 60 milligrams a day of iron supplementation.
08:10
If you've had a deficiency, you need to talk
08:12
with your doctor about what you need to supplement.
08:15
You want to make sure that your iron is not taken
08:17
with a calcium supplement
08:19
as it actually can hinder absorption.
08:21
So separate some of the vitamins out
08:23
so that you don't have a decreased absorption
08:26
of your iron supplementation.
08:28
Biotin is not required, however some of our patients
08:31
choose to take biotin as it can help with hair regrowth
08:35
and prevent shedding.
08:36
It is recommended if you do take biotin
08:38
to take 5,000 micrograms per day.
08:41
Omega-3 fatty acids can be helpful
08:44
for decreasing inflammation.
08:46
It is recommended if you do take an omega-3,
08:49
to take 2,000 milligrams a day
08:52
and many of our patients choose to take this,
08:53
but it is not required.
08:55
Thiamine, you may need a supplement if your labs are low
08:59
between one to two milligrams per day,
09:01
as well as zinc, once again, if that's needed
09:04
between 10 to 20 milligrams per day
09:07
and then copper if needed
09:09
between one to two milligrams per day.
09:12
So please look through this chart, speak with your provider
09:14
if you have any questions about vitamins
09:16
or minerals or supplementation in general.
09:19
If you have a deficiency, we need to make sure we stay
09:21
on top of that and once again, we're always here
09:23
to help you if you have questions.
09:26
Getting used to your kitchen even now can be helpful
09:28
for you after surgery.
09:30
So some post-surgery cooking rules
09:32
that we would encourage you
09:33
to implement now is to fry nothing.
09:35
Also removing any visible fat from meat prior to cooking
09:39
and adding no calories to the cooking process.
09:42
So no added butters or oils.
09:44
Our preferred method for you for cooking includes baking,
09:47
broiling, poaching, barbecuing, using a crock pot
09:51
or even an insta pot.
09:53
Trying to focus on more protein
09:55
for the calories you consume is important.
09:57
so every food that you eat should have good amount
10:00
of protein for the calories.
10:02
If you were to take the total number of calories
10:04
and divide it by the grams of protein,
10:06
it should be less than 15 calories
10:08
for one gram of protein consumed.
10:11
So if you have a 200 calorie protein bar,
10:13
it should ideally have at least 10 grams of protein in it
10:17
and you can use this chart to help you identify
10:19
other food sources
10:20
that would better fit your nutrient needs.
[Chart: Low Calorie Protein: less than 10 calories per gram of protein, choose most of the time]
[Chart: Moderate Calorie Protein: 11-19 calories per gram of protein, choose occasionally]
[Chart: High Calorie Protein: Greater than 20 calories per gram of protein, only choose 1-2x day]
10:23
Nutrition is really important as well as reading your label.
10:26
We follow what's called the rule of 15.
10:29
[First Rule] When reading your label, you want 15 total calories or less
10:33
for every one gram of protein you consume.
10:36
[Second Rule] No more than 15 grams of carbs per meal
10:39
as this could dumping syndrome.
10:42
So check your carbohydrates out on that label
10:43
and make sure you're not eating
10:44
more than 15 grams of carbs per any meal.
10:48
[Third Rule] Aiming for 15 grams of protein per meal is ideal
10:51
as it will help you to reach your protein goal
10:54
at the end of the day. [Note: use rules of 15 when buying protein bars]
10:56
Ideally choosing low-calorie protein choices are going
11:00
to be most helpful for meeting your protein goal,
11:03
but not exceeding your calorie goal.
11:05
These option include things such as fish and shellfish,
11:08
low-fat dairy such as cottage cheese or Greek yogurt
11:12
or a low-fat [mozzarella] cheese, poultry, light or dark meat,
11:17
lean beef and lean pork.
11:19
So 93 over seven would be ideal when picking lean beef.
11:23
Egg whites or egg substitutes or tofu as well
11:27
also fit these low calorie protein choices
11:30
that you can choose from more frequently.
11:33
Medium and high calorie proteins such as nuts and seeds,
11:36
vegetable proteins such as beans, high-fat pork
11:40
such as bacon sausage or ham, high sugar yogurts,
11:45
soft cheeses and whole eggs will be things we want you
11:47
to include in your diet less often.
11:50
So try and choose these medium
11:52
to high calorie proteins less often.
11:55
We want to make sure you're fueling your body appropriately
11:58
so avoid these white carbohydrates [no-no's]
11:59
as they really provide no nutrients.
12:02
Things like popcorn, white pasta, potatoes, [white] breads,
12:06
crackers, cereals, white rice and grains
12:09
and refined sugar products [most packaged products] are things we really want you
12:12
to avoid as they're not going to help you
12:14
meet your nutrient goals at the end of the day.
12:17
We also want you to get in the habit of making sure
12:20
that you listen to your body when eating.[Post Surgery Eating Considerations]
12:23
You don't need to eat until you're stuffed or full.
12:25
Really just make sure you're thinking
12:26
about fueling your body. [Always eat a little less than you think you need.]
12:28
It can actually take your brain about 20 minutes for you
12:30
to get full [stomach to send signals to brain], so don't overstuff your new stomach
12:33
as it doesn't feel good.
12:35
Give yourself that time before you decide you need
12:38
to go back for more.
12:40
Focusing on lean animal proteins
12:42
and low-fat dairy options should be something
12:44
that you choose most frequently.
12:47
Fruits and vegetables will be added back in
12:49
after about three weeks and we really want you
12:52
to stay away from soups, salads and cereals.
12:56
Once again, your focus after surgery should be hydration,
13:00
protein and making sure you get adequate amounts
13:03
of nutrition, not excessive amounts of nutrition.
13:07
You can start working on some of these habits now.
13:09
So prior to surgery, we want you to start working
13:12
on smaller, more frequent meals.
13:14
We encourage five protein rich mini meals per day.
13:17
That means eating within the first hour or so waking up
13:20
and every three hours thereafter.
13:23
We also want you to start cutting back
13:24
on those carbohydrates that we talked about.
13:26
Those pastas, the potatoes, the grains, the crackers.
13:31
We want you to start an exercise [fitness] habit
13:33
and really get your body moving.
13:34
Find something that you enjoy such as walking,
13:37
dancing, the elliptical, bike riding.
13:40
Doing something to move your body
13:42
to build a fitness habit and routine
13:44
or strength training is that something that you enjoy.
13:47
Start taking a multivitamin even now, once again
13:51
so that you go into surgery healthy as can be.
13:55
Experiment with different protein shakes and once again,
13:57
find out which ones you like before surgery.
14:00
Make sure it's high in protein,
14:02
more than 15 grams of protein per serving
14:04
and low in carbohydrates.
14:06
Less than five grams of carbohydrates per serving.
14:09
Practice taking smaller bites and chewing your food well.
14:11
This is an important habit to get into prior to surgery
14:14
because once again, that outlet may be changed
14:17
in your surgical procedure and we want to make sure
14:19
that you fully digest your food and that way,
14:21
it doesn't feel like it's going to get stuck.
14:24
Since we're working on smaller portions,
14:26
many of our patients find it helpful to use smaller plates
14:30
or appetizer silverware [or baby spoons] so that they can help
14:33
to decrease the volume of the food that they're consuming.
14:36
So getting smaller plates and smaller silverware help you
14:39
to decrease the volume of what you're consuming
14:41
and help you feel like you're eating more
14:43
because of that smaller serving.
14:46
We also want you to stop caffeine and alcohol.
14:49
So start working on this now as we don't want you
14:51
to have to struggle through this after surgery.
14:54
Prior to surgery, we want you to stop smoking.
14:56
This is crucially important and required
14:58
of your surgeon prior to surgery.
15:01
If you do not stop smoking, your surgery will be canceled.
15:04
It is really important that you stop all cigars,
15:07
cigarettes and vaping.
15:09
Even secondhand smoke can make you test positive.
15:11
So it is crucially important that you stop smoking
15:14
as this will decrease healing potential
15:16
and increase risk of your post-op complications.
15:19
So once you stop, it is forever quit.
15:23
In the rules of the tool,
15:24
there are four parts of your program.
15:26
Your diet, your exercise tool and you.
15:29
Your surgery is the tool.
15:31
These four pieces will help you to be successful
15:34
even after surgery.
15:36
The diet after surgery is something we want you
15:38
to focus on even now and work towards.
15:41
You will need to make sure you're getting 75%
15:43
of whatever you eat on your plate to be protein rich
15:47
and only 25% is complex carbohydrates.
15:50
Once again, your proteins are typically things
15:52
like animal meats, beans, nuts, dairy
15:56
and your complex carbohydrates
15:57
are typically your fruits and vegetables.
16:00
We want you to have no more than one
16:02
to two high-fat food choices per day.
16:04
So trying to limit things like bacon, sausage,
16:07
high-fat cheese's.
16:10
We want you to eat five to six protein rich meals per day.
16:13
That means within the first hour of waking up
16:15
and every three hours thereafter
16:18
and protein really should be your priority.
16:20
You should be having protein with every meal.
16:23
Your first meal within that first hour of waking up,
16:26
you may need to set a timer to help remind you
16:28
to eat every three hours and your last meal
16:31
one hour before you go to bed, if necessary.
16:35
When following your rules of the tool,
16:36
ideal volume depends on you, your surgery, your pouch size
16:41
and your specific level of restriction. 
16:43
So you don't need to eat till you're full.
16:45
Really stop eating before that point
16:48
so that you don't overstuff yourself and feel sick.
16:51
You want to make sure that after the six week point [solid foods begin],
16:53
you avoid protein drinks.
16:56
This is when food should be your focus.
16:58
Your protein drinks should be supplements
17:00
for when you can't meet your nutritional needs by food.
17:04
Protein bars can be helpful in situations
17:07
where you may not be able to prep a meal,
17:09
but we do not encourage that you use these
17:11
on a frequent basis.
17:12
They're okay as a once in a while food.
17:15
When you are picking a protein bar, you want
17:17
to pick a low [to moderate] calorie, high protein bar
17:20
and watch out for those excessive amounts
17:22
of carbohydrates that sometimes can be hidden in them.
17:26
No more than one cheat per week.
17:28
We're not encouraging that you get off your diet,
17:30
but we realized that life can be challenging
17:34
and that food obstacles can be present.
17:35
We want you to stop and plan your cheat in advance
17:37
and really think about if it's worth it
17:40
and in line with your health goals.
17:42 [Plan your cheat in advance. Stop and think before you eat it!]
Exercise is an important part of your health
17:45
as well as your continued journey for weight loss.
17:48
We want you exercising at least a 150 minutes per week.
17:52
That's thirty minutes a day, five days a week [minimum].
17:55
You can break it up however you want.
17:57
You can do 15 minutes in the morning
17:59
and 15 minutes in the evening and you can really start
18:02
to build an exercise program that you like. [Start by trying to exercise as you are able
but work up to 30-60 minutes, five days a week]
18:04
A variety of exercises can be enjoyed,
18:07
however we encourage you to wait
18:09
on strength training exercises until six weeks out
18:12
after surgery and cleared from your physician. [Start with low weight and build up]
18:15
It is important that you think
18:17
about changing up your fitness routine
18:19
about every eight weeks as this can be really helpful
18:21
in preventing plateaus as well as weight regain.
18:25
Fiit [frequency, intensity, type and time] is an acronym we use to help improve your outcomes.
18:29
Really changing the frequency, intensity,
18:32
type or time of exercise will help
18:34
to optimize your weight loss results
18:37
and improve your overall fitness enjoyment.
18:40
You may be asking, what is your tool?
18:43
The surgery is your weight loss tool.
18:45
Constantly assessing the effectiveness of your tool
18:48
will be helpful in advancing your weight loss.
18:51
We want to make sure that you're getting an adequate amount
18:53
of protein, between 10 to 15 grams of protein
18:56
every three hours.
18:58
You do not need to eat to capacity or fullness
19:01
and you do need to listen to your tool in your body.
19:03
This will help to accelerate your weight loss.
19:06
The fourth piece of the puzzle is you.
19:08
We know that patients who stay connected
19:10
and stay supported have better outcomes.
19:13
So making sure you stay connected not only online [socially],
19:17
but with your follow-ups, with your dietitians
19:19
and your surgeons are crucially important. [Adjust to your tool and trust yourself]
19:22
[Take advantage of support groups such as Vital RD Bariatric Support Group]
Behavior modification can be a challenge
19:24
so working through that with your team can be helpful
19:28
in navigating through emotional eating,
19:31
eating when you're bored or stressed or for even holidays.
19:35
Working through behavior modification can be challenging
19:37
and we're here to help you do that.
19:39
So make sure you reach out and stay connected
19:41
so that you can achieve optimal success.
19:44
Some preoperative considerations.
19:46
It's normal to have anxiety before any surgery
19:49
and concerns are normal.
19:50
So reach out with your questions, concerns
19:53
and your challenges prior to surgery.
19:56
The weeks prior to surgery, you will have a phone call
19:59
with pre-op admissions as well as your pre-op nurse.
20:03
You will need to do your labs and EKG
20:07
and you will have an appointment with your surgeon
20:09
or nurse practitioner.
20:11
Your pre-op diet instructions include 48 hours
20:14
of clear liquids or clear liquid protein drinks.
20:17
You'll also be given clear instructions
20:19
on how to prep your skin prior to surgery and once again,
20:23
a reminder, no smoking or alcohol prior to surgery.
20:27
You may be worried about pain control
20:29
during your surgical process.
20:32
Many non-narcotic pain tools will be used both pre-surgery
20:37
and post-surgery to enhance your hospital experience.
20:41
We also like to use preventive methods
20:43
which may be administered prior to your surgery
20:45
to help with your healing process. [Aid in reducing post op narcotic use which will 
increase your early ambulation and healing process]
20:48
Your medications may be adjusted after surgery
20:51
and this is something you'll want to review
20:53
with your surgeon or with the anesthesiologists.
20:56
You want to make sure you stop all NSAIDs
20:59
and pain relievers two to three weeks prior to surgery.
21:02
This includes things like aspirin,
21:04
Motrin, Aleve, ibuprofen and naproxen.
21:08
Tylenol (acetaminophen) is now your new pain med of choice.
21:12
If this doesn't cover your pain needs, once again,
21:14
reach out to your surgeon as well
21:16
as your primary care doctor
21:17
to make sure we get those adjustments taken care of.
21:21
If you're having a bypass procedure, no large capsules
21:24
or extended-release capsules are encouraged.
21:28
The size of your new pain meds
21:30
should be about the size of a pea.
21:32
Your tablet should be easy to dissolve.
21:34
If you take as an experiment at home,
21:36
one ounce of warm water with your medication
21:39
or tablet inside, it should dissolve
21:41
within 10 to 15 minutes.
21:43
As far as hormone replacement therapy,
21:45
this is something we want you to talk to your doctor about.
21:48
This next year is about you.
21:50
So make sure you're using preventive measures for pregnancy.
21:53
As your hormones after surgery
21:55
as well as fertility can be increased,
21:58
so make sure you're using back up.[No birth control pulls, patch or NuvaRing for
four weeks prior to surgery and four weeks after. Make use backup birth control for at least
one year! IUDs, depo shots, implants are fine]
22:01
Many of your medications will be reviewed
22:03
with your surgeon as well as with your anesthesiologist.
22:06
Keeping your blood sugars in check is important. [Diabetes: Check with your doctor for
blood sugar guidelines]
22:09
You should be checking your blood sugars frequently
22:11
prior to surgery and notifying your surgeon
22:13
if your blood sugar is greater than 200 prior to surgery. 
22:17
If you are on insulin, you will also need to talk
22:20
with your healthcare provider about your plan
22:22
before and after surgery.
22:25
If you struggle with high blood pressure,
22:27
you should be checking your blood pressure
22:29
more regularly as well, and adjusting your medication plan
22:32
with your primary care doctor.
22:35
If you're on a blood thinner [eg coumadin/Xarelto] prior to surgery,
22:37
you'll also want to talk with your healthcare provider team
22:40
in regards to this.
22:42
This medication may need to be stopped or you may need
22:44
to have an alternative plan [Lovenox or heparin anticoagulation bridge] for use during this timeframe [before and after surgery].
22:48
You and your surgeon have talked about
22:49
how important follow-ups are.
22:51
So make sure you get an appointment with them
22:54
shortly after surgery. [Each surgeon has a post-operative appointment schedule -- work directly with the surgeon's office
to schedule all follow up appointment. Stick with your appointment schedule, it is important!]
[Prior to discharge make an appointment with your primary care provider for one week after surgery to
review your medications and continue to manage your comorbidities (such as diabetes, hypertension, sleep apnea, etc.)
[Follow up with Bariatric Center Classes and Support Groups (in person, via teleconference and Vital RD Bariatric Facebook group)]
22:55
It is typical that you'll need to meet with them
22:57
one week after your surgery to discuss
23:00
how you're doing as well as any medications
23:02
or challenges that you might have had.
23:05
Let's talk about what your experience will be like
23:07
in the hospital.[Your Hospital Stay: First Day]
23:08
You'll be given instructions in regards to your diet,
23:11
your skin prep and what to bring to the hospital
23:13
such as your CPAP or BiPAP or oxygen tank.
23:17
You'll need to arrive three hours prior
23:19
to your scheduled surgery start time.
23:22
An IV will be started for medications as well as helping you
23:25
to maintain hydration and fluids
23:28
and antibiotics will be given prior to surgery.[This is standard]
23:31
You'll also have leg compressive devices [SCDs] on
23:34
during your surgery to help prevent blood clots.
23:38
Medications may be used also to prevent blood clots [heparin/anticoagulant] 
23:41
and your family will be with you
23:43
for most of the preoperative process, but not the surgery.
23:47
They will meet you in the recovery process
23:49
and your surgeon will notify them when it's appropriate
23:51
for them to come and meet you.
23:54
Surgery takes about an hour with one to two hours
23:57
in the PACU recovery before you are taken
23:59
into your hospital room.
24:01
So you can let your family know that they will be seeing you
24:04
about two hours after your scheduled start time.
24:08
One to two drains are typically placed in your abdomen
24:11
to help decrease any fluid collected during the surgery.[Typically removed prior to discharge]
24:15
A G-tube may be placed for some patients
24:18
who need additional nutrition support and once again,
24:20
this is something your surgeon can review
24:22
with you if needed.
24:24
You'll also be given a local numbing agent
24:27
that will help to prevent pain.
24:30
Activity is a big part of your healing process.
24:33
We encourage that all of our patients get up
24:34
and get moving three hours after surgery.
24:37
So your nurse will be helping you
24:39
in that healing process of your activity.
24:43
All of our patients will make sure
24:45
that their oxygen needs are assessed prior to surgery. [All patients have a nocturnal pulse oximetry or "NocOx"
study the night prior to discharge to assessing home oxygen needs]
24:48
You'll be given what's called an incentive spirometer
24:51
which is also known as a breathing device that you'll need
24:53
to use hourly to help in your recovery process.
24:57
Some of our patients will also have done
24:59
what's called an upper GI
25:01
if the surgeon thinks it's warranted after surgery
25:03
and this is just assessing and making sure
25:06
that your surgical process and the way
25:07
that your food is now routed is done correctly.
25:11
Our gastric band patients usually go home
25:13
from the PACU right from recovery after surgery.
25:17
They do not need to spend the night [or receive NocOx studies]
25:18
unless they have additional oxygen needs.
25:21
Expect some pain after surgery.
25:24
It is a surgical process, but you'll have many options
25:27
to help manage this pain and discomfort
25:29
so that you can be more comfortable in the healing process.
25:33
Getting up and being active is an important part of that
25:36
as well as non-narcotic pain options. [You will receive a combination of non-narcotic
pain options and a long acting numbing medicine to provide you with better post op pain
management]
25:39
Some patients may start on IV for pain medications
25:42
or transition to oral pain medications and you
25:45
and your surgeon will discuss the appropriate measures
25:48
to take for your pain control. [You will have some narcotic medication available if your pain is
severe]
25:51
The left side of your abdomen is commonly
25:53
where most discomfort is felt and this is normal.
25:56
Some people report feeling remorse or regret
25:59
the first or second day after surgery
26:01
and this is also normal as it's a stress hormone
26:04
that begins after surgery, but you've put a lot of effort
26:07
into this process and you should be very proud
26:09
of the decision you've made
26:11
to improve your health and well-being.
26:13
[Your Hospital Stay: Diet]
We have teamed up with our surgeons, dietitians
26:16
as well as nurses to provide a variety of safe,
26:19
nutritious options for bariatric patients.
26:22
Once you are cleared to start drinking
26:23
which is about three to four hours after surgery,
26:26
you'll be on what we call the bariatric stage two diet
26:29
which is one ounce of water every 30 minutes
26:32
then your diet will advance to one ounce every 15 minutes
26:35
and you'll progress as you improve.
26:38
You'll receive a tray of liquids which include a variety
26:41
of options to help meet your liquid requirements
26:44
as well as your hydration needs. [Water, broth, sugar free Jell-O, decaf tea, sugar free popsicles
and protein drinks. These liquids are the tools to help meet your nutrition needs.]
26:47
[Your Hospital Stay: Second Day] Once you're tolerating your stage two diet,
26:49
your diet may be advanced
26:51
to what we call the bariatric stage three diet.
26:53
You will be given one ounce of protein drinks per hour
26:56
as well as for one ounce portions of fluids for hydration. [Total fluids increase to four 1oz portions
hourly for hydration]
27:02
IVs are commonly continued
27:04
to help meet your fluid requirements
27:06
and you will be encouraged to get up
27:08
and get walking [ambulate] six times per day.
27:11
Our gastric sleeve patients are commonly discharged
27:14
on the second day.
27:17
When you're tolerating your fluids well,
27:19
your IV will be stopped or capped and it is encouraged
27:22
that you continue drinking your hydration
27:25
and staying on track with your fluid requirements. [Safe and independent discharge: You 
will attend a special discharge class the day of discharge and receive materials to prepare you 
for going home and knowing what to expect your first couple of weeks]
27:29
You're encouraged to continue with your walking
27:31
and breathing exercises [use IS and coughing exercises]
27:33
as well as maintaining adequate fluids.
27:36
Once again, during that first week, it is really difficult
27:39
for you to stay on top of your hydration if you get behind,
27:43
so set a timer or use an app to help you stay on track.[Continue fluids only the first week 
with some protein drinks]
27:47
It is required that a minimum of four
27:49
to eight ounces per hour be consumed from your liquids
27:52
and protein drinks do not need to be clear
27:55
during this juncture.
27:58
IV lines and drains will be removed and gastric bypass
28:01
and duodenal switch if you're doing well,
28:03
will go home on this third day
28:06
after two nights in the hospital.
28:08
For your discharge instructions, you're encouraged
28:11
to drink adequate amounts of fluid. [Drink, drink, drink: staying hydrated is critical to success]
28:13
getting at least 48 ounces of fluids in a day,
28:17
but the goal is closer to 64.
28:19
Also making sure you stay on top of your protein
28:22
and getting 60 to 70 grams a day should be a focus.
28:26
Minimum, 30 to 40.
28:30
Starting a multivitamin as well as your B12
28:32
as soon as you get home and then once again,
28:36
staying on top of your pain medication
28:38
and discussing that with your doctor.[You may cut pill]
28:41
You may also be given nausea patches
28:43
and medication if needed [Use them!] and stay on top of your activity
28:48
and walking to keep on track.
28:50
Most of our patients go home on [at least nighttime] oxygen [o2] and once again,
28:54
this is an important part of your healing process
28:57
and it will be discussed when that will be discontinued
29:00
with your surgeon. [Use it! Don't worry, this is not long-term.]
29:01
[Home oxygen] Your oxygen needs will be discussed with your surgeon
29:04
as well as potentially with a respiratory therapist. [The hospital's respiratory therapy team
will set this up with you and your insurance company. If you are self pay for surgery, they will set it up 
with your medical insurance.]
29:07
Nighttime oxygen will be retested in about three
29:10
to four weeks to determine if it needs to be continued. [Your surgeon's office will order this test.]
29:13
[If you need daytime oxygen, your surgeon's office will recheck at your first appointment.]
This is typically not a long-term thing,
29:16
however once again, it is important for the healing process.
29:19
So oxygen is not a bad thing,
29:21
it can actually help you heal faster.
29:24
[Post Op Follow Up] Your first follow up with your doctor is typically
29:26
one [to two] week out after your surgery. [Post-operative surgical office visit]
29:29
Your post-op nutrition classes are held at one week,
29:32
three weeks and six weeks after your surgery [at diet changes].
29:34
So mark your calendars and check with your surgeon's office
29:37
about when you can attend these classes.
29:39
They can be done in person or over videoconferencing.
29:44
Pain management is once again something that we want you
29:47
to be working with your doctor's office in regards to.
29:51
You will be given prescriptions for pain as well as nausea
29:54
and starting to wean yourself off of those pain meds
29:56
a few days after surgery and using Tylenol
29:59
to control your pain if needed.
30:02
[Diet progression after surgery] 
[Discharge Diet: discharge through first week post-op] 
[Fluids only: unlimited fluids, minimum 4oz/hr]
[Water, low-calorie/no-calorie fluids, protein drinks and shakes, water with a splash of juice, 
decaf tea and decaf coffee, sugar free popsicles]
When you're discharged, you're going to be focused
30:04
on your water as well as your protein drinks
30:07
for the first week making sure you're getting
30:09
at least 64 ounces of fluid in and ideally,
30:12
60 to 80 grams of protein a day.
30:15
This is what you do for the first full seven days.
30:19
On day seven, you can start what we call
30:23
the pre-select food diet.
[Pre-select Food Diet: 1 week to 3 weeks (day 7-day 21) post-op]
30:25
This will continue from day seven until day 21 post-op.
30:30
You will be doing one ounce every two hours
30:33
of these pre-selected foods which include [low-fat] refried beans [or other pureed beans],
30:38
[low-fat, small curd] cottage cheese [or ricotta cheese], egg beaters [or egg whites (no yolks until 6 weeks)], [light and] low-carb yogurt [or low-fat 
Greek yogurt (no fruit)]
30:43
as well as sugar-free pudding are appropriate options
30:46
on the pre-select diet which once again goes
30:48
from day seven to day 21.
30:52
On day 21 to day 42, your diet will advance
30:56
to the soft food diet [3 weeks to 6 weeks post-op)
30:58
[Advance to soft foods]
This will be one ounce to three ounces max per serving.
31:02
We want you to listen to your tool
31:03
and not overfill your pouch. [Portions based on procedure pouch size]
31:06
You'll be eating every two to three hours
31:08
pureed forms of protein.
31:10
These includes soft flaky fish, easy to [chew] digest proteins
31:15
such as rotisserie chicken that you can puree
31:18
as well as egg whites, cottage cheese, refried beans,
31:22
low carb yogurt and sugar-free puddings
31:24
can also be continued.
31:26
We want nothing crunchy or spicy and things should be
31:30
so easy to cut that you do not need to use a knife.
31:34
At six weeks, your diet will advance to your lifelong diet.
31:38
This is known as the solid food plan
31:40
and this is where it's time to start following
31:43
what we call the rules of the tool.
31:45
Diet, exercise, tool and you.
31:50
Now starting to prepare for eating and drinking,
31:52
those primary proteins as well as produce. [Now start separating eating from drinking]
31:56
[Primarily Protein]
Making sure that you're sticking to small bites
31:59
and chewing your food well, and not over filling your pouch.[Stop before full]
32:03
This is also when you can start adding
32:06
the fiber supplementation.
32:08
If you've had a gastric band,
32:10
you will require what's called a band fill.
32:13
These are typically done at four
32:14
to six weeks out after surgery.
32:17
Your second fill will be done on average
32:20
two weeks out after that. [Follow up fills: As needed-- if meeting criteria]
32:23
You will maintain four to six fills during the first year.
32:27
Before you get a band fill,
32:30
you'll want to make sure you have no solid food
32:32
for one to two hours prior, but liquids are okay.
[Additional guidelines of when you need fills will be discussed in class]
32:36
[Eating Warning Signs-- Watch for the 3 Too's!]
After you've received a fill, you want to be careful
32:39
of eating too much, too fast or taking too big of a bite
32:43
as it can make you feel uncomfortable.
32:46
Band adjustments may need to be done
32:48
over the course of the year depending on your weight loss
32:51
or if you're feeling under the weather.
32:53
So make sure you're reaching out to your doctor's office
32:55
to assess what is appropriate for you.
32:59
It is important that you know
33:00
potential complications after surgery.
33:03
Minor warning signs after surgery commonly require a call
33:08
to your doctor's office,
33:09
but not necessarily an emergency room visit. [Contact your surgeon's office]
33:12
Where major warning signs require a consultation
33:15
with your surgeon's office and a call to 911
33:19
or your closest emergency center.
33:23
For those minor complications
33:24
that we would consider you calling your physician's office,
33:27
that would be something like a low-grade temperature
33:29
less than 101, a little seroma
33:31
which is a blister-like appearance around your incision,
33:34
temporary numbness in your extremities,
33:37
incision or abscess along your stitch or suture.
33:41
Also mild edema or fluid retention or swelling.
33:45
Loose knot or suture from one of your surgery sites.
33:48
Digestive changes such as constipation, diarrhea,
33:52
mild nausea or an oral yeast infection
33:55
where your tongue appears white and food starts
33:58
to taste a little bit different.
33:59
This is known as thrush and these are things
34:00
that are all considered minor.
34:01
Once again, call your doctor's office,
34:04
have a conversation with them
34:06
and make sure they're aware of these issues,
34:08
but these do not require an emergency room visit.
34:11
Major concerns are fever greater than 101,
34:14
leg [or arm] pain or swelling, shortness of breath, severe nausea
34:19
with protracted vomiting, dizziness and chest pain.
34:23
Once again, call 911 or go to an emergency room
34:26
and make sure you're keeping your surgeon aware
34:28
of what's going on.
34:31
Exercise is an activity is something
34:33
that we've covered throughout this course.
34:36
It is important that you start slowly
34:37
and build up your exercise routine.
34:39
There's no limits on walking,
34:41
but the minimum is 30 minutes a day.
34:44
Keep active, even around your home.
34:47
Heavy lifting should be avoided for the first six weeks.
34:51
Things like pushing and pulling anything greater
34:53
than 15 pounds of straining which should be avoided
34:56
for the first six weeks [and cleared by surgeon].
34:59
No abdominal crunches [or exercises ] or heavy lifting
35:01
for the first six weeks.
35:04
Swimming will be approved after about three to four weeks
35:07
from your doctor's office [after wounds have healed and sealed] and working
35:10
with your health care team to develop an exercise plan
35:13
for you that works is going to be helpful
35:16
in maintaining your weight loss ability long term.
35:19
For resistance training, it is encouraged
35:22
three to four times a week and starting that once again,
35:25
after the six week post-op visit.
35:29
[Socializing and Eating Out]
There are some challenges
35:30
that many of our patients have after surgery.
35:33
This could include social eating or eating out.
35:36
Staying connected into our support groups
35:38
can help you navigate through some of these challenges.
35:41
We want you to look up nutrition facts online
35:44
before going out to eat so you know what you're getting.
35:46
Making sure once again, that you focus on protein
35:49
and produce, getting adequate nutrition.
35:53
You can always ask for a to-go box or smaller meals
35:56
and remind yourself that you're the customer,
35:58
so making modifications to your meal
36:00
is appropriate for your health. [Others will see your success by your example]
[Restaurant card and request smaller portions]
[Remember to cut your food up and chew well]
36:03
If you have questions about the risks
36:05
and complications of surgery [the fine print!], make sure you're reaching out
36:08
to your medical team and surgeon to address those
36:10
as we want to make sure you have a very clear understanding
36:13
of the surgical process and how you will heal.
[Read your surgical consent! You will sign a full legal surgical consent provided by your
surgeon-- read carefully!]
[Bariatric Surgery General Risk and Complication Highlights:
Need for reoperation, readmission or other intervention due to surgical complication, bleeding, 
constriction or stricture, dehydration, ulceration, infection, scarring, gallstones, pain, nausea, vomiting,
bowel dysfunction, deep vein thrombosis, cardiovascular complication, blood clots, allergic reaction,
blood loss, nervous system complication, pneumonia, dehiscence, abscess, injury to internal organs, anemia
reaction to anesthesia, electrolyte or vitamin or mineral imbalance, heart attack, cerebrovascular event,
depression and/or other complication.
Excessive weight may restrict or reduce ability to conduct diagnostic or other interventions
Bariatric procedures carry a risk of disability or even mortality.]
[Stay connected! #1 predictor of success: Follow up!]
36:17

Staying connected is crucially important.
36:21
Follow up every three months
36:23
until you reach [and maintain] your [weight and other] personal goals with support groups [great food/lifestyle tips from peers],
36:27
asking for a bariatric buddy or partner 
36:29
that can help you along the journey [ask about connecting up with a mentor],
36:31
visiting our social media sites [surgeon practice web site, social media virtual/closed support groups]
36:33
and reading our monthly newsletter will help you
36:36
to stay on track [class times and updates].
36:37
You can always email us with any questions
36:40
or concerns that you have or reach out
36:42
by a simple phone call.
36:43
Your support continues for a life,
36:45
so if you have challenges, we're here for you. [Yearly appointments to prevent weight regain. Support continues for life!]
36:50
[Frequently Asked Questions]
[Will my hair fall out?]
Many of our patients ask questions in regards
36:53
to will their hair fall out.
36:55
It is normal during the weight loss process
36:58
that your hair will go through a shedding phase.
37:01
You will not go bald, however it may thin
37:04
and taking adequate supplementation
37:06
as well as making sure you maintain your protein levels
37:10
will help to prevent this excessive hair loss.
37:16
[Can I drink milk?]
Many of our patients ask, can they drink milk?
37:19
And most patients can,
37:21
however sometimes the digestive enzyme for milk
37:25
called lactose is decreased in the surgical process.
37:28
So lactose free milk may be better digested or tolerated.
37:35
[What about alcohol?]
Many of our patients ask
37:36
about alcohol consumption after surgery.
37:40
Although alcohol consumption is allowed after surgery,
37:43
we encourage caution while using alcohol.
37:47
With alcohol consumption, you may absorb it differently
37:50
and so you need to be cautious when consuming alcohol
37:53
as your body now processes it differently.
37:57
Will there be weight plateaus after surgery?
38:01
Absolutely, this is something we need
38:03
to work through together.
38:05
What is considered a plateau is typically
38:08
if you haven't lost weight over the course of one month.
38:11
You may be experiencing other changes
38:14
in your waist circumference, in your body fat.
38:18
These are all continued successes,
38:20
however if your weight is not changing
38:22
over the course of one full month,
38:24
please reach out to us so we can help you address
38:27
what needs to be modified with your diet or activity
38:30
and help you get through that plateau.
38:34
[Will I Need a Tummy Tuck?]
Many of our patients after surgery
38:36
will consider cosmetic surgery such as a tummy tuck.
38:40
This is not required, however it is something
38:42
that many of our patients will opt in for
38:45
if they feel like they have excess skin.
38:50
[What is dumping syndrome?]
For our gastric bypass patients, it's important that we know
38:53
what dumping syndrome is.
38:56
Dumping syndrome is if you consume
38:58
more than 15 grams of carbohydrates in one sitting.
39:02
It will cause you to feel
39:04
like you're having flu-like symptoms
39:05
such as a rapid heartbeat, flushing, fatigue,
39:09
nausea and sometimes vomiting.
39:12
This is something you don't want to experience often
39:15
cause it's not comfortable so we encourage
39:17
that you stay away from those simple carbohydrates
39:20
and watch what you're eating.
[Thank you to the Denver Center for Bariatric Surgery for helping to develop this education.]
[Thank you!]