Nutritional Advice for Sleeve Gastrectomy

The sleeve gastrectomy (SG) is a restrictive weight loss operation. The outside part of the stomach is removed and the shape of the stomach is changed from a sac to a long narrow tube. The gastric volume is reduced from approximately 2 Liters to 100 mLs It helps you lose weight in two ways:

1. It reduces the size of your stomach, therefore you feel full after eating a very smaller meal.
2. The outer part of the stomach, that produces hunger hormones is removed, therefore you are generally not hungry and feel satisfied for longer

Stage One: Immediately post op
DIET:
Day 2 to day 4 Liquid diet
Day 4 – for 4 weeks post op Puree diet

Stage Two: Transition phase
DIET:
Week 4 Soft Diet
Week 6-8 post op Full diet

Stage Three: Long term and weight maintenance
DIET:
Week 8 post op – long term Nutrition

Stage One:
In Hospital – Fluid diet Initially your stomach is swollen and the amount of food that you can eat is very small. You also need to get to know your new stomach volume to prevent unwanted symptoms such as pain, nausea and vomiting.

You may have fluids 1-3 days after your operation – this is test diet. These include: water, diet cordial, soup, jelly, milk, custard, tea, coffee. There is a lot of swelling in your stomach pouch and it needs to heal. Do not try to eat all the food provided. Eat and drink very slowly and stop when you feel full.
At Home – Puree diet: Approximately 4 days after your operation you may start a puree diet. You will not be hungry and you feel full with a small amount of food.

To avoid any unwanted symptoms:
Use a blender and ensure all your meals are a smooth pureed consistency.
Eat slowly – take 30 – 40 min at each meal. Take small bites. Do not eat and drink at the same time – separate your fluids from your solids (30 min before and after meals).
Serve your meals on a small bowel or a side plate. Stop when you feel full. It is important to drink adequate fluid, take a multivitamin daily and eat small meals that include protein sources (see protein section).

1. Drink Adequate Fluids:
   Fluids are important in preventing dehydration and also help keep your bowels regular.
   Water will be difficult to swallow initially – it feels heavy to drink it
   Add some diet cordial to your water, this makes it easier to drink it
   Drink small amounts of fluid at a time throughout the day
   Drink at least 1 – 1.5 L per day
   Fluids may include: Water, diet cordial, low fat milk, juice (no added sugar)
   Avoid gulping fluids – this will cause pain and discomfort
2. Vitamins and Minerals:
   The amount of food you can eat is very small and to make sure you get good nutrition, we strongly recommend that you take a multivitamin and mineral tablet.
   NutriChew is the recommended multivitamin for you. This is a specially designed multivitamin for patients following surgery and it will meet all your requirements in 2 tablets daily – chew it well.
3. Protein:
   Protein is important to prevent muscle loss, whilst you are going through this rapid weight loss period.
   You need 50-60 grams of protein per day to meet your needs.
   Good sources of protein include: meat, fish, chicken, eggs, legumes and dairies
   Include the protein sources at each meal and eat them first
   Have 1-2 meals replacements (Optifast) as they are high in protein.

Stage Two:
Soft diet By 4 weeks after surgery you can progress to a soft diet. Only progress to this diet if you have tolerated the puree diet. It is still important to eat slowly and chew your food well. Continue to have small meals and eat your protein sources first. You may still include meal replacements such as Optifast at this stage. You need to follow a soft diet for the next 3 weeks.

Soft Diet
Group 1 Breads and Cereals
Quick/instant porridge or semolina or Weet-bix™ (soaked in low fat milk)
Avoid soft bread, rice or pasta.

Group 2 Fruit and Vegetables
Soft ripe, tinned or stewed fruit (with no added sugar)
Soft cooked vegetables
Avoid stringy fruit, fruit skins and raw vegetables

Group 3 Dairy Products (3 serves daily)
Skim or low fat milk (maximum 250 ml per day – including tea/coffee)
Low fat or calorie reduced yoghurt (1 tub of 200 grams per day)
1 Slice of low fat cheese
Avoid ice cream, milkshakes and flavoured milks

Group 4 Meat, Fish, Poultry, Eggs, Legumes (2 serves daily, 1 serve =50 grams)
Eggs – try scrambled or poached
Lean minced meat (lamb, pork, veal, chicken), add to casseroles and mornays
Soft, marinated fish, canned Tuna/Salmon
Well cooked beans and legumes – try adding to soups and casseroles
Avoid fatty meats or dry meat (Chicken)

Stage Three:

Solid Diet
By 6 – 8 weeks after surgery you should be able to eat normal consistency foods. It is important to eat slowly, chew your food well, stop when you feel full and not over stretch your new stomach.
Continue to have small meals and eat your protein sources first. To continue loosing weight and maintain this weight loss long term:
Use your gastric pouch effectively by:
– Avoid snacking and grazing – aim for 3 meals per day
– Have a healthy meal plan
– Avoid high calorie dense foods
– Avoid fluids that contain energy such as energy drinks, juices

Ensure increasing your incidental activity as well as maintain regular exercise.
The following meal plan aims to give you guidelines for long term healthy eating.

Group 1 Breads and Cereals
Breakfast cereals – aim for a high fibre, low sugar content
Spaghetti or noodles or rice (well cooked), Couscous
Multigrain bread – try toasted first
Avoid fresh or soft bread, rice and pasta at this stage

Group 2 Fruit (2 serves/daily) Vegetables
Fresh fruit or tinned fruit (with no added sugar)
Variety of cooked vegetables, slowly introduce salad vegetables

Group 3 Dairy Products (3 serves/daily)
Skim or low fat milk (maximum 250 ml per day)
Low fat and diet yoghurt (1 tub of 200 grams per day)
Low fat cheese slices, cottage or ricotta cheese (no more than 30 grams/day)
Avoid ice cream, milkshakes and flavoured milk

Group 4 Meat, Fish, Chicken, Eggs,
Legumes (2 serve/daily. 1 serve=50 grams)
Lean Meat (lamb, pork, veal, beef), fish or chicken, Eggs (limit to 2-3 a week), Baked beans
and legume (chickpeas, lentils etc)

Group 5 Fats, Oils (maximum 2 teaspoons per day)
Use polyunsaturated or monounsaturated margarines and cooking oils

Meal Size: After the surgery you will not be able to eat large amounts of food and fluid at one time. Having small meals will help prevent pain, discomfort, nausea and vomiting. As a general rule only aim for ½ to 1 cup of food at each meal, chew food well, eat slowly and stop eating when you feel full or feel any discomfort.

Protein: Protein is important in healing and preventing muscle loss while you are losing weight. Not enough protein results in lethargy and hair loss. We recommend at least 60 grams of protein per day. You should eat protein foods first at each meal. These include meat, fish, chicken, eggs and reduced fat dairy products.
You can also use meal replacements with protein such as: Optifast, Tony Ferguson, Dr. MacLeods. There are other commercial supplements available at pharmacies. Your dietitian will recommend these if necessary.

Minerals and Multivitamins: As the amount of food you can eat is very small, you will not be able to get all the nutrition you from food alone. This could result in vitamin and mineral deficiencies. To prevent this we recommended that you:

1. Take: NutriChew 2 x daily. This is the recommended multivitamin as it is specially designed for patients following surgery and it will meet all your requirements in 2 tablets daily – chew it well.
2. Have the recommended routine blood tests
3. Come to see us for your scheduled post op nutrition follow up. You may need other supplementations if your dietary intake is not balanced. Your dietitian will discuss this with you at the follow up clinic.

Fluids: Fluids are important in preventing dehydration and also help keep your bowels regular. It is important to drink plenty of water (6-8 glasses per day).
Avoid large amounts of fluids with meals. Drink 30 minutes before meals and wait for 30 minutes after meals.
Avoid liquid calories: these are fluids that have calories and add to your total energy intake without giving you any feeling of fullness. Drinking these on a regular basis is often one of the reasons that patients do not get goo weight loss. These include: Non diet soft drinks, cordials, juices, milkshakes or sports drinks.

Alcoholic beverages: You will be affected by alcohol much more quickly after the surgery. Therefore it is important to start with small amounts first and as per recommendations: DO NOT DRINK AND DRIVE. Alcoholic drinks such as wine, beer, spirits, sherry and port have no nutritional benefits and are also very high in calorie. It is best to limit these beverages.

Fibre: Fibre is important to keep your bowels regular. Initially your diet lacks fibre and therefore you may need to take a fibre supplement (such as Benefibre™) with plenty of water. This increases bulk and should help with regular bowel activity. As your diet progresses you should include breads and cereals, fruits and vegetables as well as adequate fluids daily. Your Daily exercise is also important in preventing constipation. If constipation is
a problem discuss this with your Doctor/dietitian.

Exercise: Successful weight control is a result of healthy eating AND regular exercise. The best type of exercise is one you can enjoy, and can continue to do on a regular basis.
Exercise will help you to improve or maintain your weight loss, increase your metabolism, and also improve your general health.
A suitable long term aim is for 60 minutes of moderate activity such as a brisk walk, on all or most days of the week. Your size may make it hard for you to exercise as much as you need to. Remember the more you use energy through exercising the more you lose weight and the easier it will be to exercise. Start with simple exercises such as walking and swimming. Then gradually increase your levels to more vigorous exercise such as cycling and jogging. You should check with your doctor about the amount and type of exercise that is best for you.
You should also increase your activity level in your daily life. For example:
Stand rather than sit
Be outside rather than inside
Walk rather than drive – if possible
Park your car further away from where you need to go so you can walk more
Climb the stairs rather than using the lifts

As mentioned earlier your success post surgery will depend on your life long efforts to change your lifestyle. This includes making some radical changes to your eating and exercise habits. Taking responsibility for every decision you make that effects your weight is the first step in your weight management.

Some of the key factors in achieving optimal weight loss and maintaining it are:

Monitor your weight closely
You need to weigh yourself once a week. This gives you feedback on how you are managing your weight problem. If your weight loss has stopped or you are regaining weight the solutions are to have your diet reviewed and increase your activity level.

Use your new stomach pouch effectively
The aim of the sleeve is to help you feel full after eating a small meal. However you still need to use your stomach pouch effectively to achieve good weight loss and maintain it.
Eat healthy and balanced meals: including lean meats, fruits and vegetables, choosing low fat dairy items
Avoid high calorie dense foods
Avoid snacking and grazing – aim for 3 meals per day
Avoid liquid calories
Do not drink 30 minutes before and 45 minutes after eating

Regular exercise
Choose an exercise that you enjoy and do it daily, e.g. Start with walking 30 minutes daily
Increase your activity level in your daily living (see exercise section for some suggestions)