DIETARY GUIDELINES PHYSICAL & EXERCISE STRATEGIE FOR BARIATRIC SURGERY PATIENTS

1. Dietary Guidelines
Physical Activity & Exercise Strategies
For Bariatric Surgery Patients
1
Weight Loss Surgery Clinic

2. Jaime Ricardo Ramos Kelly –MD FACS
Metabolic& Bariatric Surgery
Office Toll Free:(619)-600-5586)
Cell. Phone:(619)-395-5347
Fax:(619)-3150469
Email: info@wlsclinic.com
info@drramoskelly.com
Web.www.drramoskelly.com
Webwww.wlsclinic.com
2Toll free: 800-533-8160 Fax:(619)-3150469 Dr. Kelly Cell. Phone:(619)-395-5347
Weight Loss Surgery Clinic

3. www.wlsclinic.com www.drramoskelly.com Fax:(619)-31504693
Laparoscopic Duodenal Switch
Vertical Sleeve Gastrectomy

4. Dietary Guidelines After Bariatric Surgery
It is very important to follow the recommended dietary guidelines after
undergoing bariatric surgery. These guidelines were carefully designed by
your health care providers, with the goal of limiting the amount of calories
you consume, while providing balanced meals that help prevent nutrient
deficiencies and preserve muscle tissue.
This new way of eating may seem overwhelming at first, but over time, most
patients find the guidelines become an unconscious part of their daily
routine. If you are experiencing trouble following the guidelines
Email: info@wlsclinic.com Email: info@wlsclinic.com4

5. General Guidelines
Eat balanced meals with small portions.
Follow a diet low in calories, fats and sweets.
Keep a daily record of your food portions and of your calorie and
protein intake.
Eat slowly and chew small bites of food thoroughly.
Avoid rice, bread, raw vegetables and fresh fruits, as well as meats that
are not easily chewed, such as pork and steak. Ground meats are usually
better tolerated.
Do not use straws, drink carbonated beverages or chew ice. They can
introduce air into your pouch and cause discomfort.
Avoid sugar, sugar-containing foods and beverages, concentrated sweets
and fruit juices.
For the first two months following surgery, your calorie intake should be
between 300 and 600 calories a day, with a focus on thin and thicker
liquids.
Daily caloric intake should not exceed 1,000 calories.
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6. Fluids
Drink extra water and low-calorie or calorie-free fluids between meals to
avoid dehydration. All liquids should be caffeine-free.
Sip about 1 cup of fluid between each small meal, six to eight times a day.
We recommend drinking at least 2 liters (64 ounces or 8 cups) of fluids a
day. You will gradually be able to meet this target.
We strongly warn against drinking any alcoholic beverages. After
surgery, alcohol is absorbed into your system much more quickly than
before, making its sedative and mood-altering effects more difficult to
predict and control.
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7. Protein
Preserve muscle tissue by eating foods rich in protein. High-
protein foods include eggs, meats, fish, seafood, tuna, poultry, soy
milk, tofu, cottage cheese, yogurt and other milk products. Your
goal should be a minimum of 65 to 75 grams of protein a day.
Don't worry if you can't reach this goal in the first few months
after surgery.
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8. Required Vitamin and Mineral Supplements
After Weight Loss Surgery
You will not be able to meet certain vitamin and mineral needs without
supplementation. Vitamin and
mineral deficiencies have been observed in patients after weight loss
surgery. Iron, foliate, vitamin B12, calcium, and zinc are most affected after
gastric bypass surgery. If you are having gastric sleeve surgery you will not
need to take all the above supplements. Gastric Sleeve does not cause
malabsorption of nutrients from your foods. A daily multi-vitamin and
calcium supplement is usually sufficient.
All of the required vitamin supplements are listed below. They are available
over the counter at your local pharmacy. If you have difficulty locating or
tolerating any of the supplements, call your dietician
or surgeon for suggestions.
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9. Supplements
You must take the following supplements on a daily basis to
prevent nutrient deficiencies. Please remember that all pills
must be crushed or cut into six to eight small pieces. You are not
able to absorb whole pills as well as before surgery, and it can be
difficult for the pills to pass through your new anatomy.
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10. Mandatory Dosage/Day Suggested Schedule
Multi-vitamin and mineral 1-2* AM
Vitamin B12 500 mcg AM
Iron 27-28 mg PM with Vitamin C
Vitamin C 500 mg PM with Iron
Calcium citrate with Vitamin D 1200-1500 mg Take with meals in
divided doses
Optional Zinc 10-20 mg AM
Stool Softener As directed Take with Iron dose.
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11. Mandatory
1. Multi-vitamin and Mineral
Dosage: 1-2 daily with meals
*Type: 2 children’s chewable multi-vitamin OR 1 chewable or liquid adult
multi-vitamin.
Once on a regular diet can begin an over the counter prenatal vitamin OR 1
adult multi-
vitamin (does not have to be chewable or liquid)
Function: Multi-vitamins will help ensure that you are getting enough of all
the
micronutrients that you need.
Interactions: None
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12. 2. Vitamin B12
Dosage: 500 micrograms tablet or sublingual daily or 1000 micrograms
monthly of injectable B12
Type: any sublingual (dissolves under tongue), tablet, or monthly
injection (prescribed by your surgeon)
Function: Helps with blood cell and nerve function, digestion and
absorption of food, and protein synthesis. Deificiency may cause certain
types of anemia.
Interactions: None.
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13. 3. Iron
Dosage: 27-28 mg of elemental iron daily. Take with vitamin C.
Type: Any tablet of ferrous sulfate, gluconate, or fumarate that is equivalent to 27-28
mg
of elemental iron. Prenatal vitamins may already have enough iron in each tablet.
Read the label first to see if additional supplementation is required.
Function: Vital to the formation of red blood cells that provide oxygen to the entire
body.
Interactions: Take 1-2 hours before or after taking calcium. Do not take with milk,
cheese, eggs, whole-grain breads and cereals. May cause diarrhea or constipation.
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14. 4. Vitamin C
Dosage: 500 mg daily. Take with iron.
Type: Any capsule, chewable tablet or liquid form.
Function: Plays a role in body’s calcium levels and bone formation. Promotes
wound healing and reduces chances of infection. Enhances iron absorption.
Interactions: Antacids may decrease absorption. Take Vitamin C at a different
time if using Antacids.
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15. 5. Calcium citrate with Vitamin D
Dosage: 1200-1500 mg daily. Calcium is best absorbed in doses of 500-600 mg at a
time. Take with meals.
Type: Tums® initially, once tolerating regular diet switch to Citracal® +D or any
equivalent
brand with calcium citrate. The citrate form of calcium is better absorbed since it
doesn’t
require the acid from your stomach to be absorbed.
Function: Maintains bone strength; also helps heart pump correctly and repairs
soft tissue.
Interactions: Caffeinated products, spinach, and whole grain products may decrease
absorption. Take at least 1-2 hours before or after taking iron, since calcium will
decrease
iron absorption.
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16. Multivitamins
Take a high-potency daily chewable multivitamin and mineral supplement that
contains a minimum of 18 mg of iron, 400 mcg of folic acid, selenium, copper
and zinc. Brands that contain this formula include Trader Joe’s and Centrum
Adult chewable multivitamins. Take two tablets daily for at least three months
after your surgery, and then one tablet daily for life.
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17. Calcium Supplement
Take 1,200 to 2,000 mg of calcium daily to prevent calcium
deficiency and bone disease. To enhance absorption, take the
calcium in two to three divided doses throughout the day - for
example, a 500 to 600 mg supplement taken three times a day.
Calcium citrate is the preferred form of calcium.
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18. Vitamin D Supplement
Take a total of 800 to 1,000 International Units (IUs) of vitamin D
each day. This total amount should be taken in divided doses of 400 to
500 IUs twice a day. Vitamin D should be taken with your calcium
supplement. If you prefer, you can take a combination calcium-vitamin
D supplement to avoid taking multiple pills, so long as it contains the
proper dosages.
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19. Vitamin B12 Supplement
Take 500 mcg of vitamin B daily. It can be taken as a tablet, or in sublingual
forms placed under the tongue.
Other Supplements
Some patients need additional folic acid or iron supplements, particularly
women who are still menstruating. Your dietitian will discuss this with you.
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20. Diet Progression After Bariatric Surgery
Immediately following surgery, you will begin with a clear liquid diet. You may
gradually start adding thicker liquids to your diet after you are discharged from
the hospital.
Two weeks following surgery, you may progress to blended and puréed foods.
You may use high-protein (more than 20 grams protein), low-calorie (less than
200 calories) liquid supplement drinks or powders to meet your protein
requirements during this period.
It is important to know that following surgery, your stomach size is very small -
less than 1/4 cup, or about the size of an egg. The opening that allows food to
pass out of your stomach is also very narrow. For this reason, it is important to
take only two to three sips or bites at a time of any new food and then wait 10
minutes before taking more. This will help you learn your limits and tolerance.
Liquids will empty faster from your stomach than soft solids.
If you overeat or eat too quickly, you may experience nausea or pain. You
should avoid rich, creamy liquids such as gravies, sauces and ice creams.
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21. Diet in the Hotel
You will receive clear liquids such as juices, Jell-O and broth as
your first meal following surgery. Juice and Jell-O are high in
sugar content, but your portions will be very small at this stage.
Gradually increase the amount you drink at each meal as you can
tolerate it.
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22. Diet for the First Two Weeks Post-Surgery
You will begin adding thicker liquids that are high in protein and low in fat
and sugar. (For examples, see the list below.) You may use high-protein,
low-calorie liquid supplement drinks or powders to meet your protein
requirements during this period.
The goal is to consume small portions that will empty easily from your
pouch. Begin with 1 tablespoon portion sizes and increase to 2 tablespoons
as tolerated. Begin drinking 1/4 cup of liquid at a time and increase to a 1/2
cup as tolerated. Your daily caloric intake should not exceed 400 calories.
It is also very important to stay well hydrated. Drink 1 to 1.5 liters of water or
other non-caloric liquids per day.
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23. Recommended thicker liquids:
Nonfat or 1% milk, if you can tolerate milk
Lactose-free or soy-based low-calorie drinks
Sugar-free pudding
Sugar-free, nonfat yogurt
Low-fat cottage cheese
Blended broth-based soup or other low-fat soups.
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24. Recommended thicker liquids:
Refined hot cereals that are low in fiber, such as cream of rice or
cream of wheat. Make them with extra liquid to create a soup-like
consistency. Do not eat oatmeal.
• Optional high-protein, low-calorie liquid supplement drinks (drinks
containing less than 200 calories and more than 20 grams of protein
in an 8- to 11-ounce serving).
To increase your protein intake, add 2 tablespoons non-fat dry milk
powder, egg substitute or powered egg, or other protein powder to
each 1/2 cup of nonfat or low-fat milk. You can also add these to
soups, hot cereal and other thick liquids.
Remember to drink 1 cup of water or other non-caloric fluids
between meals. Take a multivitamin supplement every day.
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25. Diet for Weeks Two to Four Post-Surgery
Begin adding very small portions of puréed and soft foods as tolerated.
Take very small bites and chew everything very well. Do not take more
than two bites every 20 minutes when adding a new food.
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26. Recommended puréed and soft- foods:
•Applesauce
•Yogurt
•Cottage cheese
•Well-cooked, puréed vegetables
•Hot cereals
•Mashed potatoes
•Noodles
•Scrambled egg whites or egg substitute
• fruits
•Canned tuna fish
•Lean fish
•Tofu
•Lean ground meats or poultry
Avoid all bread and meats that are not easily chewed.
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27. At this time, your caloric intake will probably be no more than 500
calories a day, divided into six to eight small meals.
Recommended portion sizes are 1/4 cup for solids and 1/2 cup for
liquids.
Recommended Meal
Plan For Weeks Two to Eight Until Two Months Post-Surgery
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28. Sample Menu
This sample menu includes different foods that are safe for you to eat. You
may adjust the menu to fit your tastes and tolerance.
Breakfast: 1/4 cup hot cereal made with non-fat milk
Mid-Morning:1/2 cup nonfat milk*
Late Morning : Two scrambled egg whites Lunch: 1/2 cup low-fat
chicken noodle soup
Mid-Afternoon: 1/4 cup low-fat cottage cheese
Late Afternoon: 1/4 cup sugar-free, nonfat yogurt
Dinner: 2 ounces lean ground meat 1/4 cup puréed or well cooked
vegetables
Bedtime Snack: 1/4 cup non-fat milk
* Add 1 tablespoon non-fat dry milk powder to each 1/4 cup nonfat
milk for additional protein.
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29. Recommended Meal Plan for Two to Six Months Post-Surgery
Consume 900 to 1,000 calories and at least 65 to 75 grams of protein a day. For
balanced nutrient intake, your daily servings should include:
3 servings milk and dairy products (nonfat and low-fat)
3 servings meat or meat alternative (lean and low-fat)
3 servings starch (limit bread and rice)
1 serving fruit (avoid dried fruits and fruits with skin)
2 servings vegetable (well-cooked only)
Recommended portion sizes are 1/4 cup for solids and 1/2 cup for liquids
Discontinue taking high-protein liquid supplement drinks or powders if possible.
We recommend meeting your protein needs with food.
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30. Sample Menu
Breakfast: 1 egg or 1/4 cup egg substitute ,1/2 cup hot cereal.
Mid-Morning: 1/2 cup nonfat milk.
Late Morning: 1/2 cup chopped melon.
Lunch: 1/2 cup low-fat chicken noodle soupTwo Saltine crackers.
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31. The sample menu offers eight small meals per day
The sample menu offers eight small meals per day. You may wish
to eat more or less often, but be sure to eat at least six times each
day.
Remember to drink 1 cup of water or other non-caloric fluid
between meals. It is important to take a multivitamin and
mineral supplement daily, plus additional iron if required. In
addition, you must take calcium and vitamin D supplements two
to three times per day.
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32. Recommended Meal Plan for Six Months
Post-Surgery and Beyond
Continue consuming 900 to 1,000 calories per day
Decrease to three meals and only one to two snacks per day
Discontinue taking high-protein liquid supplement drinks
Increase the variety of low-fat, low-sugar and low-calorie foods, as tolerated
Avoid raw vegetables, fresh fruits with skins, dried fruits, breads, popcorn, nuts
and red meats only if poorly tolerated
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33. Long-term Dietary Guidelines
Over time, you will be able to increase the variety and consistency of
foods in your diet. Some foods may continue to be poorly tolerated,
including red meats, chicken, breads, and high-fiber fruits and
vegetables. Focus on low-fat, low-sugar and low-calorie foods and
continue to count your calories every day. Try to meet your serving
goals for all food groups based on the 900 to 1,000 calories diet plan
described above.
To stay well hydrated, drink at least 2 liters of water or non-caloric
fluids daily, unless this is contraindicated due to a medical condition.
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34. Sample Menu
Mid-Afternoon: 1/4 cup low-fat cottage cheese,1/4 cup
canned fruit packed in water or juice.
Late Afternoon:1/2 cup sugar-free, nonfat yogurt.
Dinner:2 ounces lean meat or fish, 1/4 cup mashed
potatoes,1/4 cup pureed or well-cooked vegetables.
Bedtime Snack:1/2 cup nonfat milk
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35. 35
Lab Work Requirements
Lab Work For Post Bariatric Patients
Please ensure that you have had nothing to eat or drink past midnight on the day before your lab work.
* B1
* B12
* Vitamin D
* PTH
* Hgb/Hct
* Total Cholesterol
* Glucose (Fasting)
* Total Protein
* Iron
* A1C (Only if patient was Diabetic before surgery)

36. 36
Lab Work Requirements
Lab Work For Post Bariatric Patients
Please ensure that you have had nothing to eat or drink past midnight on the day before
your lab work
* Vitamin A
* Vitamin B6 (Pyridoxal phosphate level)
* Vitamin B-12 level
* Vitamin E
* Vitamin D, 250H
* Copper
* Calcium
* Magnesium
* Phosphorous
* Zinc
* Folate
* Prealbumin/Total Protein/Albumin
* Iron/TIBC, Ferritin, Transferrin
* CBC (Complete Blood Count), Hemoglobin and Hematocrit
* Chem. 7 (Comprehensive Metabolic Panel)
* Liver Panel: SGOT/SGPT, Alk Phos, T/D Bilirubin
* Cholesterol/Triglyceride Levels
* Hemoglobin A1C level(only if patient was diabetic before surgery)
* DHEA
* TSH,T4 (required if have thyroid disease)
* PTH

37. Benefits Of Physical Activity
In order to lose your maximum amount of weight and to maintain that weight loss,
it is extremely important to incorporate exercise into your daily routine.
Remember that exercise doesn’t just include going to the gym.
There are many ways to get a great workout that can be enjoyable at the same time.
Bariatric surgery is a wonderful tool that helps patients with clinical obesity lose
weight and gain their lives back. Physical activity plays an important role in
helping patients find success.
Many patients find it extremely difficult to exercise prior to surgery due to health
conditions such as difficulty breathing/shortness of breath upon excurtion, knee or
back pain, and heart conditions. You will work with the team of surgeons, nurses
and dietitians to start an exercise regimen that is appropriate for you.
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38. BENEFITS OF PHYSICAL ACTIVITY
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39. Why is exercise important?
- Burns calories
- Reduces fat while building muscle
- Increases energy
- Helps lower blood pressure
- Improves mood and self-esteem
- Enhances the immune system and
strengthens bones
- Relieves stress
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40. What exercise routine should I follow after surgery?
Hospital Stay
You will need to get up and walk. This will help you feel better and get you on the
right track for going home
Initiation Stage: Home After Surgery (Week 1-4)
-Start slow. You may feel tired or fatigued. It is important to still get up and
move around. Walk around the house or use the stairs as tolerated. You
are just beginning to heal after surgery so light activity is recommended
Advancement Stage: Week 5-6
Check with your surgeon for approval to increase activity/exercise.
- Patients with specific complications or special needs may need to stay at
the Initiation Stage until medically cleared with the surgeon.
- If you are able to increase your regimen, start slowly with low impact exercise. This
may include: stationary
bike riding, treadmill, and/or house work
Maintenance / Lifestyle Modification Stage
- At this stage, you should be increasing activity/exercise on a regular basis
as tolerated. A long-term goal should include 30-minutes of moderate
activity daily. This does not have to be all at one time. Moderate activity
includes: stair walking, gardening, cycling, and tennis, dancing and walking
one mile in 15 minutes.
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41. Physical Activity to Stay Fit
Start your activity with a warm-up. This will build a better work out and
help prevent
injuries to your muscles.
• Use stairs instead of taking elevators or escalators.
• Park your car farther from your intended destination.
• Go on a nature tour at a local park or forest preserve.
• Go sledding, ice skating or skiing.
• Water aerobics and swimming provide great exercise with low impact
on the body.
• Housework or outdoor activities such as gardening and yard work are great
opportunities to be active. Don’t forget moving the lawn or shoveling.
• Find a hobby. Turn off the television or computer.
• Sports are fun and help you stay fit.
• Exercise with friends or family. Make a date to go for a daily walk, play
sports or other activities.
• Yoga has many positive benefits including building muscles and reducing stress.
• Be creative in finding ways to be active.
What activities do you enjoy?......
41

42. Success With Physical Activity & Exercise
1. Begin slowly
● It is important to begin your activity regimen at a slow pace. Start with light activity and
work your way up.
● Begin your exercise with walking or water aerobics. Low impact activity is still beneficial.
When your body is ready, increase the amount of time spent exercising or advance to a higher
impact activity.
2. Set realistic goals
● Start an exercise journal. Set small, weekly goals that are realistic and attainable. Document
the type of
activity and time spent on a daily basis.
At the end of the week, check to see if you have met your desired goals.
● Set a new goal each week. As time goes on, you will see how many successes you have
accomplished.
● If you do not meet a desired goal, determine why you didn’t and create a new goal.
3. Reward yourself
● If you have met the goals that you have set, reward yourself. It’s important to find ways to let
ourselves know that we are doing a good job and that we have accomplished something that we
have worked hard for.
● Be sure to choose healthy rewards. It is important to continue to make healthy lifestyle
choices.
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43. Do Planned aerobic activities
Accumulate a total of 30 minutes: Walk 3-4 km (total) Bike 12-
16km (total),Row. Stair climb, Ski(cross country).Paddle
Increase Incidental activity
Regard movement as an opportunity not an inconvenience; Take extra steps in the
day . Take the stairs Mow the lawen Walk the dog ,park the car and walk. Dont use
remote controls
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44. Success With Physical Activity & Exercise
4. Stay healthy
● Always check with your doctor before starting a vigorous exercise program.
● Be aware of how your body feels. If something doesn’t feel right, slow down or stop.
● Choose well-respected facilities. When working with personal trainers or other staff, check to make sure
they have the proper credentials.
● Always use the proper exercise equipment and gear to help prevent injury.
5. Keep yourself hydrated
● It is important to stay hydrated before, during and after exercise. You will need to hydrate yourself to
replenish the fluids you have lost through sweat.
● Stay hydrated, don’t wait until you are thirsty. By the time you are thirsty, you’re most likely already
dehydrated.
● Avoid carbonated beverages and fruit drinks. These take longer to absorb
and can cause cramping, nausea and/or diarrhea.
● Cool or chilled fluids may work best. Cooler liquids help to lower and normalize the body’s elevated core
temperature.
6. Protein, protein, protein
● Make sure you are consistently maintaining your recommended protein requirements.
The protein will help you build muscle as well as keep your energy at a high level. If you do not get your
protein, you will feel tired and sluggish.
• - Roux-en-Y Gastric Bypass & Gastric Sleeve: 60-75g protein/day
• - Duodenal Switch: 75-90g protein/day
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45. Exercise For Weight Loos And Maintenance
Energy intake and energy output play a role in weight gain, weight loss and weight
maintenance. It takes 3,500 calories to create 1 pound of fat.
1.Weight loss = Energy Intake (food) < Energy Output (physical activity)
2.Weight gain = Energy Intake (food) > Energy Output (physical activity)
3.Maintenance = Energy Intake (food) = Energy Output (physical activity)
This is why it is important to balance both diet and exercise.
You will gain weight if you take in more calories than you burn off.
An exercise regimen that includes aerobics and conditioning promotes the best
overall benefits.
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46. Aerobic Exercise
Aerobic exercise helps to condition your lungs and heart by utilizing oxygen more
efficiently. This helps your body reach and maintain it’s Target Heart Range(THR).
(Your THR is the safest and most beneficial range of heartbeats per minute during exercise).
Activities such as walking, jogging, running and swimming are all aerobic.
THR = (220 – age) x 60% - 80%
The lower number suggests a safe rate for beginners, while the higher number
should be a long-term goal.
*Remember, consult your physician before starting any vigorous exercise programs.
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47. Conditioning Exercise
Conditioning exercise helps improve muscle strength and flexibility. In order to
build muscle and strengthen bones, exercises that incorporate weight resistance
and flexibility should be included in your overall fitness plan.
Resistance exercises include weights, rowing machine and push-ups.
Flexibility includes warm-up routine, stretching and yoga.
Calorie Used in 20 minutes of Different Activities
Activity Calories Activity Calories
Walking – 2 mph 83 Basketball (moderate) 124
Walking – 4.5 mph 100 Dancing 105
Golf 85 Housework 63
Skipping rope 245 Swimming – 800 yards 152
Yard work 54 Ice Skating 100
Mowing lawn 150 Washing car 65
Cycling 135 Running 190
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