Ahmedabad - Bariatric Surgery

Obesity is not just a problem of excessive fat and its aesthetic implications on the human body, as many people believe but can cause associated serious health issues, like diabetes, hypertension, arthritis and cardiovascular diseases, among others.

Considered a disorder exclusive to the Western rich for a long time, obesity is now emerging as a serious health concern in developing countries like India as well.

With rapidly changing lifestyles, improper dietary habits and absence of physical activity in our lives, a large part of the Indian population is falling into the trap of lifestyle disorders – obesity being one of them. The incidence of obesity is increasing in the country, particularly in urban areas like Pune where rising incomes have increased over the past decade.

Obesity not only affects the quality of an individual’s life, but has also been found to reduce the life span by 13-20 years. It costs the nation millions of rupees in medical expenses and lost wages due to obesity related illness.

The scientific basis to lose weight is either to restrict calorie intake by diet or burn the excess body fat by exercise and work out. The available options for this are:

  • Diet and exercise: This can reduce the weight for a short term, but more than 90% of people fail to maintain the lost weight in long term and become obese again. This is due to hunger caused by a hunger hormone called Ghrelin produced from stomach. People weighing more than 100 kg or so cannot perform any effective exercise.
  • Medicines: Till date there is no effective medication to reduce hunger or to burn the excess fat in the body.
  • Liposuction:  This is a cosmetic surgery to remove accumulated fat from thigh, tummy etc to contour the body and has no health benefits. The fat will again accumulate after sometime.

In addition to the above, bariatric (weight loss) surgery is a scientifically proven and well established method of weight reduction being practiced all over the world for more than five decades. Weight loss surgery is the only permanent treatment for people who are morbidly obese.

The weight loss surgery is a key hole method to reduce the stomach size and suppress hunger by removing the hunger hormone producing area of stomach. After surgery, the amount of food (calories) intake reduces and fat deposited in the body melts. Hence patients who have sleeve gastrectomy or gastric bypass operations gradually lose their excess weight and then maintain the same lifelong. The healthy food, life style and daily exercises help to maintain a disease-free body. With modern hospital care and technology, the risks associated with these operations are negligible and the benefits far outweigh the risks.

Why Columbia Asia

  • The hospital has highly skilled surgeons, multi-specialties like endocrinology, psychiatry, cardiology, support personnel and contemporary infrastructure to provide comprehensive care for obese patients
  • The Operation theatre is well equipped for obesity surgery
  • Back up services like 64 slice CT, 1.5 T MRI, Endoscopy, Fluroscopy. Laboratory service and round the clock ICU/ monitoring is available
  • We have a bariatric support group to help patients and families

Obesity

Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems. An increase of 20% or more above the “ideal body weight” is the point at which excess weight becomes a health risk. India is now facing an epidemic of obesity with about 5% of its population having morbid obesity. (NFHS 2007). Indians are genetically susceptible to obesity especially around the waist

What causes obesity?

Obesity is most commonly caused by a combination of excessive food intake, lack of physical activity and genetic susceptibility although a few cases are caused primarily due to hereditary causes, endocrine disorders, medications or psychiatric disorders

Morbid obesity is a complex multi factorial, chronic disease, where weight and symptoms build up slowly over time. Obesity becomes “ Morbid” when it reaches the point where it has an adverse effect on health, particularly causing heart disease, type 2 diabetes, obstructive sleep apnoea, certain types of cancer and osteoarthritis. Class II and class III obesity is considered morbid obesity.

Body Mass Index (BMI) is a tool to measure the extent of obesity, where weight and height are used in a formula. 

BMI = Weight in kgs/(Height in meters2).

Classification of Obesity

  • Overweight (pre-obese) if BMI is between 25-  29.9
  • Class I Obesity if BMI is between 30- 34.9
  • Class II Obesity if BMI is between 35 – 39.9
  • Class III Obesity if BMI is =/>40

Overweight and class I obesity can usually be treated with diet modification, exercise and behavioural changes and do not require surgery. Class II and III require bariatric surgery

Consequences of Morbid Obesity

  • Cardiac disease
  • Arteriosclerosis
  • CVA
  • Renal failure
  • Hypertension
  • Hypercholesterolemia
  • Type-II Diabetes mellitus
  • Drowsiness (day time)
  • Sleep Apnea
  • Heart Burn
  • Barrett's oesophagus
  • Gallstones
  • Jaundice
  • Stress urinary incontinence
  • Accelerated arthritis of spine
  • Degenerative arthritis of the Hip, Knees
  • Venous stasis in legs
  • Anxiety
  • Depression
  • Pseudo tumor cerebri
  • Migraines
  • Polycystic ovarian syndrome
  • Asthma
  • GERD (Gastro esophageal reflux disease)
  • Infertility
  • Pregnancy complications

Management of obesity

To manage obesity, one needs to measure it, so that doctors can decide on a patient specific regimen for treating the obesity. BMI (Body Mass Index) is the most accepted obesity measurement tool.  Patients with a BMI between 25 to 29.9, who are considered overweight, will benefit from diet and exercise. But for patients whose BMI is 30 and above, diet and exercise alone will not be helpful and for long term sustained weight loss, such patients will need surgical weight loss methods which are clinically proven and safe.

The biggest challenge that the obese people face is the craving for more food, which is due to a hormone Ghrelin secreted by the stomach. Unfortunately, there are no pills that doctors can prescribe to overcome the effects of this hunger hormone.

The solution is surgery, which has become simple and safe due to the laparoscopic approach. Laparoscopically, the hunger hormone producing area of the stomach can be removed and the size of the stomach can be reduced making it like a tube so that one cannot eat too much following surgery. The procedure is called Vertical Sleeve Gastrectomy and this is a great blessing for the morbidly obese people who have high BMI. This is usually done for those with BMI over 40 or those with BMI over 30 with associated diseases like diabetes, hypertension and others. The weight loss is dramatic and permanent. One loses about 60% of excess weight in a graded fashion over a year or so. In the meantime, it is important to be committed to a healthy way of life eating low calorie diet and doing regular exercises for the rest of one’s life.

Eligibility Criteria for Bariatric Surgery

  • BMI greater than or equal to 32.5 kg/m2 with one or more significant obesity related conditions including:
    • High blood pressure
    • Diabetes
    • Arthritis
    • Obstructive sleep apnea
    • Obesity hypoventilation syndrome
    • High cholesterol
    • Family history of early coronary heart disease
  • BMI greater than or equal to 35:
    • Obesity-induced physical problems interfering with lifestyle.
    • Body size problem precluding or severely interfering with social life, employment, family function, and ambulation).
    • Age between 16 -65 years (with some exceptions).
    • Have failed multiple attempts with supervised dietary, behavioural and medical therapy.
    • Understand and accept the operative risks.
    • Have realistic expectations and are motivated.

 Exclusion Criteria:

  • Drug and/or alcohol addiction.
  • Generally, age under 16 years or over 65 years (however age is not a strict criteria)
  • History of serious heart disease or severe lung problems. These can put one at increased risk during anaesthesia.
  • Chronic pancreatitis (or have a history of this).
  • Certain types of cirrhosis of the liver.
  • Autoimmune disease such as systemic lupus erythematosus.
  • Blood disorder which increases risk of heavy bleeding.
  • History of severe psychiatric illness.
  • Receiving cancer treatment (e.g. chemotherapy).
  • Suffer from Crohn’s disease or ulcerative colitis (inflammatory bowel diseases)
  • Pregnancy.

Types of Bariatric Surgery

All types of bariatric surgeries are done under general anesthesia. These are minimally invasive surgeries which require a short stay in hospital, recovery after surgery is faster and resumption of routine activities is also possible earlier. Since such procedures are as the name implies, minimally invasive (key hole), there is usually less loss of blood and damage to tissues, hospital stay is shorter (about 3-4 days) and no post-operative ICU stay or bed rest.

Gastric banding

A soft band is placed at the upper part of the stomach, which reduces the amount of food consumed at one time and provides a feeling of fullness for a longer time. Hence there is weight loss

Laparoscopic sleeve gastrectomy

About two-thirds of the stomach is removed laparoscopically and this makes the stomach look like a tube. The part of the stomach that produces Ghrelin hormone (which stimulates appetite and promotes fat deposition in body) is removed

Gastric bypass

Size of the stomach is reduced and a part of small intestine is bypassed so that digestion process is altered and less food is consumed and absorbed

Mini Gastric Bypass Procedure

The Mini-Gastric Bypass (MGB) is a type of obesity surgery which is a simple, successful and inexpensive technique in weight loss surgery. It is a hybrid procedure that has the advantages of a restrictive procedure (like Laparoscopic sleeve gastrectomy) and also the advantages of a malabsorptive procedure ( like Roux-en-y gastric bypass).It involves creating a long narrow tube of stomach along its right border and then joining it to a loop of small intestine about 180 cms from the starting point of the jejunum. The MGB is a viable and effective alternative to the Roux en-Y procedure due to the simple jejunal loop creation, thus reducing the morbidity and malasborption seen with a proper gastric bypass. MGB is fast becoming popular because of low risk of complications and good sustained weight loss. It has the effectiveness of sleeve and Roux-en-y gastric bypass without their complications or reflux problem.

In the MGB restriction of stomach volume is achieved by surgically altering the stomach to make its size and capacity smaller as in sleeve gastrectomy. Next mal-absorption is accomplished by looping and attaching the small intestine to the stomach tube bypassing about 150 to 180 cm of intestine as in Roux-en-Y gastric bypass

Advantages

  • Single stage permanent procedure
  • No resection or removal of parts stomach or intestine
  • No implants like a balloon or band
  • No reflux or acidity problem
  • Hunger is reduced
  • Sustained long term weight loss
  • Easily reversible and revisable if necessary
  • No prolonged hospital stay
  • No major mal-absorption complications

Hospital stay

  • Is usually 2-3 days
  • Patient should be able to take enough fluids and nutrients by mouth before discharge
  • Lack of physical activity.

Evaluation for bariatric surgery

Patients who come for treatment of obesity will not be taken up for surgery straight away. The following steps are taken prior to advising surgery

First visit:

Initial Assessment shall include:

  • Presenting complaints/history
  • Height
  • Weight
  • BMI (Body mass Index)
  • Clinical Examination: heart rate, blood pressure, respiratory rate, saturation on room air
  • Systemic examination: of the cardiovascular system, respiratory system, neurological system and abdominal examination
  • Previous weight loss methods
  • Co-morbid conditions: Diabetes Mellitus, Coronary artery disease, Hypothyroidism, Dyslipidemia, Osteoarthritis, Psychiatric illness, Obstructive sleep apnea, cancer, chronic obstructive pulmonary disease, Hypertension etc
  • Family counselling

 

Initial Consultation is done with:

  • Anesthetist
  • Endocrinologist
  • Pulmonologist
  • Cardiologist
  • Dietician
  • Physiotherapist
  • Intensivist only in high risk cases

Investigations:

3 weeks pre-operative

  • Hematology
    • Complete blood count
    • Coagulation profile
    • Fasting and post prandial blood sugar estimation
    • HbA1C (Glycosylated haemoglobin)
    • Urea
    • Creatinine
    • LFT
    • Thyroid profile
    • Fasting lipid profile
    • HIV, HCV, HbsAg
    • Renal profile
    • Serum vitamin B12
  • Radiology
    • Chest X Ray
    • Ultrasound abdomen and pelvis to r/o gallstones and polycystic ovarian disease
  • Cardiac evaluation
    • Resting ECG
    • ECHO
  • Pulmonology
    • PFT (pulmonary function tests)
    • Sleep study (as decided by anesthetist/ pulmonologist)
  • Gastro enterology
    • OGD to rule out tumor/ large hiatal hernia and treat H. Pylori if positive

Benefits of bariatric surgery

Who are the patients who will benefit from Bariatric surgery?

  • If BMI is > 35 or > 32 .5 with co-morbid conditions
  • Multiple attempts of weight reduction by diet and exercises has failed
  • No treatable underlying endocrine disorder is found
  • No major psychiatric illness is found
  • Patient is committed to post-operative diet and lifestyle modifications

What are the health benefits of bariatric surgery?

  • In Type 2 diabetics sugar levels are known to come down after bariatric surgery and in some cases the medications are no longer needed
  • Relief of sleep apeoa and hence better of quality of sleep
  • Hypertension improves and in some cases medication is no longer needed
  • Cholesterol level comes down drastically and patients can lower or stop lipid lowering medicines
  • Improvement in diabetes, hypertension and cholesterol levels has a direct effect on reducing the risk of heart diseases
  • After surgery patients are known to have fewer and less severe asthmatic attacks. There is increased efficiency of breathing and exercise tolerance
  • Those with gastro esophageal reflux disease (GERD) show relief of all symptoms of reflux within a few days
  • Stress incontinence responds dramatically to weight loss
  • After surgery patients get tremendous relief from low back ache and joint diseases
  • Women with polycystic ovarian syndrome show a return to normal regular menstrual cycles after weight loss surgery. Further, level of fertility also shows improvement

What is the difference between liposuction and Bariatric surgery?

  • Liposuction is a cosmetic surgery in which localised fat is sucked out from an area like thigh or tummy. It is not a weight loss surgery and it has no health benefits.
  • Bariatric surgery is a weight loss procedure in which accumulated fat from the body melts away uniformly over 4 to 6 months’ time after surgery and it has all the health benefits as mentioned

Diet after Surgery

Diet after Laparoscopic sleeve gastrectomy

Principles of diet: 

  • Energy 800 Kcals, Protein 50 g, Fat 15 g
  • Quantity = 200ml
  • Frequency = 2nd hourly.

Instructions:

  • All porridges to be in flowing consistency.
  • All juices/ coconut water to be taken fresh and no packed juices.
  • Skimmed milk only.
  • No added sugar to any juices and less than a teaspoon of salt per day.
  • Add powdered Almond (4 in no) in milk/porridge.
  • Temper soups with oil

Avoid:

  • All fats including butter/cream/cheese/ghee.
  • Sugars and artificial sweeteners.
  • Tinned/canned/processed and pre-packed food.

Recipes:

  • Optifast VLCD:
    • To 200ml water add a sachet of optifast and shake well.
  • Rava/ Ragi /Dalia Porridge:
    • Ingredients: Rava, Milk (skimmed), Water
    • Method:
      • Roast the rava.
      • In a saucepan, boil milk with water and simmer.
      • Add the roasted rava gradually with constant stirring.
      • Cook till well done.
  • Vegetable Puree:
    • Ingredients: Mixed vegetables - beans, carrot, knolkhol, green leafy vegetables like palak, methi
    • Method:
      • Wash and chop the vegetables.
      • Pressures cook the vegetables.
      • Blend to the desired consistency.
      • Filter / strain and serve with a pinch of salt.

NOTE: For lentil soup replace the vegetables in vegetable soup with lentils.

Diet after Sleeve Gastrectomy

The smaller gastric capacity will call for dietary modifications especially in the early post-operative phase. The patient must adhere to these changes for optimum weight loss.

Diet Principles:

  • Drink 6-8 cups of fluids each day
  • Sip one cup of liquid over an hour
  • Stop drinking within 30-60 minutes before a meal, during meals and 30 minutes after meals
  • Sip allowed beverages slowly
  • Do not use a straw.
  • High calorie foods, beverages and snacks to be avoided.
  • Start nutritional supplement when permitted by the doctor
  • Eat very slowly. Food needs to be thoroughly chewed
  • Stop eating when full. Indications of fullness are: a) a feeling of pressure in the centre just below your rib cage, b) a feeling of nausea, c) a pain in your shoulder area or upper chest. Contact your doctor if above symptoms persist or worsen.

In general, the patient will advance through the following diet phases, and at each phase avoid food high in sugar and fat

Phase 1Clear liquid DietInitiated about 48 hours post- surgery
Phase 2Full liquid DietInitiated about 3-4 days post- surgery
Phase 3Semi-solid DietInitiated about 15 days after surgery
Phase 4Low-fat solid DietInitiated about 4 weeks after surgery

Day 0 and 1:

You will consume nothing orally, not even water on the day of operation as well as the next day till your con-ray test is performed.  All fluids will be provided through an intravenous drip.

Phase 1 – Clear liquid Diet

On the 2nd day after your operation, we will do a con-ray test to affirm that there is no leak through the staples.

  • Low sugar diet is recommended to prevent dumping syndrome, which can occur when concentrated sweets or hydrating liquids are consumed with meals causing foods to rapidly pass in the small intestine in 10-15 minutes rather than gradually. Symptoms include rapid heartbeat, nausea, possible diarrhoea or feelings of cold and clammy
    For your clear liquids, choose from the following list - (List-1)
    • Whey water
    • Clear apple juice
    • Clear vegetable soup
    • Tender coconut water
    • Clear spring onion soup {strained}
    • Clear lemon coriander soup {strained}
    • Clear cucumber soup
    • Clear Dal water
    • Clear chicken soup
    • Fresh lemon water
    • Black tea/ coffee
    • Herbal tea (without milk)
  • When initiating intake, consume only a small amount about 15-30 ml, each time. Sip slowly and be alert to realize a feeling of fullness.
  • After a few sips, pause to check if you are comfortable enough to consume more. You constantly must be cautious not to distend the small pouch or else it would cause vomiting.  Do not use a straw since it will fill your stomach pouch with air making you feel uneasy.
  • If you can abide by the clear liquid diet, you can step up to the next phase within 2-3 days.

Phase 2– Full Liquid Diet (Day 3 to Day 15)

It is essential during this initial phase you stick to only liquids for about the next 12 days or so as chunks of food could block the opening leaving your stomach and result in vomiting and pain. Start with small amounts of above mentioned foods as you will feel full quickly.

The appropriate fluid choices during this phase are as follows. Keep your fluids thin for the first 2 weeks

  • Skimmed milk
  • Tea/coffee with skimmed milk
  • Buttermilk
  • Curd/yogurt (skimmed/ low fat and unsweetened)
  • Fruit/vegetable juices (unsweetened)
  • Soups (homemade without adding corn flour/ thickeners)
  • Dal soup (use washed dals like moong / arhar/ masoor etc)
  • Blended and strained chicken soup
  • Blended and strained vegetable soup
  • High protein meal replacement supplements (Optifast/obesigo/ positrim)- start with ½ sachet in water twice daily

Initially, drink small amounts frequently (15 - 30 ml at a time).
Do not take more than 100 ml of liquid at one time.
In addition, keep sipping 4 cups (1 cup = 60-100 ml) of low calorie liquids from list throughout the day to prevent dehydration.

Phase 3 – Semi solid diet (Day 15 to Day 30)

This is the transition phase from a liquid to a regular diet and will progress slowly. Gradually, thicken the liquids that you were consuming for the first 15 days, for instance, the soups can become thicker, the fruits and vegetables can be pureed. Begin consumption of soft foods like egg whites, mashed potatoes and paneer. Avoid bread, red meat as they are difficult to digest.

Remember to add one new food at a time and gauge your body’s response/tolerance to it. Aim at 4 – 6 small meals and no meal should exceed the volume of a measuring cup. Take your time to eat, take small bites and chew thoroughly.

Continue to sip on low calorie liquids in between meals. However, avoid any liquids 30 minutes prior to and 90 minutes post a meal. 

Avoid skin of raw vegetables and fruits at this step of your diet. The intake of liquid calories has to now be slowly reduced.  Try to moisten meats and vegetables with broth or low fat gravy as moist foods are better tolerated.

Your diet can now include:

  • Mashed potatoes made with milk
  • Cooked Egg White, any form except fried
  • Milk based Dalia / Porridges/ oats/muesli (well blended in mixer)
  • Khichri (over cooked rice and washed pulses)
  • Well cooked chicken and fish (cooked soft: use method like boiling/steaming)
  • Cottage cheese
  • Peeled and Deseeded soft textured fruits (Avoid Dry Fruits/Nuts and hard fresh fruits).
  • Well cooked vegetables without seeds or skins
  • Low fat pudding or custard, soft jellies – In Small Amounts
  • Pureed meat – Lean Chicken or fish, vegetables or fruits (Cooked soft, blenderized and sieved, use them even in soups)
  • High protein meal replacement supplements (Optifast/obesigo/ positrim)-   start with ½ sachet in water twice daily

If you still experience discomfort while eating soft textured food:

  • Slow down on the speed of your eating
  • Use smaller portion sizes
  • Remember you are re-educating your stomach. If you eat too much, too fast or don’t chew enough you are bound to feel uneasy.
  • Limit your fat intake to 2-3 tsp/day

Keep sipping water in between to avoid dehydration, also the more water you drink the better the weight loss!!!

Phase 4 - Regular Diet

Transition back to solid foods can begin from the 5th week after surgery. It is most likely that one month post bypass you may experience some vomiting or diarrhea. If either of these persists, contact the doctor. The first couple of months post the surgery may be a period of loss of appetite. This is due to a change in certain stomach hormones as well as reduced stomach capacity. This should pass in a few months.

Once you have established a diet based on solid food you will stay with that permanently. Continue adding one new food at a time to help determine what foods are tolerated. Keep breads and red meat last on your list. As a rule, you will maintain a low fat, low sugar diet with a high intake of proteins and complex carbohydrates.

Remember to chew your food completely. You will experience discomfort if you eat too fast or don’t chew well. You have to adapt to this new way of eating to stay healthy and successfully lose excess weight . . . . and keep it off.

Food guide
Aim at incorporating the foods listed under the following categories each day. Our efforts should not only be aimed at weight loss but towards a healthy weight loss.
Cereals:

  • Key – Whole grains/complex carbohydrates
  • Options – (select any 2 options each day)
  • One roti (minus the oil/ghee)
  • Two heaped tablespoons of cooked cereal like rawa, dalia, rice flakes (poha)
  • Two slices whole wheat bread
  • Two tablespoons of wholemeal breakfast cereals (cornflakes, rolled oats)
  • To be restricted – maida and its products like White bread, naan.

Pulse:

  • This food group is an important source of protein for vegetarians.
  • Key – For Vegetarians, 2 tablespoons of cooked thick dal/pulse for lunch and dinner; Non vegetarians can replace this group with chicken/fish for one meal. 

Remember
* Avoid legumes and whole pulses in the night. Dals are the best option for dinner.
* Try and incorporate at least 1 tablespoon of sprouts each day, in some form or the other. Sprouting not only increases the nutritive value of pulses but also improves digestibility.
* Make use of soy in your daily diet. Replace a part of wheat flour with soy flour while making roti’s and make use of soy chunks/nuggets in vegetable and even rice preparations.

Non vegetarian group:
Key – 30-45 g of fish, poultry or 1 egg white every day.
Remember:

  • No red meat
  • Trim all visible fat
  • Remove skin from poultry
  • Grill, bake or boil/steam
  • Avoid deep frying

Dairy Products:

  • Although milk and curds are essentially liquid form of calories, they cannot be avoided due to the calcium they provide.
  • Key – 3 measuring cups (or 600 ml) of skim milk/curds each day, inclusive of use in cooking for cereals, tea, coffee etc.
  • Options – You could reduce the daily consumption of milk/curds to about 2 cups and use 30-45 g paneer (cottage cheese) or 25 g cheese 3 times a week.

Fruits and Vegetables:

  • Now you can do away with the juices and soups. Start with peeled and deseeded soft fruits and vegetables.
  • Key – 2-3 different vegetables and 2 pieces of seasonal fresh or stewed fruit daily.
  • Remember – To include a portion of dark green or orange vegetable daily.
  • Fats and Sugars
  • Limit your daily intake to 1-2 teaspoons of sugar and 3-4 teaspoons of oil/ghee/butter.

Fluids:

  • The more the water intake, the better the weight loss as it will keep your pouch full. Optimum intake of fluids is also essential to prevent dehydration. 
  • Key – 2.5 liters of water/day
  • Remember – Do not mix solid food with fluids. Liquids will make you feel full before you have consumed enough food. Low calorie, non-carbonated liquids should not be consumed 30 minutes prior to or 90 minutes after a meal.

Food to be Restricted:

  • Sugar, honey and jaggery are ‘empty calorie’ foods that provide no other nutrient except for calories and thus should be avoided. Products containing large amounts of sugar should be omitted. e.g. jam, marmalades, preserves, soft drinks, cordials, desserts and other items that have sugar listed as one of the first three ingredients. These foods have practically no nutritive value and thus should be excluded from the diet.
  • High fat foods such as chips, chocolates, puffs, pastries, pies and carbonated drinks should be avoided.
  • Alcoholic beverages like whiskey, beer, wine, port, champagne etc are also empty calorie and thus we recommend you to stay away from them. It is recommended that you give up alcohol for the rest of your life. At minimum, you must avoid it strictly for 1 year post surgery

A few guidelines:
Eat three meals and two protein snacks per day, not more than a cupful for any meal.

No munching in between meals. The stomach pouch is created to hold the amount of food that can fit into a cup. If you consume more than your pouch size on a single occasion, you are likely to feel sick and vomit. It is therefore essential for you to learn how much your stomach can accept at one time and not exceed that.

Aim at a balanced diet and prioritize proteins.

A well balanced diet is very essential. Now that you have a smaller capacity to eat, you must eat the right foods and avoid filling your small pouch with nutritionally poor foods. Protein rich foods and complex carbohydrates are most suitable whereas foods high in fats and simple sugars should be avoided.

We have to prioritize proteins when resuming diet. Protein is important for wound healing, sparing loss of muscle mass, minimizing hair loss and preventing protein malnutrition. Foods high in protein include dairy products, eggs, fish, poultry, tofu, dried beans and legumes.

During the first month or so you might need to use a protein supplement until you can take in adequate protein from the foods you consume.  

Eat slowly, sense your satiety signals and stop.

Satiety stands for the feeling of fullness. The nerve endings in our stomach connect to the satiety centers in our brain. When the stomach is sufficiently full, these signals tell us that we should stop eating. However, it takes a good 30 minutes for this feedback mechanism. If you eat too fast, you would have eaten too much before even your body is able to signal you to stop eating. Thus we advise you to eat as slowly as possible, observe any feeling of discomfort and if not, then proceed with more. As a guideline, you should consume only 2-3 tbsp of food over a 10-15 minute period, pause to sense fullness and if not then proceed. 

Chew your foods well

Chew food until it is almost liquid in your mouth. Well-chewed food will place less stress on your gastric pouch.

Sip on plenty of zero calorie liquids and no liquids with meals.

As mentioned earlier, fluid intake is very crucial after surgery. It is essential to sip liquids slowly and constantly throughout the day. Fluid intake is important for weight loss, to prevent dehydration and also to help minimize constipation. Fluid intake should be at least 1 liter to begin with. Our ultimate target should be to consume at least 2.5 liters everyday.

The timing of fluid intake is also an important consideration. Always adhere to the following:

  1. Take no liquids with meals.
  2. Do not drink liquids 30 minutes before or 90 minutes after meals. Drinking liquids with meals, too close to mealtime, or too fast, may cause bloating or vomiting.
  3. Drink plenty of water.
  4. Do not gulp liquids. A sipper is a convenient way to get small sips and to avoid gulping.
  5. The longer you wait after meals before drinking is better. This avoids flushing out the stomach, and therefore avoids rapid hunger.
  6. Do not use a straw. This can cause your stomach pouch to fill with air.
  7. Avoid regular soda, sweetened beverages and alcoholic beverages. These have no nutritional value and could cause weight gain.
  8. Most fluids should be non-caloric such as water, coffee, unsweetened tea.

Reserve at least 30 minutes of your time for exercise each day.

With your excess weight earlier, exercise was indeed troublesome. But now that you are on a weight loss spree, it will be easier for your body to execute physical activity. Exercise is important not only from a weight loss perspective, but also to keep you healthier and fitter for life.

Set aside at least 30 minutes of your day for moderate intensity exercise. Begin with simple options like walking, swimming and slowly step up to aerobics, jogging etc. Besides, try to be as active as possible and incorporate physical activity into your lifestyle, for instance, use the stairs, instead of sitting idly in front of the T.V/computer, engage in some house hold chore, walk a street extra each day and so on.

As you shed weight, your stamina for physical activity will improve and you have to further make use of this improved state of well-being for your own good.  

Lastly, we would like to reiterate that surgery is not a one-time solution for your obesity. It is a means to provide assistance to help control your weight. It is very crucial to emphasize that you take your multivitamin, calcium and iron tablets for life. There is no substitute for that.  Further, any period of continuous vomiting for more than a week needs to be brought to our notice immediately.

Remember, your pouch is a tool to help control weight loss by enabling you to make healthy nutrition choices & lifestyle changes

Potential problems following weight loss surgery and suggested dietary modifications

  1. Nausea and vomiting
    • If nausea and vomiting occurs after eating a new food, wait for some days before trying that food again.
    • It may be necessary to return to liquids or pureed food temporarily.
    • Eating/ drinking too fast may cause nausea or vomiting.
    • Eating/drinking too much may cause nausea or vomiting.
    • Insufficient chewing may cause nausea or vomiting.
    • Avoid cold beverages and those with caffeine or carbonation.
    • If nausea and vomiting persists, call your surgeon.
  2. Dumping Syndrome (abdominal fullness, nausea, weakness, warmth, rapid pulse, cold sweat, diarrhoea)this does not occur gastric banding.
    • Avoid all sweetened foods and beverages.
    • Avoid high fat, fried,greasy foods.
    • Do not drink fluids with meals.
    • Wait at least 30 minutes to drink beverages after meals.
  3. Pain in shoulder or upper chest area(occurs when you eat too much or eat something hard to digest.)
    • Stop eating if pain occurs during eating and try to eat later after pain has resolved.
    • If pain persists, call your surgeon.
    • Dehydration
    • Dehydration can occur with inadequate fluid intake, persistent nausea, vomiting or diarrhoea.
    • At least 6-8 cups of fluid a day are recommended.
    • Avoid caffeine.
  4. Lactose Intolerance/Diarrhoea (this does not occur after gastric banding)
    • Use lactase - treated milk and lactase enzyme tablets.
    • Try low fat milk or soy milk.
  5. Constipation
    • Constipation may occur temporarily during the first post-operative month.
    • This generally resolves with adaptation to changes in volume of food.
    • Drink low calorie fluids regularly -this will help prevent constipation.
    • You may need to add a stool softener or fiber supplement speak with your dietician or surgeon about available products.
  6. Diarrhoea
    • Limit high fibre, greasy foods, milk and milk products.
    • Avoid very hot or cold foods.
    • Eat smaller meals.
    • Sip fluids between meals.
    • If diarrhoea persists, call your surgeon.    
  7. Heartburn
    • Avoid carbonated beverages.
    • Avid caffeine.
    • Do not use a straw.
    • Avoid citrus fruits and beverages such as lemonade, orange or pineapple juice.(you may resume citrus foods and beverages once on a  regular diet, you do not have to avoid citrus after gastric banding)        
  8. Bloating
    • Limit liquids to 60 ml at one time.
    • Sip slowly 
  9. Taste/Sensory changes
    • This may occur during the first few months after surgery but will resolve over time.
    • Some foods may taste too sweet or have a metallic taste.
    • Strong smells from cooking may affect you, try to avoid the kitchen while someone else is cooking
  10. Blockage of the Stoma (opening of the stomach)
    • The stoma may be temporarily blocked if foods with large particle size are eaten without thorough chewing.
    • If symptoms of pain, nausea and vomiting persist, your surgeon should be contacted.
    • Do not progress to solid foods until your surgeon tells you to
  11. Rupture of the staple line after gastric bypass
    • Rupture of the staple line is unlikely; however, avoid eating an excessive quantity of food at one time.
    • Stretching of the stomach pouch/stoma dilation
    • Avoiding large portion of food at one time can reduce the risk of stretching the stomach pouch.
    • The risk can be decreased by gradually increasing the texture of foods in the early post-operative weeks.
    • Follow the recommendations for advancing your diet to prevent this stretching.
    • Avoid carbonated beverages.
    • Weight gain or no further weight loss
    • You might be eating high calorie foods or beverages.
    • Keep a record of all foods, beverages and snacks eaten to determine the exact reason for this.
    • Measure portion sizes.
    • Avoid prolonged use of nutritional supplements like Ensure, Boost, etc.
    • Use only low calorie beverages in addition to fat free milk.
    • If you had gastric banding, you may need your band adjusted.

 

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