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www.bidmc.org/wls

Main Phone: 617-667-2845

Fax: 617-667-2866

Diet Stages 1 through 3

for Weight Loss Surgery

Your Dietitians: Michelle Mamis, RD, LDN

Office Phone: 617-667-2824

Kate Otto, RD, LDN

Office Phone: 617-667-9081

For Confidential Email use https://www.patientsite.org You must login under one of our Surgeons (Dan Jones, Ben Schneider)

Updated: 05/2016

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Nutrition: Diet Stages 1 through 3

Your Dietitians:

Michelle Mamis, RD, LDN

Kate Otto, RD, LDN

This chapter has been designed to help you, your family, and your close friends start

learning about nutrition for weight loss surgery. In order to be successful losing weight

and keeping it off, you must learn how to modify your eating behavior permanently.

The surgery is only part of the treatment. These diet stages are different than any other

diet you may have followed in the past. It will progress through a series of 5 stages, the

first 4 lasting a total of 6-8 weeks. The Bariatric Surgery Team has designed each diet

stage to provide nutrition consistent with healing and tolerance. During your first post-

op appointment, 2 weeks after surgery, you will be evaluated if it is medically safe to

advance your diet and review the Stage 4 information. It is important to NOT self

advance your diet.

(Progression may slightly vary with each individual and type of surgery)

LOCATION AND

APPROXIMATE

SCHEDULE

STAGE GENERAL

DESCRIPTION

LENGTH

OF STAGE

(May vary)

Starts after surgery with IV

fluids continuing 1 water

(1 oz per hour) One day or less

Completed in the Hospital 2

low sugar, decaffeinated,

non-carbonated

clear liquids

(2-4 oz per hour)

One day or less

Getting ready for discharge you

will be introduced to Stage 3

and evaluated for tolerance. 3

low sugar, high protein

modified full liquids

(4-8 oz per hour)

Two to Three

weeks

Home - follow up in clinic

(2 weeks after surgery) 4 lean soft/ground Four to Five

weeks

Home - follow up in clinic

(Approx 6-8 weeks after

surgery) 5

lean meat, fish, & poultry,

protein bars,

fresh fruit & veggies,

whole grains & legumes,

healthy fat, and low fat dairy

Lifetime

3

Goal # 1 = Stay Hydrated (2 to 4 L = 64 to 128 oz fluid)

Fluid is an essential nutrient needed everyday for normal body functioning

Generally women aim for 2-3 liters (64-96oz) and men 3-4 liters (96-128oz) per day

o Extra fluid is needed during illness and exercise (perspiration)

Signs and symptoms of dehydration: unquenchable thirst, dry mouth,

lightheadedness, headache, muscle cramps, ears ringing, chronic fatigue

(although fatigued is normal following major surgery)

“Catch up” is almost impossible after surgery

Monitor your urine production to make sure you are properly hydrated

You may not be well hydrated if:

o Your urine is dark in color

o Your urine has a strong odor

o You are urinating less than 4 x per day and/or in a small amounts (< 1 cup)

Normal urine color is usually darker in the morning and lighter as the day goes on

Vitamins can darken the color of your urine

Caffeine must be avoided for at least 2 months following surgery. It is a diuretic

which only promotes dehydration and may be irritating to your new pouch.

Tips to increase you fluid intake:

1. Drink fluids throughout the day

2. Keep fluid by the bedside, on your desk, in your car, & in your purse/bag

3. Keep on sip, sip, sipping!

4. Drink water before, during, and after activity

5. Bring your own bottled water when traveling

Meeting your daily fluid needs helps to:

Prevent dehydration

Prevent constipation

Removes waste products

Prevent kidney stones

Keep you full between meals

Regulates body temperature

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Goal # 2 = Preserve Lean Mass (60 to 80g Protein daily)

Protein is essential for body growth, development, and healing

o Especially for wound healing

o As well as maintain muscle while you are losing weight

Generally aim for 60 to 80 grams per day

Your individual protein requirements will be assessed during your first follow up

appointment by your dietitian

The goal is to promote fat loss not muscle loss, lean muscle tissue burns more

calories

Goal # 3: Nourish and Energize (600 to 800 calories)

Weight loss occurs when calories IN minus calories OUT is negative

Your body uses calories to conduct its daily functions and provide energy

In the first 3 weeks we anticipate you will be able to consume approximately 600

to 800 calories daily

Over time your food tolerance will be enhanced and your calorie goals will

increase to 1200 (for women) and 1600 (for men)

Immediately Following Surgery

You will be “NPO” which, simply means that you will not receive fluid by mouth. You

will receive intravenous fluid to keep you well-hydrated and moist swabs to prevent

mouth dryness. You will begin Stage 1 when you become more alert and it is

determined that your stomach and intestines are showing signs of normal activity.

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Stage 1: Water Completed in Hospital

Lasts 1 day or less

1 oz (30 cc) of water per 15 minutes in a medicine cup

Sip slowly and stop sipping if you start to feel uncomfortable

Stage 2: Clear Liquids

Completed in Hospital

Lasts 1 day or less (Stage 2 helps to stimulate digestive function)

2-4 oz of clear liquids per hour

o non-carbonated: can put pressure on new sutures & possibly stretch the pouch

o decaffeinated: caffeine promotes dehydration

o low sugar: promotes dumping syndrome and add unnecessary calories

In Hospital Fluid Choices include water and broth (no juices…too much sugar)

Use a 1 oz medicine cup to prevent gulping and drinking too fast

Sip slowly and stop sipping if you start to feel uncomfortable

to

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Stage 3: Modified Full Liquids

Started in the hospital

Continued at home for 2-3 weeks (Do not self advance your diet)

Stage 3 is all liquids (no chunks) to avoid any irritation from food particles

o high quality protein, low saturated fat, low sugar

Start with 4oz low sugar protein supplement over 1 hour 3 times per day to help

meet protein goals

In Hospital Protein Choices include Gelatein 20, Optisource, Beneprotein, and

Low Sugar Carnation Instant Breakfast (CIB)

At Home: Additional options are on the next page

Continue to have sips (4-8 oz per hour) of low sugar clear liquids in-between

protein

Your tolerance to Stage 3 beverages should improve with time as you heal & the

swelling decreases

As a general rule, start your fluid intake with 4-8oz per hour but gradually

increase as tolerated

NO straws…this may add air to your digestive system and fill you up

Remember flavored water, gelatin, ice pops, and broth all count towards your

fluid goal

Taste test stage 3 foods and supplements PRIOR to surgery

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Stage 3 Beverages & Foods These choices start AT HOME!

BEVERAGES: 1. Low sugar, decaffeinated, non-carbonated fluid

(i.e. water, Crystal Light, Smartwater, Mio, Wyler’s light, Fruit 2 O, sugar free Kool Aid,

Minute Maid Light, Propel, Welch’s Low Cal, AquaCal, VitaZest, Diet Ocean spray, herbal

tea)

DAIRY PRODUCTS:

1. Skim or 1% milk (i.e. Hood, Over the Moon, Simply Smart)

2. Skim or 1% Lactaid, unsweetened soy or rice milk (good for lactose intolerance)

3. Smooth low fat, light yogurt (i.e. Dannon Light n’ Fit, Yoplait Light, Hood’s Carb

Countdown, Colombo Light, FAGE or Chobani Greek 0%, store brand) 4. Sugar free, fat free pudding (i.e. Jello, Hunt’s, Kozy Shack)

5. Blended/whipped low fat cottage cheese (i.e. Breakstone’s, Light n’ Lively, Friendship)

6. Part skim ricotta cheese (i.e. Dragone, store brand)

7. Home made Low fat, sugar free custard

SOUP:

1. Strained or blended low fat cream soups (i.e. Campbell’s, Pacific, Imagine, homemade)

2. Low fat broth/boullion (i.e. Swanson, College Inn, Healthy Valley, homemade)

OTHER NOURISHMENT: 1. Thin (able to pour) low sugar hot cereals (i.e. Quaker Oats, Uncle Sam, store brand)

• soupy cream of wheat, oatmeal, grits, and cream of rice

2. Sugar free ice pops (i.e. Popsicles, Edy’s)

3. Unsweetened applesauce (i.e. Musselman’s, Mott’s, store brand, homemade)

4. Sugar free gelatin (i.e. Jell-o, store brand)

5. Dried skim milk powder (i.e. Carnation, store brand: 8g PRO/1/3 cup)

ARTIFICIAL SWEETENERS:

1. Splenda (Sucralose)

2. Sweet n’ Low (Saccharine)

3. Equal (Aspartame)

4. Truvia (Stevia)

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Handy Utensils

o Shaker Cup

o Hand held blender

o Cooler for your car or office

o Strainer

o Whisk

o Measuring cups and spoons

o Small utensils (i.e. baby or cocktail spoons and forks)

o Sippy Cup or twist/squeeze top water bottles: allows only one sip at one time;

beneficial for those that like to drink fast or chug fluids

Protein and Calorie Cheat Sheet

The nutrition values below are estimates and may vary.

For accuracy, it is always best to read the nutrition fact label.

Food/Beverage Portion Calories Protein

(g)

water or flavored water - 0 0

skim and 1% milk (Lactaid too) 1 cup 80-110 8

low fat, Light yogurt 6-8 oz 60-120 5-8

low fat, Light yogurt smoothies 8 oz 80 6

fat free, Greek yogurt 6 oz 100 18

sugar & fat free pudding (mixed w/ milk) 4 oz 70 4

whipped low fat cottage cheese 4 oz 100 12-16

part-skim ricotta cheese ¼ cup 100 8

low fat cream soups ½ cup 35 1

low fat broths 1 cup 10 1

thinned hot cereals 1 cup 100 3-5

sugar free ice pops 1 pop 15 -

unsweetened applesauce 4 oz 50 -

sugar free gelatin 4 oz 10 1

dried skim milk powder 1/3 cup 80 8

protein powder 1 scoop 100 20

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Understanding Labels

Food packaging and claims can be very misleading. Therefore it is very important to do

some detective work and read the nutrition fact label as well as the ingredient list. The

ingredient list provides useful information for finding hidden Trans fats and sugars.

Remember the ingredients are listed from the most abundant to the least abundant.

Rules of Thumb Low sugar = 8 grams of sugar per 100 calories.

Except fruit and dairy have natural sugar so 15 grams of sugar per serving is

OK for these foods (i.e. milk, yogurt, and applesauce).

Low fat equals 3 grams of fat per 100 calories

What to look for in a protein supplement? 15-20 grams protein per serving

Check ingredient list for: Whey protein isolate (Best), Soy (Good), Collagen

based protein (NOT recommended)

~100 calories per serving

Low sugar (8 grams of sugar per 100 calories)

Minimal to no fat per serving

Serving Size: The list of

nutrients (i.e. fat and

protein) is the amount in

ONE serving only. It’s

important to look at how

many servings are listed

per container or bag.

Calories: This is a

measure of energy. The

number of calories listed

is for one serving.

Fat: Not all fat is alike.

Saturated fat (usually found in

animal products) and Trans fat

are linked to heart disease and

should be used sparingly. Poly

and Monounsaturated fat

(usually found in plants) are

better choices. Limit healthy

fat to 20-35% of total calories. Sugar: It is important to

limit foods high in added

sugars because this means

higher calories. Protein: remember your total protein

goal is 60-80 grams per day. So try

to pick foods with some protein

listed.

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Protein Supplements

1. Bariatric Advantage Meal Replacement (Lactose Free): www.bariatricadvantage.com

Sold online or by phone 1-800-898-888

15g PRO/ ready-to-drink bottle

2. Designer Whey Protein: www.designerwhey.com

Sold at GNC and Vitamin Shoppe

18g PRO/scoop of powder

3. EAS Myoplex and AdvantEdge: www.eas.com

Sold online at various websites and at GNC, Vitamin Shoppe, Target, and Shop & Stop

This company offers a variety of high protein products.

4. GNC Pro Performance: www.gnc.com

Sold online and at GNC stores

This company offers a variety of high protein products.

5. Isopure (Lactose Free): www.naturesbest.com

Sold online and at CVS, GNC, Vitamin Shoppe, and Rite Aid

40 g PRO/20 oz ready-to-drink bottle, 25 g PRO/scoop of powder

6. Nectar: www.syntrax.com

Sold at Vitamin Shoppe and online at various websites (i.e. www.bariatricadvantage.com)

23 g PRO/scoop of powder

7. Vitamin Shoppe 100% Soy Protein Powder: www.vitaminshoppe.com Sold online, and at Vitamin Shoppe

26 g PRO/ 2 scoops of powder

8. Unjury (Lactose Free): www.unjury.com

Sold online or by phone 1-800-517-5111

20 g PRO/packet or scoop of powder

9. Worldwide Pure Protein Shake: www.sportnutrition.com

Sold online, by phone (800) 854-5019, and at Trader Joe’s, Vitamin Shoppe, and GNC

21-35 g PRO/11 oz can

10. GNC Total Lean Shake: www.gnc.com

Sold online and at GNC stores

25 g PRO/ 2 scoops of powder or 14 oz bottle

11. Optimum Nutrition Gold Standard 100% Whey: www.optimumnutrition.com

Sold online and at GNC, Vitamin Shoppe

24 g PRO/scoop of powder

Places to Shop: www.bariatricadvantage.com

www.gnc.com

www.vitaminshoppe.com

GNC

Vitamin Shoppe

Vitamin World

Trader Joe’s

Whole Foods

Market

Victory Market

BJ’s

Sam’s Club

Stop & Shop

Shaw’s

Market Basket

A Typical Day on Stage 3

The number of protein supplements you will need each day depends upon your

selections and gram of protein it contains

As a general rule, start your fluid intake with 4-8oz per hour but gradually

increase as tolerated

Ability to consume fluids vary from person to person, some patients find it easy

while others struggle

You should be able to take in more fluids by weeks 3 & 4, than weeks 1 & 2

Generally sip/drink fluids every hour you are awake

Be creative to prevent flavor fatigue (see “Flavor Tips”) & choose a variety of

foods

Example # 1: Simplified Typical Day 8AM 4 oz blended cottage cheese

9AM 8 oz water

10AM 8 oz protein drink

11AM 8oz water

NOON 8oz protein drink

1PM 8 oz water

2PM 8 oz protein drink

3PM 8 oz water

4PM 8 oz sugar free gelatin

5PM 8 oz 1% milk

6PM 8 oz low fat broth

7PM 8 oz decaf tea

8PM 8 oz water

TOTAL Protein intake on this day will vary depending upon protein supplement choice

Example # 2: Detailed Typical Day 9AM 1 scoop “Designer Whey” (18g PRO/1 scoop)

mixed with 8 oz skim milk or reduced lactose milk (8g PRO/cup)

10AM 1 cup sugar free gelatin

11AM 24 oz bottle of “Propel”

2PM 8 oz low fat, light yogurt (8g PRO/cup)

3PM 1 cup broth

mixed with 1 scoop unflavored PRO powder (20 g PRO/scoop)

4PM 24 oz bottle of water

7PM low sugar “Carnation Instant Breakfast” (4g PRO/powder packet)

mixed with 8 oz 1% milk (8g PRO/cup)

8PM 8 oz glass of water

TOTAL 72 oz non-nutritive fluids, 66 grams of PRO, 605 calories

Hunger expectations after surgery:

The primary goal is to heal after surgery and

following the diet stages is important to avoid

complications.

Band: Since there are no hormonal changes it is

normal to still feel hungry.

Band: You may be able to drink/sip more

quickly than described.

Bypass/Sleeve: Patients may not feel hunger.

Bypass/Sleeve: You will probably feel full very

fast and need to drink/sip more slowly.

Call a dietitian if your hunger is unmanageable.

Flavor Tips

Add sugar free extracts to your protein supplement or other stage 3 foods:

“DaVinci”- sold online at www.bariatriceating.com or in TJ Max and Marshall’s

“McCormick” - sold at local grocery store in the spice isle

“Torani”- sold online at www.torani.com or at Shaw’s supermarket

Warm chocolate protein supplement in microwave to have a hot cocoa like drink

Blend protein supplement with crushed ice to make a frosty

Make your own soup and blend to a liquid, strain if still chunky (i.e. chicken

vegetable, lentil soup)

Invest in a few WLS cookbooks: o Recipes for Life After Weight-loss Surgery by Magaret Furtado, MS, RD

o Eating Well After Weight Loss Surgery by Patt Levine and Michele Bontempo-Saray

Search for recipes and flavor ideas online (see below)

Recipes from www.UNJURY.com makers of Unjury protein powder

Hi-Pro Jell-O Use Sugar Free Jell-O

Follow directions for preparation of a 4 oz/4 servings box of Sugar Free

Jell-O, any flavor

Follow package directions for dissolving Jell-O in boiling water.

Measure 1/2 cup of cold water.

Add two scoops of Unflavored UNJURY to cold water, one scoop at a time, stirring slowing to dissolve.

Add ice to water with UNJURY to equal one cup.

Stir UNJURY with ice into dissolved Jell-O until ice has melted

Place in freezer for at least 30 minutes to chill quickly.

Important Comments:

-- The protein will settle somewhat toward the bottom, but the taste is unchanged.

-- If you like this recipe with UNJURY Unflavored, you might also like it substituting the Vanilla UNJURY for

UU.

-- 1 cup Jell-O as prepared has 20 grams of protein

Hi-Pro Yogurt For Plain Yogurt use Vanilla UNJURY.

For Fruit-Flavored Yogurt you can use Unflavored UNJURY or Vanilla UNJURY.

Put about half of a 6 ounce container, or all of a 4 ounce container, in a small bowl.

The first time you try this recipe, mix in 1/4 or 1/3 scoop UNJURY. Stir until well blended.

If this works well, the second time you might experiment with 1/2 scoop.

Proteina Colada Mix one scoop Vanilla UNJURY with 8 oz Skim Milk

Add 2 drops McCormick Imitation Pineapple Extract, and

And 2 drops McCormick Imitation Coconut Extract

Adjust to taste.

Protein: 20 grams per serving

Adjustments for Diabetes

You will be discharged from the hospital on Stage 3, but you must carefully monitor

and record your blood sugar levels. This will provide pertinent information to your

diabetic doctor or PCP so that your medications can be adjusted accordingly. You may

need to incorporate a steady amount of healthy carbohydrates to maintain normal blood

sugar levels. The goal is to prevent your blood sugar from getting too low or too high.

Aim for safe levels as directed by your doctor (generally >80 mg/dL & <120 mg/dL). If

you are on insulin, it is important that you consume similar foods synchronized with the

time actions of insulin.

SIGNS OF LOW BLOOD SUGAR SIGNS OF HIGH BLOOD SUGAR Excessive sweating, faintness

Low blood sugar <80

Headache/irritability

Pounding of heart

Excessive hunger

Slurred speech

Increased thirst and urination

Elevated blood sugar >120

Weakness

Fatigue

Loss of appetite

High Protein Hot Cereal Recipe*

Yield = two servings

~15 grams of protein per serving

Ingredients

1 cup hot cereal (instant, unsweetened cream of wheat, oatmeal)

1/3 cup unflavored protein powder (“UNJURY”, “GNC unflavored whey”)

1/3 cup of milk

Flavorings: spice (i.e. cinnamon or nutmeg), sugar substitute (ex. Splenda), sugar free

syrup to taste

Directions

Prepare hot cereal according to package directions. Mix protein powder into 1 cup of

cooked cereal, add milk to THIN DOWN to yogurt consistency. Add spice, sugar

substitute, and/or sugar free syrup to taste.

* This recipe is not just for people with diabetes. Anyone can use this recipe.

Vitamins & Minerals

Vitamin and mineral supplementation will be a life-long commitment to maintain

your health after surgery

Depending upon which surgery you choose, your past medical history, and blood

work you may need a specific amount and kind of supplement

Supplementation may include:

o Calcium with Vitamin D to prevent bone disease

o Vitamin B12 for the nervous system

o Iron to help produce blood cells

Your dietitian will review your needs and make personalized recommendations

Once you are home from the hospital start with one chewable multivitamin per

day (ex. Flintstones Complete, Centrum Chewable, or a comparable brand)

o NO gummy multivitamins- they typically do not contain iron

Remember that vitamins and minerals are not replacements for meals or healthy-

eating, they “supplement” your food intake before and after surgery.