Preface

Dr. Luna and his staff would like to welcome you to his practice and
are thankful you have chosen us to provide you with the skills to
begin your journey to a new life. The most successful patients are
educated and understand how to use this surgical tool to aid them to
obtain a weight that is healthy and allows them to enjoy life.

This manual is an education tool and assistant to you as you embark

on this new life of health and should be read carefully and often to
ensure you understand the concepts of life after weight loss surgery.
It is intended to assist in education and help document your journey.
This manual should be brought to each online appointment so any
questions you have can be addressed and your physician can utilize it
to go over issues you may be having at the time of your visit.

Remember, each person is different and unique and your weight loss
journey will be different from other patients. It is important to follow
the advice of your surgeon to ensure you have the best results from
your surgery.
The success of bariatric surgery involves the unconditional adherence to the
nutritional guidelines that your doctor or dietitian will recommend, these rules
gradually culminate with an objective to change your life. The caloric
requirements of the patient will depend on the stage at which they are and their
energy balance during the day, even so the patient must focus primarily on foods
high in protein.

The pre operative dietary program will be composed of healthy foods composed
mainly of low glycemic index complex carbohydrates, low on fats, and hi on
protein with an detox phase in which the patient commits to decrease intake of
un healthy foods, artificial sweeteners and other similarities. Protein is the most
important nutrient for the bariatric patient; any kind of impairment (negligent,
medical issue, self purpose) to achieve the adequate intake of protein will cause
malnutrition and will increase the risk of disease.

Committing to bariatric surgery requires that you prepare ahead of time by

eating a healthy diet and ensuring adequate levels of physical activity. Pre-
surgery diet changes are needed to help you lose a percentage of your excess
body weight, and to learn new eating patterns to help you lose weight after
surgery and keep it off. Following the nutritional recommendations may help you
demonstrate that you are able to make a commitment to the changes you will
need to continue to follow lifelong.

These Guidelines embody the idea that a healthy eating pattern is not a rigid
prescription, but rather, an adaptable framework in which individuals can enjoy
foods that meet their personal, cultural, and traditional preferences and fit within
their budget. Several examples of healthy eating patterns that translate and
integrate the recommendations in overall healthy ways to eat are going to be
provided. This program is provided with the objective of creating healthy eating
patterns before surgery reviving health and reducing generalized inflammation in
your body. This is not a conventional diet, is guidance for the bariatric patient to
start the journey of bariatric living and to learn to eat after surgery.

A large body of evidence now shows that healthy eating patterns and regular
physical activity can help people achieve and maintain good health and reduce
the risk of chronic disease throughout all stages of the lifespan.
The Bariatric Nut Pre-op Guidelines encourage healthy eating patterns,
recognizing that individuals will need to make shifts in their food and beverage
choices to achieve a healthy life style.

An underlying premise of the Pre op Dietary Guidelines is that nutritional needs

should be met primarily from nutrient dense foods. All forms of foods, including
fresh, canned, dried, and frozen, can be included in healthy eating patterns.

Foods in nutrient-dense forms contain essential vitamins and minerals and also
dietary fiber and other naturally occurring substances that may have positive
health effects. In some cases, fortified foods and dietary supplements may be
useful in providing one or more nutrients that otherwise may be consumed in
less than recommended amounts.

For most individuals, achieving a healthy eating pattern before and/or after
bariatric surgery will require changes in food and beverage choices. In our
induction phase of pre op we focus to emphasize on shifts to make
substitutions—that is, choosing nutrient-dense foods and beverages in place of
less healthy choices—rather than increasing intake overall. Most individuals
would benefit from shifting food choices both within and across food groups.
Some needed shifts are minor and can be accomplished by making simple
substitutions, while others will require greater effort to accomplish.

Although individuals ultimately decide what and how much to consume, their
personal relationships; the settings in which they live, work, and shop; and other
contextual factors strongly influence their choices, and should be taking account
before deciding bariatric surgery.

Bariatric surgery is a major event in a patient’s weight-loss journey, but the event
is best seen as a new beginning. Obesity is a lifelong disease and there is no
operation, diet or medication that can by itself offer a permanent cure. Surgery
with good aftercare and moderate lifestyle changes can give wonderful long-
term results for health and weight.
Physical activity
Physical activity is very important for long-term weight management. Different
patients may have different needs and abilities. As you progress in your fitness
program, your body becomes more efficient at the same activity, which means
that you tend to burn fewer calories. As you lose weight, the number of calories
burned per hour tends to decrease as well. And so, throughout time, it is
necessary to gradually increase the intensity or length of your fitness activities.

Healthy eating has the biggest impact on training; a good meal will help support
consistent training and make metabolic adaptations for training stimulus.

Despite recognition that physical activity promotion is an important component

of a comprehensive surgical weight loss program, there are currently no
evidence-based preoperative or postoperative physical activity guidelines.
However, several organizations have issued recommendations recently. The
American Society for Metabolic and Bariatric Surgery (ASMBS) recommends mild
exercise (including aerobic conditioning and light resistance training) 20 min a
day 3 to 4 days a week before surgery to improve cardiorespiratory fitness,
reduce risk of surgical complications, facilitate healing, and enhance
postoperative recovery. The American Heart Association recommends a similar
‘‘mild’’ preoperative exercise regimen of low to moderate intensity physical
activity at least 20 min a day 3 to 4 days a week. The 2007 Expert Panel on
Weight Loss Surgery recommends that patients be encouraged to increase
preoperative to postoperative physical activity, in particular, low to moderate
intensity exercise. In addition, evidence points to a dose response relationship
between physical activity and both weight loss and long term weight loss
maintenance such that higher levels of physical activity translate to greater
benefits

Nutrition density
Nutrient density is a measure of the amount of nutrients a food contains in
comparison to the number of calories. A food is more nutrient dense when the
level of nutrients is high in relationship to the number of calories the food
contains. Healthy eating styles are based on choosing foods that contain
vitamins, minerals, fiber and other healthful nutrients or ingredients and choosing
amount of calories you need to maintain a healthy weight. The most nutrient
dense foods include vegetables, fruits, whole grains, seafood, eggs, beans and
peas, unsalted nuts and seeds, fat-free dairy products, and lean meats and
poultry.

Leading a healthy lifestyle involves eating foods high in nutrients while avoiding
empty, or suboptimal, calories. In order to identify the most nutrient dense
foods, we must look for foods high in the most essential nutrients while being
lowest in calories.

Mental Health
Not surprisingly, when a person goes through major lifestyle and body changes
after surgery, major adjustments occur in how we think about ourselves and how
others think of us. Some patients gain much more confidence as they successfully
change their lifestyle and manage their weight. Others struggle with continuing
to see themselves as affected by obesity. Marriages and relationships can be
strained with the adjustments that occur. Strong relationships can become
stronger as those involved communicate and work through these changes. Weak
relationships can fracture and suffer as a result of these changes. Your workplace
dynamics can change; some of your teammates at work may support and cheer
you on, while others may be less supportive. For all of these reasons, access to
an experienced mental health professional can be an important part of
postoperative recovery. Above all, each patient should be prepared for “bumps
in the road” along the journey, whether it’s interpersonal conflict, marriage
stress, a surgical complication, or a plateau in weight-loss.

Eating habits are frequently affected by emotions, stress, boredom, mindless

eating, or even eating disorders. These are very common but not always obvious.
If you find yourself eating to relieve stress or eating when you are full or not
hungry, you should seek additional help from your surgeon, qualified
psychologists, or behavioral therapists. These issues can be successfully treated
to get patients back on track if identified.
BENEFITS OF PRE-
SURGICAL WEIGHT
LOSS
 Benefits of pre-surgical weight loss
Some of the surgical complexities of obesity surgery may be overcome with
weight reduction prior to surgery. However, it is essential that clinicians and
patients realize that the initial weight loss program is seen as the
commencement of a life long management plan incorporating surgery,
behavioral change, dietary modification and increase exercise and movement. In
addition, preoperative weight loss is not undertaken to delay surgery nor it is a
substitute for surgery.

The key benefits of pre surgical weight loss include:

• Reduced visceral fat levels and liver size:

Weight loss prior to bariatric surgery can effectively reduce visceral fat
levels and liver size, leading to greater access for the surgeon into your
abdominal cavity, which facilitates the procedure.

• Reductions in visceral adipose tissue and

hepatomegaly haven demonstrated the following:
1. Improved exposure and view of anatomical markers. When anatomical
markers are more visible, damage to nearby vessels and structures is less
likely.
2. Reduced pre-existing metabolic abnormalities. Weight loss has a
strongly beneficial effect on related metabolic diseases including,
hypertensions, hyperlipidemia, insulin resistance, hyperglycemia and
sleep apnea.

• The positive effects of weight loss before surgery is

usually related to the degree of weight loss achieved,
although a modest loss of 5%-10% can result in
significant health benefits.
1. Weight loss before surgery also reduces the risk of deep venous
thrombosis post surgery.

• Successful pre operative weight loss may also

increase patient’s confidence that they can deal with
postoperative program.
 PRE-OPERATIVE
NUTRITIONAL
BASIC PRINCIPALS
1- Follow a healthy eating pattern
An eating pattern represents the totality of all foods and beverages consumed.
All foods consumed as part of a healthy eating pattern fit together like a puzzle
to meet nutritional needs without exceeding limits, such as those for saturated
fats added sugars, sodium, and total calories.

Individuals have more than one way to achieve a healthy eating pattern, any
pattern can be tailored to the individual sociocultural and persona preferences.

2- Focus on variety, nutrient density

and amount
Get the most out of your calories by eating nutritionally dense food, foods in
nutrient dense forms contain essential vitamins and minerals and also dietary
fiber and other naturally occurring substances that may have positive health
effects.

These foods are relatively low in calories, but high in nutrition, so they can help
you maintain a healthy weight while giving you a good dose of vitamins,
minerals, protein, and fiber. At the same time, you'll want to cut down your
intake of foods with "empty calories", those that have high calorie counts with
little nutritional benefit. These foods often get their extra calories from fats and
refined sugars. That's why a piece of fruit in the morning will do you more good
than a sugary pastry would.

In some cases, fortified foods and dietary supplements may be useful in

providing one or more nutrients that otherwise may be consumed in less than
recommended amounts.

Fruits and vegetables

Fruits and vegetables are a natural choice for nutritionally dense foods, so you
can be generous when serving up these highly nourishing treats.
Fruits and vegetables should make up half of your plate at any given meal. You
can choose a diverse selection of colors to add variety in both flavor and
nutrition.

Whole grain foods

Grains should also account for a sizable portion of your plate, about 15 percent.
The U.S. Department of Agriculture (USDA) recommends that whole grains make
up at least half of those grains. Whole grains not only can give you more fiber,
but they usually contain more nutrients, too.

Lean sources of protein

Lean protein is important to a smart diet, about 25 percent of your plate. There
are many good sources of lean protein, including:

• Lean meats (chicken, turkey, beef, pork, etc.)

• Seafood (fish, shellfish, etc.)
• Soy products (tofu, veggie burgers, etc.)
• Eggs
• Beans and nuts

Dairy and other calcium-rich foods

Dairy products can be a good source of protein and calcium, especially if they're
nutritionally dense low-fat and fat-free versions. Dark leafy vegetables, like turnip
greens, kale, Chinese cabbage, and mustard greens, are naturally rich in calcium,
too. Other calcium-fortified food sources include cereals, breads, and some
juices, as well as soy, rice, and nut beverages.

Water
Drinking plenty of water is an important part of proper nutrition. Foods like raw
fruit and vegetables can also help keep you hydrated. It's important to realize
that your body can have trouble distinguishing hunger from thirst pangs, so
being well hydrated can often keep you from eating too much. Sometimes, when
you think your body is saying "I'm hungry," it could actually be trying to tell you
that it simply needs more water.
3- Limit calories from added sugars,
saturated fats and sodium

While some foods clearly get the "green light" nutritionally, others deserve a
yellow or even a red light. Approach fats, sugars, and other high-calorie/low-
nutrition foods with caution. Sodium should also be on your list of "yellow light"
foods, too, and in some cases, it deserves a red light.

Sugars and other simple carbohydrates

Added sugars include syrups and other caloric sweeteners. When sugars are
added to foods and beverages to sweeten them, they add calories without
contributing essential nutrients. Consumption of added sugars can make it
difficult for individuals to meet their nutrient needs while staying within calorie
limits. Naturally occurring sugars, such as those in fruit or milk, are not added
sugars. Specific examples of added sugars that can be listed as an ingredient
include brown sugar, corn sweetener, corn syrup, dextrose, fructose, glucose,
high-fructose corn syrup, honey, invert sugar, lactose, malt syrup, maltose,
molasses, raw sugar, sucrose, trehalose, and turbinado sugar.

Healthy eating patterns limit added sugars to less than 10 percent of calories per
day. This recommendation is a target to help the public achieve a healthy eating
pattern, which means meeting nutrient and food group needs through nutrient-
dense food and beverage choices and staying within calorie limits. When added
sugars in foods and beverages exceed 10 percent of calories, a healthy eating
pattern may be difficult to achieve.

Be aware of your daily sugar consumption. Less than 10 percent of your calories
should come from added sugars. To decrease your sugar intake:

• Read nutrition facts to limit your sugar and sugary snacks.

• Drink water or fruit infused water instead of sugary beverages, you can
also try mineralized water like perrier.
• Avoid simple carbohydrates (like white rice, white bread, enriched white
pasta, etc.)
Sodium
Be aware of your sodium intake. When choosing meals and snacks, keep in mind
the average person should reduce daily sodium intake to 2,300 milligrams (mg)
or less. For people sensitive to the effects of sodium or who are at risk of
experiencing certain medical conditions like high blood pressure, heart disease,
diabetes, or chronic kidney disease, daily sodium intake should be 1,500 mg or
less.

To minimize your salt intake:

• Limit processed foods, which can be high in sodium.

• Keep track of your daily sodium intake.
• Try flavoring foods with herbs, spices, and other seasonings—instead of
salt.
• Remember meals from restaurants can be high in sodium. Check the
nutritional and sodium content of a restaurant's food, either on its menu
or online.

Fats, trans-fatty acids, and cholesterol

Be aware of your saturated fat consumption. Less than 10 percent of your calories
should come from saturated fat. Strong and consistent evidence shows that
replacing saturated fats with unsaturated fats, especially polyunsaturated fats, is
associated with reduced blood levels of total cholesterol and of low-density
lipoprotein-cholesterol (LDL-cholesterol). The main sources of saturated fats
in the U.S. diet include mixed dishes containing cheese, meat, or both,
such as burgers, sandwiches, and tacos; pizza; rice, pasta, and grain dishes;
and meat, poultry, and seafood dishes. Although some saturated fats are
inherent in foods, others are added. Healthy eating patterns can
accommodate nutrient- dense foods with small amounts of saturated fats,
as long as calories from saturated fats do not exceed 10 percent per day.

To lower your saturated fat consumption:

• Avoid trans-fatty acids (sometimes called trans fats). Trans-fatty acids

come from the hydrogenation process that turns liquid oils into solids (like
shortening and margarine) and are often found in processed and fast
foods.
 • Check the nutrition label of margarines, shortenings, fried foods, crackers,
cookies and other baked goods to see if they contain trans-fatty acids.
• Replace saturated fat and trans-fatty acids with unsaturated fats when
possible.
• Look for non-hydrogenated monounsaturated and polyunsaturated fats
(from vegetable sources, such as olive, soybean, corn, and sunflower oils)
while limiting tropical oils, like palm and coconut oils.

Alcohol

Alcohol is high in calories with minimal

nutrition. So, if you're limiting your
calories and you want every calorie to
count, avoid the empty calories in
alcohol.

4- Shift to healthier
food and beverage
choices
Shifting for vegetables
Strategies to increase vegetable intake include choosing more vegetables
in place of foods high in calories, saturated fats or sodium such as some
meats, poultry, cheeses, and snack foods. One realistic option is to
increase the vegetable content of mixed dishes while decreasing the
amounts of other food components that are often over consumed, such as
refined grains or meats high in saturated fat and/or sodium. Other
strategies include always choosing a green salad or a vegetable as a side
dish and incorporating vegetables into most meals and snacks.
Shifting for fruits

Strategies to help achieve this shift include choosing more fruits as snacks,
in salads, as side dishes, and as desserts in place of foods with added
sugars, such as cakes, pies, cookies, doughnuts, ice cream, and candies.

Shifting from grains to whole grains

Shifting from refined to whole-grain versions of commonly consumed foods—

such as from white to rye bread or 100% whole- wheat breads, white to whole-
grain pasta, and white to brown rice—would increase whole-grain intakes and
lower refined grain intakes to help meet recommendations. Strategies to
increase whole grains in place of refined grains include using the ingredient list
on packaged foods to select foods that have whole grains listed as the first grain
ingredient. Another strategy is to cut back on refined grain desserts and sweet
snacks such as cakes, cookies, and pastries, which are high in added sugars, solid
fats, or both, and are a common source of excess calories. Choosing both whole
and refined grain foods in nutrient-dense forms, such as choosing rye bread
instead of white bread and whole pasta instead of refined pasta, can help in
meeting recommendations for a healthy eating pattern.

Shifting to consume more dairy products in nutrient-

dense forms
Strategies to increase dairy intake include drinking fat-free or low-fat milk
(or a fortified soy beverage) with meals, choosing yogurt as a snack, or
using yogurt as an ingredient in prepared dishes such as salad dressings or
spreads. Strategies for choosing dairy products in nutrient-dense forms
include choosing lower fat versions of milk, yogurt, and cheese in place of
whole milk products and regular cheese.

Shifting to consume variety in protein foods

Shifts are needed within the protein foods group to increase seafood
intake, but the foods to be replaced depend on the individual’s current
intake from the other protein subgroups. Strategies to increase the variety
of protein foods include incorporating seafood as the protein foods choice
in meals twice per week in place of meat, poultry, or eggs, and using
legumes or nuts and seeds in mixed dishes instead of some meat or
poultry. For example, choosing a salmon steak, a tuna sandwich, bean
chili, or almonds on a main-dish salad could all increase protein variety.
Shifting to nutrient-dense options, including lean and lower sodium
options, will improve the nutritional quality of protein food choices and
support healthy eating patterns.

Importance of Calorie Balance

Within Healthy Eating Patterns

Managing calorie intake is fundamental to achieving and maintaining calorie
balance—the balance between the calories taken in from foods and the calories
expended from metabolic processes and physical activity. The best way to
determine whether an eating pattern is at an appropriate number of calories is to
monitor body weight and adjust calorie intake and expenditure in physical
activity based on changes in weight over time.

All foods and many beverages contain calories, and the total number of calories
varies depending on the macronutrients in a food. On average, carbohydrates
and protein contain 4 calories per gram, fats contain 9 calories per gram, and
alcohol has 7 calories per gram. The total number of calories a person needs
each day varies depending on a number of factors, including the person’s age,
sex, height, weight, and level of physical activity. In addition, a need to lose,
maintain, or gain weight and other factors affect how many calories should be
consumed
Preparing for Bariatric Surgery
Before undergoing any type of bariatric surgery, it is important that patients
follow their doctors' instructions closely and educate themselves on the risks and
potential benefits of the procedure. To mentally prepare yourself for obesity
surgery, do the following:

• Understand the surgical process and what to expect afterwards

• Talk to people who have had surgery for obesity
• Start a journal about your experience
• Get your family to write you a letter of support

All patients must undergo preoperative counseling before undergoing obesity

surgery. This counseling will help you better understand that bariatric surgery is
only one part of a multidisciplinary approach to weight loss. In no way should this
surgery be viewed as a "quick fix." Rather, bariatric surgery patients will be
required to make lifelong changes to their diet and exercise habits to ensure a
lasting result after bariatric surgery.

Behavioral Therapy

A thorough psychological evaluation is a crucial part of every obesity surgery

patient's surgical preparations. Once you have spoken with a doctor about the
possibility of bariatric surgery, you will meet with a behaviorist trained in
counseling bariatric patients. The evaluation will include your social, personal,
and psychiatric history.

In addition to asking about your reasons for desiring gastric bypass surgery, the
behaviorist will also determine whether you are prepared to alter your diet and
exercise plan before and after bariatric surgery. The patients with the highest
rate of long-term success are those with a strong support system of family and
friends who are willing to assist patients physically and emotionally.

Certain physical and psychological conditions can reduce the chance of bariatric
surgery success. These conditions include:

• Substance or alcohol abuse

• Undiagnosed, untreated depression
• Schizophrenia or other personality disorders
Evaluation by a behaviorist can uncover these conditions, allowing your doctors
to treat them and giving you the best chance of success after bariatric surgery.

Physical Preparation for Obesity Surgery

 

A careful regimen of exercise and diet must be adhered to before bariatric

surgery to ensure that your body is ready for both surgery and for the drastic
changes that it will undergo in the months following treatment.

• Nutrition and Diet Therapy: Obesity surgery candidates should meet

with a registered dietician on a regular basis to determine diet needs both
before and after bariatric surgery. Caloric and nutrient needs should be
determined based on medical history, actual weight, food preferences,
and meal frequency. Individualized meal plans can then be customized to
each patient's eating habits, lifestyle, budget, and nutritional needs.

• Fitness and Exercise Therapy: Developing an individualized exercise

and physical activity plan is one of the most important steps of obesity
surgery preparation. This exercise plan should begin well before and
should be resumed as soon as possible after bariatric surgery.
Even a small increase in exercise can improve a patient's flexibility, range
of motion, and balance, as well as decrease the chance of injury and
soreness.
Pre-operative Instructions
All new fitness and diet plans should begin well before bariatric surgery and be
closely supervised by a doctor. The doctor will provide the patient with a set of
guidelines, which are likely to include the following provisions:

• Drink at least 64 ounces of water each day.

• Stop smoking for at least eight weeks before obesity surgery.

• Cease consumption of caffeinated beverages.

• Take a multivitamin each day, unless you are allergic or your

doctor advises you not to.

• Keep a detailed written food diary.

• Eat at least three meals per day and healthy snack in between

- don't worry about the calories for now, focus on the

behavior.

• Begin a walking program if possible.

• Write down your feelings every day to remind yourself of your

commitment to begin a new and healthier lifestyle.

• Attend support groups for patients considering gastric bypass

surgery or other obesity surgery.

• Follow your surgeon's instructions regarding any medications

you may be taking to control other health conditions.