Why is there a Diet Progression? ©

Many patients have heard there is a diet progression after weight loss surgery (and possibly before).  Many patients report being nervous about the liquid diet.  But why is there a diet progression?  Why do you have to follow different diets?  I promise it is not to make your life miserable.  Let’s take a look at a brief description of the common diet progressions and why they are recommended.

This is the one time I readily use the word “diet” as a diet is a short-term change to your eating pattern.  The “diet” that is being recommended long-term, I personally call a healthy eating plan instead of using the word diet.

Examples of Diet Progressions.  The diet progression allows patients to move through different phases, eventually eating solid foods again.  The amount of time in each stage may vary according to each surgeon or dietitian’s recommendation as well as each individual patient.  Be sure to follow the exact recommendations of your program.

Pre-Operative.  Some surgeons have their patients follow a special diet pre-operatively.  This diet may include either a full-liquid meal plan or it may be a combination of food and meal replacements.  Some surgeons may recommend patients follow some sort of a low-carbohydrate eating plan.  These types of diets are done to make your surgery safer.  In many obese patients, the liver is enlarged.  The liver sits in front of the stomach and in order to operate in a safe manner the liver is held in what is called a retractor in laparoscopic procedures.  If the liver is too large it may not stay within the retractor (what holds the liver out of the way) and increases the risk of surgical complications.  By following a low carbohydrate, low fat, low calorie diet (liquid or food) it allows the liver to shrink making the surgery safer.

Post-Operative Diets.  Most patients start on a liquid diet (often clear or full; some use both phases of clear liquids and then progress to full liquids) immediately following surgery.  The length of time on the liquid diet post-op will vary from program to program.

  • A clear liquid diet allows you to have an adequate intake of fluid, electrolytes, and permits your stomach and/or intestines (depending upon which surgery you had) time to heal, reducing your risk of complications post-operatively.  Based on one survey of dietitians working in bariatrics, this stage averaged 1-2 days.
  • A full liquid diet is slightly thicker (more like a milk consistency as opposed to a water consistency) and allows more calories and nutrients to promote healing and reduce the risk of complications.  Based on one survey of dietitians working in bariatrics, this stage averaged 10-14 days.
  • The next stage is typically pureed.  Most dietitians describe the pureed stage as an applesauce consistency.  Typically there are no solid pieces during this stage.  Most patients are still sensitive to spicy or dairy foods at this phase.  Following a pureed diet allows you to gradually increase the tolerance of foods in your stomach and intestines.  Based on a survey of bariatric dietitians, this stage lasted greater than 10 days.
  • Following pureed, most patients progress to soft foods.  Typically if you can mash the food with your fork, it is acceptable to eat.   This stage allows patients to eat foods that will pass easily through the stomach to the intestines.  Based on a survey of bariatric dietitians, this stage lasted greater than 14 days.
  • The final stage is moving onto solid foods.  Spicy foods, among other foods, may still be difficult to tolerate.  It is important to start slowly and add new foods one at a time to determine what exactly you can tolerate.

Safety.  One of the biggest reasons there are different diets includes safety reasons.  The diet progression allows the staple line of your stomach (in gastric bypass and/or sleeve gastrectomy) to heal without being stretched by the foods that you eat.  A diet progression also allows you to adjust to eating smaller amounts of foods to learn what is digested comfortably and safely.  Following the recommended diet progression helps to avoid side effects and complications.  Some of the risks associated with not properly following your recommended diet progression may include.

Dumping Syndrome – if you had gastric bypass you might experience dumping syndrome if you eat foods high in sugar (or even simple carbohydrates – e.g., mashed potatoes, white bread, white pasta, etc.) or fat.

Dehydration – dehydration is one of the most common reasons patients are readmitted to the hospital following weight loss surgery.  Some programs recommend that patients do not drink with their meals making it difficult to achieve the recommended fluid intake.  Also, it is difficult to drink large amounts of fluid immediately following surgery, thereby increasing your risk of dehydration.  Starting on a liquid diet only increases the chances of achieving your fluid goals.

Reflux – following the proper diet stages will also help to minimize acid reflux.

Nausea and vomiting – eating too much, eating too fast, not chewing your food properly, and eating foods before they are recommended may cause nausea and/or vomiting following your bariatric surgery.

Constipation – not eating regularly, not getting in enough fluid, not eating fibrous foods, and not exercising (or being physically active) may increase your risk of constipation post-operatively.

Satiety – satiety is the feeling of fullness.  Following the recommended diet stages will help you to re-learn your feeling of fullness and help you to avoid overeating.

As previously discussed (previous articles), part of going through the different diet stages will help you to learn your new signs of fullness and what foods you tolerate.

As you progress in your diet stages, it is important to try only one food at a time.  Certain foods may not be tolerated and this can vary between individuals.  Chew each new food to an applesauce consistency before swallowing.  If food causes a discomfort, you may want to avoid it and then try it again in a couple weeks.  Most often, patients can tolerate most foods with time.

Think of this diet progression like feeding a baby.  Just as a baby progresses from liquid (breast milk or formula) to puréed (like applesauce) to soft (like mashed sweet potatoes without the skin) to regular, you will also.  Once babies start solid food, they add one food at a time decreasing the risk of food allergies.  Granted we are not concerned about allergies with weight loss surgery patients at this time, but you can see the similarities.

Keeping a food journal may help you to see which foods you tolerate well and which ones may need to be saved for later.  Keep in mind you can better understand emotional triggers as well from journaling.  Don’t just write down the foods; also record the amounts, how you felt that day (happy, stressed, etc.), and how well it was tolerated.

Energy and Healing.  One of the other reasons there is a diet progression is not only for safety, but also for healing.  By following the recommended diet plan, you will consume adequate energy (calories) and nutrients, which are necessary to support healing.  The consumption of adequate protein and calories also assists in maintaining lean muscle mass as often times muscle mass is lost during extreme weight loss.  This is important because muscle mass helps to keep your metabolism burning at a higher rate (burning more calories per day) while even at rest.

Keep in mind every patient and every surgery is different.  Be sure to follow the instructions of your physician and/or dietitian to reduce your risk of surgical complications.  Even the stages may vary from surgery to surgery or be different lengths.  Remember as much as these stages are not fun, they serve a purpose and they are not forever!  You will be eating regular food in a short time and all of this will be well worth it!

By Heather K. Mackie, MS, RD, LD

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