When eating totally sucks…
I think it’s time to go back to the beginning – as the guy says in “The Princess Bride” – the beginning is a very good place to start. It holds true here, as well.
First, there are some tools that you may need to have on hand:
- An egg timer. I like the hourglass type. I feel strongly about this one – particularly for people who are having a hard time with nausea and/or vomiting past the first couple of weeks of surgery. We have this very same one – got it at Kitchen Kaboodle here in Portland for less than $2. They still sell them – at the same price! What a deal!
- Why an egg timer? Because it will help you to learn to go slow. Going slow is VITALLY important.
- Here’s how you use it – just in case there is any need for clarification – you get your food at the table, you get your egg timer, you sit down. You relax (this step is important – if you’re stressed out, it’s not going to go well!), you take a bite. You chew it up slowly. You swallow. You put the fork or spoon down. You flip the egg timer over. And then you wait until the sand is all the way down to the bottom side. It’s about 2 to 3 minutes. It’s a long time. But it’s important that you wait. Repeat these steps as necessary.
- SOMETIMES 2 to 3 minutes is not ENOUGH time between bites. Sometimes folks need 5 or 10 minutes. It’s okay to take your time.
- And sometimes it’s best to have something to do to keep you focused elsewhere. John reads the paper in the morning while he’s eating his breakfast. I do dishes between bites of my breakfast. It’s okay to get up and do stuff between bites if you need the distraction.
- One of those obnoxious kitchen timers that you can set for 1 hour. You probably have one – the kind that you can carry around the house, car, wherever you go – is best. A lot of people have reported back to me that the Pampered Chef kitchen timers are awesome. I’ve never used one, so I can’t tell you for sure. I’m not much in the know about Pampered Chef, but have a friend who sells it – if you need someone to talk to – her name is Lee Anne, she’s a DS post-op, and you can see her web page here: http://www.pamperedchef.biz/leeannekrause
- Why an obnoxious kitchen timer? Because if you’re having a hard time with nausea and vomiting and are not getting in enough calories, you really and truly DO need a reminder to eat more often.
- Set a timer at the end of your snack or meal – set it for 1 hour.
- Yes, you really do need to eat – at least 1 or 2 bites of something – at least once an hour.
- A teacup and saucer. Think demitasse size, not full huge-o Venti Starbucks drink a gallon of tea or coffee sized.
- The teacup is your new bowl. The saucer is your new dinner plate. Think small. Small plates. Small bites.
- I don’t know why – but having smaller sized dinnerware just takes a lot of pressure off of me at meals. I feel less pressure to keep up with the others at the table. I feel less stress over wondering if I’ve served myself an appropriate sized serving. Try it, you might like it.
- A teaspoon (some folks prefer a demitasse sized spoon, too).
- Small bites really are imperative. A teaspoon is the biggest size bite you should be taking. Not heaping teaspoon. Small is good.
- When you’re taking bites cut off of a piece of something large – say a piece of steak. Look at your fingernail. The denser the food, the smaller the bite.
- A water bottle or cup that you LIKE, maybe even two or three – one to stay with you at home, and another to go with you in the car and out and about, and a third for work – wherever else it is you frequent.
- You really and truly do have to take a sip EVERY 5 MINUTES during waking hours. Get used to it. It’s your new reality.
- Having a cup you like – that has an easily recognizable quantity measurement – is very handy. I love mine because they’re 20 ounces each time I fill them up. It’s not so much that I feel overwhelmed by the quantity contained therein. And it’s not so small that I’m overwhelmed by the number of times I have to fill it up in a day to get my required number of minimum ounces.
- And this one is totally optional, but I feel is worth every penny invested – it’s SO helpful and educational: an electronic kitchen scale.
- Seems a little weird, maybe, but it really is very handy to have one of these. Particularly if you are using www.fitday.comto track your intake. And if you’re not using Fitday or some other equivalent to track your intake, I need to ask you – WHY AREN’T YOU?! If you’re struggling with nausea/vomiting, it is VERY important to know what you are getting in and keeping down. (Quantity wise, calorie wise, nutrient wise!)
- It is VERY difficult to eyeball how much one is serving oneself. Getting used to what a particular quantity weighs is a very helpful tool. Using an easy to use electronic scale like this is very educational.
Okay, so now you’ve got the hardware. Now you need to come up with a game plan about WHAT to attempt to eat. But before you do that, let’s make sure we’re on the same page….
Some Ground rules:
- When starting back at the beginning, gushy is best.
- When starting back at the beginning, not super chunky tends to work well.
- When starting back at the beginning, getting calories wherever you can find them is important.
- When starting back at the beginning, diligence is a MUST. Sometimes that means having someone you can trust as a back-up person to make sure you’re following through. (We’re not asking for the food police here, just someone who can lovingly spot check to make sure you really and truly did drink more than a thimbleful of water today.)
And some more important information – just basic stuff that all DS post-ops need to know:
- As an early post-op, it’s virtually impossible to get in all of your water requirements from drinking that takes place at meal time. (Okay, as a later out post-op that’s basically true, too!) Drinking (a *minimum* of 64 oz of WATER each day) is something you do ALL day long, every day, about every 5 minutes during waking hours. (Detect a recurring theme yet?)
- BARFING IS NOT NORMAL. BARFING IS NOT GOOD. BARFING SHOULD HAPPEN ONLY WHEN YOU HAVE THE STOMACH FLU, and hopefully not even then. Don’t accept it as just something that DS’ers have to live with cause it’s happening to you. It’s not – you’re not supposed to be experiencing it, it’s not normal, and you shouldn’t have to live with it.
- For the first 6 months post-op NEVER (let me say that a little louder) – *NEVER* go more than 2 hours without putting a little something in your tummy. You’ll eventually figure out what’s going on with your body and get into the swing of things, but going too long without food is cardinal sin number one as a DS post-op.
- NEVER leave home without a bottle of water in hand. You MUST be drinking – even when you’re not at home! Even when you’re in the car! Even when you’re at work! Drinking does not happen in 20 minutes – drinking happens all day long.
- Small bites are VITALLY important. A bite is not the size of one-fourth of a sandwich. A bite IS about the size of a medium sized grape.
- Taking your time is not optional. You go fast, you’ll eat too much, it’ll hurt, and you’ll potentially barf – or at least wish you could.
And first and foremost important rule of DS Post-Op Life:
***APPETITE HAS *NOTHING* (as in absolutely NOTHING) TO DO WITH WHETHER OR NOT YOU SHOULD EAT.***
Just because you don’t feel hungry, or like eating, or nauseous does not excuse you from the responsibility *TO* eat.
As Dr. Baltasar has told me several times, “Anorexia and the DS *DO NOT* go together!”
There are some basic milestones that folks should be reaching.
By 10 days post-op – you should be getting in 64 oz of water nearly every day.
By 1 month post-op – you should be getting in 64 oz of water EVERY day.
By 1 month post-op – you should be getting in at minimum 800 calories a day.
By 3 months post-op – you should be getting in a bare minimum of 70 grams of protein daily.
It’s gonna take you a L-O-N-G time to be able to get in a normal typical number of calories a day. Some folks do it effortlessly. It’s not like a huge milestone that you try to shoot for. Way more important than the number of calories you’re getting in each day, is making sure you’re meeting basic daily requirements. Eating a balanced healthy diet. And choosing to eat because food is fuel, not because it makes you feel good, warm and fuzzy, or cause you feel like it. (Although, believe it or not, that will come again at some future point in time!)
By the time you’re about 3 to 4 months post-op, you need to have some daily goals:
Minimum of 70 to 90 grams of protein daily
As much dietary fiber you can get in – if you can do 15 grams a day – woo hoo! Gold star!
*Minimum* of 64 oz of non-sweetened (artificially or otherwise) fluids daily. (That’s the jumping off point – you really need more like twice that a day!)
And that’s just on the food side of the coin. Of course, we’re DS post-ops, and we can’t neglect the fact that vitamins are no longer optional – they are MANDATORY.
So, at 4 weeks post-op you start working in:
2 multivitamins daily
Vitamins A, D, E, and K daily
2000 mg calcium citrate daily
Super B Complex
220 mg zinc sulfate
That’s a LOT of pills. You can try the liquid form, the chewable form, whatever – just make sure you don’t make the mistake of assuming that they are optional. As Trinka, a Baltasar post-op says, “They used to be optional, now I have to recognize that they are LIFE SUPPORT.” Not optional – at all!
So to sum up – at the risk of repeating myself – VITAMINS ARE NOT OPTIONAL. YOU MUST TAKE THEM.
If you are having a hard time getting them in with your current system, try a different system or product – try chewable, try liquid, try a different brand, try changing the time of day you take them, try taking them with food, or try taking them without food, try taking them with warm liquid, try taking them with cold liquid, try taking them with room temperature liquid.
There are *NO* excuses for not taking vitamins. Yes, even if you’re feeling barfy. (I’m sorry, this sounds harsh, huh? But it’s vitally important to you health.)
I don’t think it’s realistic to assume that you can handle getting in all of these vitamins 100% right the first day. I think it makes way more sense to work yourself up to where you need to be. Start day one of vitamins by getting in one of your multivitamins and one of your Vitamin A, D, E, or K. Add another pill each day until you get them all in. Within a month you should be getting them all in – *EVERY* day.
If you’re feeling like you have to choose between food and vitamins (I’ve been there, I remember rationalizing through that!) let me assure you, vitamins win. Food wins, too. So you have to decide how you’re going to balance the two.
Okay. So let’s say you’re 3 months post-op and you’re getting in 400 calories on a good day, and you feel barfy, weak, like you just can’t make it through the day.
It’s time (well, way past) to deal with the nausea.
Stuff that helps nausea:
Peppermint (tea, mints, gum…)
Ginger (tea, sucking on ginger root, candied ginger, ginger ale if you can find the hand-crafted kind that actually still has ginger in it)
Benadryl (aka antihistamines)
Sometimes Reglan is prescribed
(There really are quite a few meds available)
What causes nausea?
Sometimes it’s anesthesia
Sometimes it’s dehydration
Sometimes it’s excess acid production
Sometimes it’s heightened sense of smell and taste
Sometimes it’s artificial sweeteners or chemical-heavy drinks or food products
Sometimes it’s irritation to the vagus nerve
Sometimes it’s impossible to figure out
So how do you know where to start? Well, you start with the basics:
If you’re experiencing nausea and vomiting past 4 weeks post-op, are you still taking Pepcid or Prilosec? If you’ve taken 1 each day (typically at about 8pm), then it’s okay to bump it up to 2 each day (one in the morning, one in the evening). If this isn’t helping, it’s totally fine to ask your PCP for bigger guns.
Of course, dehydration is really a huge cause of nausea and vomiting. Let me say something here at the risk of repeating myself: you need to take a sip of water every 5 minutes during waking hours. You need to get in at minimum 64 ounces of water each day. If water doesn’t work for you, try Gatorade or a sport drink of some sort. If that doesn’t work for you, try mixing 7up and fruit juice. If that doesn’t work for you, try ginger ale. If that doesn’t work try iced green tea. If that doesn’t work try watered down fruit juice. If that doesn’t work try hot tea. If that doesn’t work try super iced cold water. The whole idea here is: YOU MUST DRINK. It’s not an option not to! There is no excuse for not doing it. The big keys here are SMALL sips, five minutes apart. If even drinking makes you gaggy, then go to a smaller sip – until it just feels like you’re barely wetting your mouth, and then work your way up once you get than down without gagging.
Here’s an important fact: your gag reflex becomes heightened if you are not getting enough in!
Here’s another important fact: you go long enough without enough hydration – you’re gonna end up in the hospital on I.V.’s getting tanked up.
It is completely reasonable to ask your PCP for an RX for nausea – there are LOTS of them out there. If one doesn’t work, try another one. There are also little helpful things like Queasy Pops. Don’t be afraid to think a little outside the box. If RX’s and the like aren’t working, try acupuncture. If acupuncture doesn’t work, try therapeutic massage.
Oh – and here’s a secret weapon against nausea – fresh air. Stale or perfumed or strong odored air only makes nausea worse. Best way to get fresh air? To get out and walk a bit. Even if it’s just to the end of the drive way and back. Even if it’s just to the end of your block and back. Even if it’s for just a few minutes. Fresh air can work wonders for feelings of nausea!
So…… my dear friends – I don’t want to come across as being angry. I’m not. I’m concerned. And I’m trying to get some basic facts across. Paramount is the fact that this is not something you can just let slide. You must be diligent. You must be proactive for yourself. It *IS* hard work.
Okay, so let’s move on to food.
I know – makes you want to hurl. Sorry. But you’ve got to get there. You must eat. If you’re still experiencing nausea and vomiting past 4 weeks post-op then you need to go back to the beginning and give your tummy the chance to settle down, heal up some, let the inflammation go down, and relax some. That means going back to fluids. That may mean staying there for a few weeks.
Now here’s the difference between right after surgery and later on down the road – when you’re a newbie (less than 3 months post-op) you don’t need to stress about how much protein you’re getting in; if you’re a little bit further out, then you *do* need to be concerned about how much protein you’re getting in. If that means you need to try out some protein drinks, shakes, powders, or the like – then do it. Vitalady (www.vitalady.com) is an excellent resource. She sells samples – and believe me, you don’t want to be buying lifetime supplies of protein powders without getting to try them out first. GNC has a good return policy, too, so if you get something local you can return it even if it’s been opened (last I heard anyway).
Now – keep in mind that there are some classic irritants that some folks struggle with. If you need to do a little experiment on how you’re doing with milk products (i.e., have you developed lactose intolerance) or gluten, then do. Obviously, if you’ve historically been intolerant or allergic to something – avoid those items.
So, let’s talk fluids. What qualifies?
- Broth or consommé
- Soup (avoid chunky stuff) – cream-of’s are okay if you’re not lactose intolerant
- Yogurt – look for yogurt with live cultures in it! (that’s acidophilus, it’s good stuff!)
- Ice cream or milkshakes – if you’re not having a problem with milk products
- Pretty much anything that will be liquid by the time it hits your gut.
So – you have to start out SMALL. Remember the demitasse spoon? It’s kind of like a baby spoon. It would be completely reasonable to start with that size. And I don’t mean forever more – I mean until you can get a handle on pacing yourself appropriately. With fluids – tea, soup, yogurt, etc – one very small spoon full at a time. Put the spoon down. Swallow slowly. Turn the egg timer over, and wait your 2 to 3 minutes. Longer if need be.
EVEN IF YOU ONLY GET IN ONE BITE AND KEEP IT DOWN – that, my friend, is progress.
If you can only get one bite in and keep it down. Accept it for the victory it is, set your obnoxious kitchen timer for 30 minutes. Then when it goes off 30 minutes later, repeat the process. You can’t rest on your laurels at all here – they simply won’t do you long enough. You’ve got to keep plugging away at it.
SOMETIMES you’ll have a perfectly fine day, getting your 1 or 2 bites in every 30 minutes, and then you go to bed. Then you wake up in the morning and you feel like you’re gonna die. Nausea and vomiting all over again. Wanna know why? It’s been too long since you last got something into your gut. SOMETIMES you have to set a timer and get up during the night and get calories in. It won’t last forever. But if it’s what you need to do to get better – then DO IT!
Here’s the rub… This whole DS thing really requires you to learn to listen to your body. Our culture doesn’t really allow us time to do that, and in fact, kind of pooh poohs the whole concept. Well, with the DS, we have this tiny little tummy that one day seems like it could hold all of the barbeque in Texas, and then the next can only handle a ½ cup of broth. If you try to shove too much in there – it’s gonna fight back. You have to go slow. You have to take small bites. WHY? Because you’ve got to give your brain and your stomach time to synchronize – figure out what the other is doing. Okay?
Okay, so let’s say you have victory at getting in your liquids 1 or 2 bites at least every 30 minutes for oh, say 3 or 4 days. And, let’s suppose that your nausea and vomiting is more or less been somewhat tamed because you’re getting adequate hydration (yes, that’s one sip every 5 minutes during waking hours) and more calories in. That’s awesome! Time to congratulate yourself. But, not time to get comfortable yet. There’s more work ahead of you. It’s time to up the ante a little bit.
So, this is the juncture where you move from liquids to soft foods. You need to stay here for a couple of weeks if your tummy is still on the sensitive side, just to make sure you’re getting it down and giving your tummy a chance to adjust.
Remember the BRAT diet? Banana, rice, applesauce, toast – it’s what you give a kid who is getting over stomach flu. Well, it works pretty good for DS post-ops, too. Think bland. Crackers are your friend! Think stuff that will soak up all that extra stomach acid!
Here’s another important little tidbit: If you’re a newer DS post-op, you probably have a heightened sense of smell and taste. If that’s the case, then it may be best to stay away from the kitchen while foods are being prepped. If this means that you need to call in favors from friends and family and request that they provide meals for a while, then do it!
So, let’s recap what soft foods are. Dr. B told me that soft foods are anything you can cut EASILY with a fork. Don’t let the excitement of moving on to heartier fare overcome your need to be mindful of the very foundation of DS post-op eating! SMALL BITES, 2 to 3 MINUTES APART. If you need more than 2 to 3 minutes, then take more than 2 to 3 minutes.
Okay, here are some ideas:
- Eggs – scrambled, poached, fried, hard boiled – however you like them.
- Fresh fruit – melons, peaches, pears, canned mandarin orange slices – remember soft, easily cut with a fork.
- Soft cheeses – cream cheese, baby bels, and the like – see http://www.thelaughingcow.com/lc/lc.nsf/ProductsL1?OpenPage
- Steamed veggies – really steamed – even a little oversteamed.
- Potatoes – boiled, mashed, baked.
- Toast – with butter, or spreadable cheese. Heartier breads (like Oroweat’s Winter Wheat – http://www.oroweat.com/varieties.html) tend to settle better.
- Salads – tuna, chicken, egg, ham, macaroni, potato
- Mild fish filets – like halibut or tilapia – try it without breading, and with a little lemon juice squirted on it.
- Shrimp – broiled, stir fried, bbq’d, etc.
Again – some really basic fundamentals:
- You do not have to clean your plate.
- Claim your victories and do not stress about the misses. I.e., if you do great one day, but struggle the next, that’s okay, the coming day is another chance to do better!
- It’s okay to not like something that tasted really good yesterday. It’s a well known fact that we get finicky when we get post-op!
- Do not buy lifetime supplies of anything.
- Just because you never liked it before in your lifetime doesn’t mean you’re not allowed to try it now.
- Foods do not need to be relegated to particular meal times. I.e., if you want breakfast food for lunch, eat breakfast food for lunch. If you want dinner food for breakfast, have dinner food for breakfast.
And of course… SMALL BITES. 2 to 3 minutes apart – AT LEAST.
Here’s the thing that’s so hard to get our brains around when we’re new post-ops…
Eating a typical pre-op sized meal is a thing of the past.
When I say eat something AT MINIMUM every 2 hours, I’m not saying, “Sit down to a huge meal every 2 hours.”
- Some times your every 2 hour “meal” or “snack” will be 1/4th of a sandwich that takes you 30 minutes to get down.
- Sometimes your every 2 hour “meal” or “snack” will be ½ a cup of tuna salad with a handful of potato chips.
- Sometimes your every 2 hour “meal” or snack” will be 1/4th of a cup of mashed potatoes with gravy.
- Sometimes your every 2 hour “meal” or “snack” will be ½ a cup of watermelon.
- Sometimes, for some unknown reason, your every 2 hour “meal” or “snack” will be 2 bites of deli meat or soup or crackers and cheese – and you just can’t bring yourself to eat anything else.
THAT’S OKAY. It’s the way it goes. That’s why we go slow, that’s why we take small bites. So we don’t over do it and stress our tummies out, and then make ourselves barf.
So – at risk of sounding repetitive, the real key to this whole thing is:
- Hydration!!! That means 1 sip every 5 minutes during waking hours.
- Small bites
- 2 to 3 minutes apart – at least!
- Eat something – AT MINIMUM – every 2 hours.
Why? You ask? Why should you? Because, honestly, there is a little bit of a power trip associated with for the first time in your life!
Because, my friend, you can end up in kidney failure. You could end up with your labs getting so crappy that your heart and your lungs and your brain stop functioning the way they’re supposed to. You could end up dead.
So, just in case you don’t know this – it’s not worth going there. You are worth the effort it takes to fight your way back to getting adequate hydration and nutrition in. Getting back to a more normal way of life *IS* the goal. It is the norm. It’s the place that we all assume you’ll be – soon – if you can make the commitment to do the work that it takes to get there.
And – I know this might seem a little stupid, i.e., kind of obvious, but here’s another basic fact. Sometimes all of this is about behaviors or fears or phobias or hurts that have been buried for a long time. Sometimes it takes all of the hard work of relearning how to eat and drink AND therapy. Sometimes issues that we haven’t dealt with in ages – literal decades – need dealt with on top of it all.
So, if you’re the poor soul going through ongoing nausea and vomiting, I’m so sorry. Why you’re going through it I can’t say for sure. Sometimes it’s just adjusting to a new set of behaviors. Sometimes we have overactive scar tissue formation that makes function an issue. Sometimes it’s hormones affecting our attitudes and willingness to “play the game” required to adjust to the new ground rules. Sometimes it’s a hidden emotional issue rearing it’s ugly head.
I wish I could wave a magic wand and make it all better. But I can’t. I can only offer you what I’ve learned over the years. So this is pretty much it.