Nutrition Intervention for

Bariatric Surgery Patients

Content
❖Bariatric surgery
❖Pre-operative Nutrition Care
❖Post-operative Nutrition Care
❖Vitamins and Minerals
❖Nutrition-related Complications
❖Follow up
Bariatric surgery
Bariatric surgery:
The term “bariatric” refers to the field of medicine that addresses the causes, prevention and
treatment of obesity.
Bariatric surgery refers to a number of different surgical interventions designed as a tool to
assist in obesity management.
Bariatric surgery is currently the most effective and sustainable method of weight loss for the
treatment of morbid obesity.
Which patients should be offered
bariatric surgery?
➢ Patients with a BMI ≥ 40 kg/m2.
without coexisting medical problems and for whom bariatric surgery would not be associated
with excessive risk should be eligible for 1of the procedures.
➢ Patients with a BMI ≥35 kg/m2.
with 1 or more severe obesity-related co-morbidities: (are conditions that tend to
worsen as weight increases and generally improve as weight decreases).
 Cont.
obesity-related co-morbidities, include:
➢T2D, HTN.
➢ hyperlipidemia
➢obstructive sleep apnea (OSA), obesity-hypoventilation syndrome(OHS),Pick- wickian syndrome(a combination of OSA
and OHS).
➢ non-alcoholic fatty liver disease(NAFLD) or non-alcoholic steatohepatitis(NASH).
➢ pseudotumor cerebri.
➢ gastroesophageal reflux disease(GERD).
➢Asthma.
➢venous stasis disease.
➢severe urinary incontinence.
➢ debilitating arthritis.
➢considerably impaired quality of life, may also be offered a bariatric procedure.
Cont.
➢Patients with BMI of 30–34.9 kg/m2
with diabetes or metabolic syndrome may also be offered a bariatric procedure although current
evidence is limited by the number of subjects studied and lack of long-term data demonstrating
net benefit.
Effects of bariatric surgery on obesity-
related comorbidities

AACE 2009
Categories of Bariatric surgeries:
The goal of weight loss procedures in general is to:
➢reduce the amount of consumed calories (restrictive) per day.
➢alter the absorption of nutrients (malabsorption) in the food one consumes.
➢cause metabolic changes.
Gastric Banding (GB):
(purely restrictive)
➢Limit food intake.
➢micronutrient deficiencies related to changes in dietary intake.
➢It is commonly accepted that because no alteration is made in the absorptive pathway,
malabsorption does not occur as a result of GB procedures.
➢However, nutrient deficits would be likely to occur because of the low nutrient intake and
avoidance of nutrient-rich foods in the early months postoperatively and later possibly as a
result of excessive band restriction.
➢Food with high nutritional value such as meat and fibrous fresh fruits and vegetables might be
poorly tolerated.
Sleeve Gastrectomy (SG):
(restrictive and metabolic)
approximately 80% of the stomach, is removed.
The size of the gastric sleeve is approximately 60 to 120 ml.
No alterations are made to the intestine, leaving absorption of food unchanged.
Reduction of stomach acid may impact digestion and absorption of iron, calcium and vitamin
B12.
Production of grehlin, a hormone involved in appetite, is reduced, resulting in decreased hunger.
Rapid nutrient pass to intestine, Increase GLP-1 and PYY 3–36 production. (producing key
metabolic effects).
Roux-En-Y Gastric Bypass (RYGB):
(Restrictive, micronutrients malabsorption)

➢A minimal amount of macronutrient malabsorption is thought to occur.

➢A small gastric pouch is created at the upper normal stomach.
➢Next, the small intestine is dissected at about 100 to 150 cm from the stomach.
➢The distal end is attached to the pouch and the proximal end is re-attached to
➢ the small intestine.
Cont.
➢ This small pouch (less than 30 ml immediately following surgery) results in a significant
reduction in the amount of food a patient can consume in one sitting.
➢Then ingested food bypasses the rest of the stomach, the entire duodenum (first portion of the
small intestine), and a short segment of jejunum (second portion of small intestine).
➢This bypass results in mild fat and protein malabsorption due to a slight delay in mixing of food
with bile and pancreatic enzymes.
➢Specific micronutrients appear to be malabsorbed postoperatively and present as deficiencies
without adequate vitamin and mineral supplementation.
(Iron, Calcium, Vitamin B12, and Folate), (Thiamine, with persistent postoperative vomiting).
Biliopancreatic Diversion (BPD) / Duodenal
Switch (DS)
(Primarily malabsorptive procedures with some restriction)
Produces weight loss primarily through malabsorption.
There is a minor restrictive effect because of some reduction in the size of
the patient’s stomach, but relative to the malabsorption effect this is
minimal.
Involves two components:
First, a smaller, tubular stomach pouch is created by removing a portion of
the stomach, very similar to the sleeve gastrectomy.
Next, a large portion (Roughly three-fourths) of the small intestine is
bypassed.
Cont.
Two mechanisms for malabsorption effect:
➢60% of the small intestine (the primary site for the absorption of nutrients) is bypassed.
▪decrease in gastrointestinal transit time
▪This means that food is in contact with the absorptive surface of the intestine for less time,
thereby leaving less opportunity for the nutrients to be extracted in by the body.
➢Because of this food rerouting, there is less mixing with bile and pancreatic enzymes.
▪The mixing of bile and pancreatic enzymes with food after this type of surgery occurs in only
10% of the most distal small intestine.
Cont.
Around 25% of protein and 72% of fat malabsorbed.
Vitamins and minerals relying on fat metabolism, including vitamins A, D, E, K, and zinc, may be
affected when absorption is impaired.
The decrease in gastrointestinal transit time may also result in secondary malabsorption of a
wide range of micronutrients related to bypassing the duodenum and jejunum or limited contact
with the brush border.
Other micronutrient deficiency include iron, calcium, vitamin B12, and folate.
average weight outcomes after bariatric
surgery
Weight outcomes for bariatric procedures are described as the percentage of initial weight lost
or the percentage of excess weight lost (% EWL).
Excess weight is the total amount of weight above a reference standard for “ideal” weight (BMI
of 24.9).
Ex.
ABW= 164 KG, Ht= 178 cm, BMI= 51.8 kg/m2
IBW= 79 kg
EWL= 85 kg
Cont.
On average, bariatric surgery produces a weight loss of approximately 20-30% initial weight or
about 50-60% EWL.
Ex.
ABW= 164 kg, Ht= 178 cm, BMI= 51.8 kg/m2
IBW= 79 kg, EWL= 85 kg
• Percentage of initial weight lost: 20-30% initial wt= 32.8- 49.2 kg
To reach 114.8 - 131.2 kg
Percentage of excess weight lost: 50-60 %EWL= 42.5- 51 kg
To reach 113- 122 kg
Cont.
Five years after surgery a weight loss of 50% EWL or 20% loss of initial weight is considered a
successful outcome.
Rate of weight change: The most rapid weight loss often occurs in the first 3 months after
surgery.
Weight loss usually continues for 12 to 18 months.
Most clients will experience weight stability at 18 to 24 months and by 36 months experience
some weight regain.

Although weight outcomes are important, the most important outcomes after bariatric surgery
are resolution of co-morbid conditions and improvement in quality of life.
How should healthcare providers discuss post-
bariatric surgery weight outcomes with clients?
Providers should reinforce that although weight outcomes are important, the most important
outcomes after bariatric surgery are resolution of co-morbid conditions and improvement in
quality of life.
It is not possible to exactly predict the weight outcomes for an individual.
Outcomes depend on many variables affecting weight regulation.
Each person and situation is different.
The weight outcomes after bariatric surgery are not to achieve a “normal” weight based on
height and weight reference tables or BMI ranges.
Weight loss to a “normal” weight represents an excessive loss to ≥100% EWL and is not
recommended.
Healthcare providers should discuss the average post-surgical weight outcome.
Questions
Pre-operative Nutrition
Care
Evaluation:
All patients should undergo an appropriate nutritional evaluation, including micronutrient
measurements, before any bariatric surgical procedure.

In comparison with purely restrictive procedures, more extensive perioperative nutritional

evaluations are required for malabsorptive procedures.
Cont.
Between 35–80% of bariatric candidates are in a state of ‘high calorie malnutrition’ and show
some dietary deficiency pre-operatively,7 with a reported prevalence of 60–80% for vitamin D,
24% for folate, 14.5% for selenium and up to 35% for iron.
Nutrient-poor food choices, chronic dieting cycles, side effects of medications to treat
comorbidities and other factors contribute to this state of ‘malnutrition’ masked by an ample
energy intake.
Therefore, regardless of the bariatric procedure proposed, a comprehensive screening is
recommended, ideally in sufficient time to correct deficiencies before surgery.
Cont.
In addition to a full blood count, lipid profile and diabetes markers, nutrient marker
investigations suggested prior to bariatric surgery:
❖ Iron, Folic acid, B12, Vitamin D, A, E, zinc and Thiamine.
The screening tests and subsequent ongoing monitoring enable the practitioner to recognize
and distinguish between pre-existing nutritional concerns and those due to post-operative
complications, known deficiency risks linked to the specific procedure performed and non-
compliance with recommended nutrient supplementation.
Preoperative diet
Preoperative weight loss can reduce liver volume and may help improve the technical aspects of
surgery in patients with an enlarged liver or fatty liver disease and is therefore encouraged
before bariatric surgery (Grade B;BEL1;downgraded due to inconsistent results).
Preoperative weight loss or medical nutritional therapy may also be used in selected cases to
improve co- morbidities, such as reasonable preoperative glycemic targets (Grade D).
(2013)
Preoperative weight loss should be considered in patients in whom reduction of liver volume
can improve the technical aspects of surgery.
(2009)
Cont.
➢For 2–4 weeks immediately before surgery.
➢very low energy diet (VLED). 800-1000 kcal/day
➢Approximately 100 g CHO, Low fat, Moderate protein.
➢Helps reduce liver volume by up to 25%, which in turn reduces intra-operative complications.
➢90% of morbidly obese patients has suffer from nonalcoholic fatty liver disease.
➢These patients present an enlarged left lobe of the liver that may disturb the visual field of the
surgeon and that is particularly susceptible to bleeding.
➢Liver enlarged due to additional stores of glycogen, fat deposits and water.
Physical activity
Mild exercise (20 min./day 3-4 times/week) may be beneficial for reducing surgical
complications, facilitate healing, and enhance post-operative recovery.
Every patient should consider exercise prior to surgery.
Regimen:
1. Improve lung capacity by blowing up balloons.
2. Improve aerobic conditioning with walking, swimming, or bike riding.
3. Increase muscle strength with light weights or resistance training with rubber bands.
Questions
Post-operative Nutrition
Care
Diet and texture progression
The purpose of nutrition care after surgical weight loss procedures is twofold.
➢ First, adequate energy and nutrients are required to support tissue healing after surgery and to
support the preservation of lean body mass during extreme weight loss.
➢Second, the foods and beverages consumed after surgery must minimize reflux, early satiety,
and dumping syndrome while maximizing weight loss and, ultimately, weight maintenance.

➢Many surgical weight loss programs encourage the use of a multiphase diet to accomplish
these goals.
Clear liquid
A low-sugar clear liquid meal program can usually be initiated within 24 hours after any of the
bariatric procedures. (ASMBS 2013)
A clear liquid diet is often used as the first step in postoperative nutrition, despite some
evidence that it might not be warranted.
Sugar-free or low sugar bariatric clear liquid diets supply fluid, electrolytes, and a limited
amount of energy and encourage the restoration of gut activity after surgery.
The foods that are included in clear liquid diets are typically liquid at body temperature and
leave a minimal amount of gastrointestinal residue.
Cont.
For 24-48 hours.
increasing the volume gradually to reach 8 cups/d (2 L).
Drink in small portions as tolerated, with no more than a half cup per serving.
Sips, no Straw.
non-carbonated, non-caffeinated.
Protein supplement or shake.
Includes:
water
Fruit juice that does not contain pulp such as apple juice.
broth
Fruit-flavored water
Decaf coffee and tea
Full liquid diet
➢Sugar-free or low-sugar full liquid.
➢Full liquid diets have slightly more texture and increased gastric residue compared with clear
liquid diets.
➢Amount: 1/4 -1/2 cup (2-4 Tbsp.) at a time
➢Protein supplement.
➢The liquid texture is thought to further allow healing and the caloric restriction provides energy
and protein equivalent to that provided by very-low-calorie diets.
Pureed diet
➢consists of foods that have been blended or liquefied with adequate fluid, resulting in foods
that range from milkshake to pudding to mash potato consistency.
➢This diet fosters additional tolerance of a gradually progressive increase in gastric residue and
gut tolerance of increased solute and fiber.
➢Amount: About 2-4 oz. (4-8 Tbsp.) or ¼-½ cup at one time.
➢foods such as scrambled eggs and canned fish (tuna or salmon) can be incorporated into the
diet.
➢Fruits and vegetables may be included, although the emphasis of this phase is usually on
protein-rich foods.
➢Protein supplement.
Mechanically altered soft diet
texture modified food requires minimal chewing, and that will theoretically pass easily.
This diet is considered a transition diet that is achieved by chopping, grinding, mashing, flaking,
or pureeing foods.
Amount: About ½-1 cup of food at each meal. Meals should last about 20-30 minutes.
Solid diet
Working toward balanced diet.
Patients should be counseled to eat 3 small meals during the day and chew small bites of food
thoroughly before swallowing (Grade D).
Patients should adhere with principles of healthy eating, including at least 5 daily servings of fresh
fruits and vegetables (Grade D).
▪At least 8 servings protein.
▪At least 2 servings non starchy vegetables
▪2 servings fruit
▪2-3 servings starch
Avoid textures that are difficult to chew (e.g. sticky, doughy, stringy, tough) as they may cause
discomfort and vomiting.
Amount: About ½-1 cup of food at each meal. Meals should last about 20-30 minutes
Cont.
Possible ‘Problem Foods’
Your stomach can be sensitive for 3-6 months after surgery, and sometimes longer. The following
foods have unique textures that may be difficult to tolerate if eaten too soon. Be cautious!
Protein: Tough red meat, hamburger, lobster, scallops, clams, shrimp
Fruits: Stringy, thick skins, peels (like oranges, grapes, pineapple)
Vegetables: Stringy, fibrous (like asparagus, celery)
Starches: Rice, pasta, doughy breads, popcorn
Foods commonly restricted
The American Society for Metabolic and Bariatric Surgery members reported in the survey
that patients were instructed to avoid or delay the introduction of several foods.
Research to support these clinical practices is limited, especially with regard to caffeine and
carbonation.
Practitioners might theorize that certain foods and beverages will cause gastric irritation, outlet
obstruction, intolerance, delayed wound healing, or alter the weight loss course; however, much
of the information is anecdotal and lacks empirical evidence.
Eating behavior
➢Aim to make a meal last 20–30 minutes, but no longer than an hour.
➢Take bites the size of a dime.
➢Chew, chew, chew; Use the tongue to feel for remaining food (puree) lumps before swallowing.
➢Wait between bites to see how stomach feel.
➢Fluids are the number one priority. (Sips throughout the day).
➢Fluids should not be consumed within 30 minutes (before or after) of eating any solid foods.
➢Aim to finish protein food first.
Cont.
➢Stop eating or drinking at the first sign of fullness. Sometimes this can feel like chest pressure
or nausea.
➢Space out eating events evenly during the day.
➢Some days you won’t have room for everything. Do your best to reach your protein goal.
➢You might not feel hungry but you still need to eat regularly
➢Avoid distraction when eating- overconsumption.
Fluid
➢Fluids should be consumed slowly, preferably at least 30 minutes after meals to prevent
gastrointestinal symptoms, and insufficient amounts to maintain adequate hydration.
➢More than 1.5 liters daily. (ASMBS 2013)
➢30 ml/kg of ideal weight per day.
➢ 30 minutes before, to be able to eat the meal
Protein
➢A minimal protein intake of 60g/d and up to1.5g/kg ideal body weight per day should be adequate.
➢Additional 30 g for BPD/DS.
➢Higher amounts of protein intake—up to2.1g/kg ideal body weight per day—need to be assessed on
an individualized basis (ASMBS 2013 Grade D).
➢Half (50%) of the plate must contain proteins.
➢For meals such as lunch and dinner, one should place sources of iron-rich proteins such as meats -
beef, chicken, fish and eggs - to make up half of the plate, that is, 50% of the total to be ingested.
➢Always use low fat options.
➢ The average food intake of the operated patients is around 4-6 tablespoons of food per meal.
Therefore, it would be 2-3 tablespoons of food coming from proteins.
➢For the breakfast or snacks, it is necessary to prioritize sources of calcium rich proteins, such as milk
and dairy products. Start the day with skim milk, cottage-type cheeses, ricotta and Greek yogurt.
Cont.
➢The ideal amount of proteins is up to 30 g per meal in the first year after the operation.
➢Protein supplements: whey.
➢ It is ideal to use isolated, hydrolyzed, lactose-free, gluten-free and sucrose-free formula to
facilitate use adhesion.
➢The powder can be diluted in water or in milk (to increase total protein value).
➢Protein drinks and shakes: 20-35 grams protein per serving.
➢Protein bars: 10-20 grams protein per serving.
➢Total fat: five grams or less per serving.
➢Total carbohydrates: 10 grams or less per serving.
➢Products should be low in sugar, five grams or less per serving.
 Physical activity
Exercise after surgery is absolutely imperative, and it may be the most important factor that can help a patient
achieve long-standing and successful weight loss.
Patients should be advised to incorporate moderate aerobic physical activity to include a minimum of 150
minutes per week and goal of 300 minutes per week, including strength training 2 to 3 times per week (ASMBS
2013, Grade A)
In addition to loss of fat mass, there are other numerous benefits to exercise.
Including:
➢prevention of loss of muscle mass when losing weight rapidly after surgery, and improved overall weight loss.
➢One’s immune system is enhanced by exercise and this will help maintain overall general health.
➢Exercise may also reduce a person’s appetite.
➢Fatigue, which sometimes is problematic after surgery, may be reduced.
➢Improved self-confidence, and overall improved sense of well being.
Cont.
Regimen:
1. Start walking from day 1.
2. Increase your walking each day. Add other aerobic exercises like swimming and bicycle riding
as your surgeon permits and as you feel so inclined.
3. Start light weight training and sit-ups as your surgeon allows. Increase weights and number of
reps gradually. This type of exercise will increase muscles mass which improves strength,
increases bone density, and increases metabolism.
4. Consider using a personal trainer to educate one about exercise, improve motivation, and
help assure proper routines.
Cont.
Independent of what phase a patient may be in before or after surgery, there are certain basic
safe and reliable rules to follow in regard to exercise:
1. Consider your goals and how you want to accomplish them. You can achieve it!
2. Use exercise in combination with weight loss surgery to maximize results.
3. Remember everyone starts from a different state of physical ability and strength. Gradually
increase your activity and exercise capacity. Mild discomfort from exercise is acceptable, but
pain should be avoided. Ignore the cliché, “No pain no gain.”
4. Drink plenty of water before, during, and after exercise.
Questions
Vitamins and Minerals
Pre-WLS Nutrient Screening
Recommendations
Thiamin
Prevalence of thiamin deficiency pre-WLS is reported to be as high as 29%.
Vitamin B12
Prevalence of B12 deficiency is reported to be 2–18% in patients with obesity.
Serum B12 levels alone may not be adequate to identify B12 deficiency.
Elevated MMA (methyl malonic acid) levels(values 40.4 mmol/L) may be a more reliable indicator of
B12 status because it indicates a metabolic change that is highly specific to B12 deficiency.
Folate
Prevalence of folate deficiency is reported to be as high as 54% in patients with obesity.
↓RBC folate and ↑serum homocysteine and normal MMA levels indicate folate deficiency.
Cont.
Iron
Prevalence of iron deficiency is reported to be as high as 45% in patients with obesity.
Lab tests indicate iron deficiency: iron < 50 μg/ dL, ferritin < 20 μg/dL, TIBC > 450 μg/dL.
Calcium and Vitamin D
Prevalence of vitamin D deficiency is reported to be as high as 90% in patients with obesity. Use
a combination of laboratory tests:
Vitamin D, 25-OH, serum alkaline phosphatase, PTH, and 24-h urinary calcium in relationship to
dietary intake.
 Cont.
Fat-soluble vitamins (A, E, K)
➢Prevalence: vitamin A 14%, vitamin E 2.2%, no data on vitamin K deficiencies in pre- WLS patients.
➢Use physical signs and symptoms and labs:
Vit A deficiency: ↓Retinol binding protein and ↓plasma retinol
Early signs/symptoms: Nyctalopia (night blindness or difficulty seeing in dim light),Bitot’s spots(foamy white
spots on sclera of eye),endophthalmitis, poor wound healing. Hyperkeratinization of the skin, loss of taste
(vitamin A and zinc metabolism inter related) Labs:
Vit E deficiency: ↓plasma α-tocopherol
Early signs/symptoms: Hyporeflexia, gait disturbances, neurologic damage, muscle weakness, decreased
proprioception, and vibration Ophthalmoplegia, nystagmus, nyctalopia, RBC hemolysis(hemolytic anemia)
Vit K deficiency: ↑DCP (des-gamma- carboxy prothrombin)
Early signs/symptoms: Hemorrhage due to deficiency of prothrombin and other factors, Easy bruising, bleeding
gums, delayed blood clotting, heavy menstrual, nose bleeding.
Cont.
Zinc for RYGB, BPD/DS
Prevalence: 24– 28%
Use physical signs and symptoms and labs.
Labs: ↓ serum or urinary zinc or RBC zinc
Early symptoms: Rash, acne Hypogeusia or ageusia (change in or absence of taste) Immune
deficiency, increased infections, Infertility.
Copper for RYGB, BPD/DS
Prevalence of copper deficiency is reported to be as high as 70% in pre-BPD women.
Serum copper and ceruloplasmin are recommended for screening indices, but area cute-phase
reactants and thus affected by inflammation, age, anemia, and medications.
 Post-WLS Nutrient Screening
Recommendations
Thiamin
Routine post-WLS screening is recommended for high-risk WLS groups:
✓Patients with risk factors for TD (malnutrition, excessive and/or rapid weight loss)
✓Females
✓Blacks
✓Patients not attending a nutritional clinic after surgery
✓Patients with GI symptoms (intractable nausea and vomiting, jejunal dilation, mega-colon, or constipation)
✓Patients with concomitant medical conditions such as cardiac failure (especially those receiving furosemide)
✓Patients with SBBO
If signs and symptoms or risk factors are present in post-WLS patients, thiamin status should be assessed at least
during the first 6 mo, then every3–6 mo, until symptoms resolve.
Cont.
Vitamin B12 for RYGB, SG, or BPD/DS.
More frequent screening (e.g., every 3 mo) is recommended in the first post-WLS year, and then
at least annually or as clinically indicated for patients who chronically use medications that
exacerbate risk of B12 deficiency:
nitrous oxide, neomycin, metformin, colchicine, proton pump inhibitors, and seizure
medications.
Vitamin B12 deficiency can occur due to food intolerances or restricted intake of protein and
vitamin B12–containing foods.
Cont.
Folate
Particular attention should be given to female patients of childbearing age.
Poor dietary intake of folate-rich foods and suspected non adherence with multivitamin may
contribute to folate deficiency.
Iron
Routine post-WLS screening of iron status is recommended within:
3 mo after surgery, then every 3–6 mo until 12 mo, and annually for all patients.
Additional screening if indicated.
Post-WLS iron deficiency can occur after any WLS procedure, despite routine supplementation.
Cont.
Vitamin D and Calcium
Routine post- WLS screening of vitamin D status is recommended for all patients.
Prevalence of vitamin D deficiency is reported to occur in up to 100% of post-WLS patients.
Vitamin A, E, K
A: within the first post operative year, particularly those who have undergone BPD/DS,
regardless of symptoms.
Also, should be measured in patients who have undergone RYGB and BPD/DS, particularly in
those with evidence of protein-calorie malnutrition
E and K: patients who are symptomatic should be screened.
Cont.
Zinc
Post-RYGB and post-BPD/DS patients should be screened at least annually for zinc deficiency.
Zinc should be evaluated in all post-WLS patients when the patient is symptomatic for iron
deficiency anemia but screening results for iron deficiency anemia is negative.
Deficiency of zinc is possible, even if taking zinc supplements and especially if primary sites of
absorption(duodenum and proximal jejunum)are bypassed.

Copper for BPD/DS and RYGB

Routine post-WLS screening of copper status is recommended at least annually, even in the
absence of clinical signs or symptoms of deficiency.
Summary
Nutrient screening Pre-WLS Post-WLS
Thiamin ☑ For high risk
B 12 ☑ RYGB, SG, or BPD/DS
Folate ☑ ☑
Iron ☑ ☑
D and Calcium ☑ ☑
A, E, K ☑ A: RYGB, BPD/DS
E, K: symptomatic
Zinc RYGB, BPD/DS RYGB, BPD/DS
symptomatic for iron deficiency anemia
Copper RYGB, BPD/DS RYGB, BPD/DS
Supplement Recommendations to Prevent
Post-WLS Micronutrient Deficiency
Thiamin
Above RDA.
At least 12 mg/ day
And preferably a 50 mg dose of thiamin from a B-complex supplement or multivitamin once or
twice daily.
Vitamin B 12
Supplement dose for vitamin B12 in post-WLS patients varies based on route of administration:
Orally by disintegrating tablet, sublingual, or liquid: 350–500 mg daily
Nasal spray as directed by manufacturer
Parenteral (IMorSQ): 1000 mg monthly
Cont.
Folate
400–800 mg oral folate daily from multivitamin.
Women of childbearing age should take 800–1000 mg oral folate daily.

Iron
At low risk(males and patients without history of anemia) for post-WLS iron deficiency should
receive at least 18 mg of iron from multivitamin.
Menstruating females and patients who have undergone RYGB, SG, or BPD/DS should take at
least 45–60 mg of elemental iron daily (cumulatively, including iron from all vitamin and mineral
supplements).
Cont.
Vitamin D and Calcium
The appropriate dose of daily calcium from all sources varies by surgical procedure:
oBPD/DS: 1800–2400 mg/d
oLAGB, SG,RYGB: 1200–1500 mg/d

The recommended preventative dose of vitamin D in post-WLS patients should be based on

serum vitamin D levels: Recommended vitamin D3 dose is 3000 IU daily, until blood levels of
25(OH) D are greater than sufficient (30ng/mL).
Cont.
To enhance calcium absorption in post-WLS patients:
oCalcium should be given in divided doses.
oCalcium carbonate should be taken with meals.
oCalcium citrate may be taken with or without meals.
Cont.
Vitamins A, E, and K
Based on type of procedure:
o LAGB: Vitamin A 5000 IU/d and vitamin K 90–120 ug/d
oRYGB and SG: Vitamin A 5000–10,000 IU/d and vitamin K 90–120 ug/d
oLAGB, SG, RYGB, BPD/DS: Vitamin E 15 mg/d
oDS: Vitamin A (10,000IU/d) and vitamin K(300 mg/d)
Cont.
Zinc
Take > RDA
Based on type of procedure:
oBPD/DS: Multivitamin with minerals containing 200% of the RDA(16–22 mg/d)
oRYGB: Multivitamin with minerals containing100–200% of the RDA (8–22 mg/d)
oSG/LAGB: Multivitamin with minerals containing 100% of the RDA(8–11 mg/d)
To minimize the risk of copper deficiency in post-WLS patients, it is recommended that the
supplementation protocol contain a ratio of 8–15 mg of supplemental zinc per1mg of copper.
Cont.
Copper
Take > RDA
Based on type of procedure:
oBPD/DS or RYGB: 200% of the RDA (2mg/d)
o SG or LAGB: 100% of the RDA (1mg/d)
In post-WLS patients, supplementation with 1 mg copper is recommended for every 8–15 mg of
elemental zinc to prevent copper deficiency.
In post-WLS patients, copper gluconate or sulfate is the recommended source of copper for
supplementation.
 Summary
Nutrient Prevent deficiency dose Repletion dose
Thiamin At least 12 mg/ day Oral therapy: 100 mg 2–3 times daily until symptoms
And preferably a 50 mg dose of resolve.
thiamin from a B-complex
supplement or multivitamin once or
twice daily.
B12 Oral: 350–500 mg daily 1000 mg/d to achieve normal levels
Folate Oral 400–800 mg Oral 1000 mg of folate daily to achieve normal levels
Iron At least 18 mg/d 150–200 mg of elemental iron daily to amounts as high
least 45–60 mg/d as 300 mg 2–3 times daily.
Vitamin D and Calcium D3: 3000 IU/d Vitamin D deficiency or insufficiency: Vitamin D3 at
Calcium: least 3000 IU/d and as high as 6000 IU/d, or 50,000 IU
BPD/DS: 1800–2400 mg/d vitamin D2, 1–3 times weekly.
LAGB, SG,RYGB: 1200–1500 mg/d Calcium:
BPD/DS: 1800–2400 mg/d
LAGB, SG,RYGB: 1200–1500 mg/d
 Cont.
Nutrient Prevent deficiency dose Repletion dose
Vitamin A Based on type of procedure Without corneal changes:
Oral 10,000–25,000 IU/d
With corneal changes:
IM 50,000–100,000 IU 3d, followed by 50,000IU/d IM for 2wk
Vitamin E Based on type of procedure The optimal therapeutic dose not been clearly defined. There is potential for
antioxidant benefits of vitamin E to be achieved with supplements of 100–
400 IU/d.
Vitamin K Based on type of procedure with acute malabsorption: a parenteral dose of 10 mg
With chronic malabsorption: 1–2 mg/d orally or 1–2 mg/wk parenterally
Zinc Based on type of procedure insufficient evidence to make a dose-related recommendation for repletion.
(8-22 mg) Previous recommendation: 60 mg elemental zinc orally twice/d.
Copper Based on type of procedure Mild to moderate deficiency: 3–8 mg/d oral, until indices return to normal
(1-2 mg) Severe deficiency: 2–4 mg/d IV, can be initiated for 6 d or until serum levels
return to normal and neurologic symptoms resolve.
Once copper levels are normal: monitor copper levels every 3 mo.
Nutrition-related
Complications
Nutrition-related Complications
Constipation
Short-term Solutions
➢Increase fluids – aim for more than 2.0 l/day
➢Try a laxative
➢ Try psyllium, a natural soluble fiber.
Long-term Solutions
➢Increase fluids – aim for more than 2.0 l/day.
➢ Increase fiber intake.
➢Eat more fruits, vegetables, and whole grains if your diet stage permits. (25-30 g fibre/day)
➢If unable to add more fiber through your diet, try a fiber supplement, such as Benefiber or
Metamucil.
➢Continue taking a stool softener as needed.
Cont.
Diarrhea
➢Limit or avoid foods with lactose. Lactose intolerance can occur after surgery. Please see page 8 for
more details.
➢Eat slowly and chew thoroughly.
➢Do not drink fluids with meals.
➢Avoid high sugar, high fat, and spicy foods.
➢Limit the amount of sugar-free products (like sugar-free candies). These products may contain sugar
alcohols (artificial sweeteners that end with –ol such as malitol, sorbitol, xylitol, etc.) that can cause
diarrhea.
➢Limit caffeinated beverages.
➢Try psyllium, a natural soluble fiber.
Cont.
Nausea and/or Vomiting
➢Recurrent vomiting needs to be addressed urgently, particularly in the first 8 weeks after RYGB
and SG surgery, as it may lead to thiamine depletion and dehydration.
➢Remind the patient not to rush through texture transition phases.
➢ Reinforce the need to dramatically reduce total volume consumed at any single time
➢eating behaviors; Take small bites, chew thoroughly and pause after each bite.
➢Stop eating or drinking at the first sign of fullness, which may feel like pressure in your upper
chest.
➢Stay hydrated. Drink at least 1.5-2.0 of fluids.
➢Avoid eating and drinking at the same time.
Cont.
Bloating/Gas/Cramping
➢Limit or avoid foods with lactose. Lactose intolerance can occur after surgery. Please see page 8
for more details.
➢Limit or avoid sugar alcohols (artificial sweeteners that end with –ol such as malitol, sorbitol,
xylitol, etc.).
➢Avoid carbonated beverages.
➢If drinking through a straw causes these problems, avoid using one.
Cont.
Overly decreased appetite
➢Five or six half volume meals spread over the day are better tolerated and help achieve an
adequate protein intake
➢Low energy, high protein meal replacements or protein supplements may be necessary to meet
➢protein requirements
➢Avoid unplanned snacking or ‘grazing’ behaviours, especially on ‘poor quality’ foods
Cont.
Dumping syndrome
➢Encourage adequate protein and low glycaemic index carbohydrate foods
➢Remind patient to separate fluid and foods
➢Discourage highly refined and processed sugar foods and drinks
Cont.
Hair Loss
Hair loss is normal in the first six months after surgery and will usually resolve on its own.
If hair loss continues past six months, it may be related to nutrition.
➢Meet your protein goal of 60-70 grams daily. (1.5 g/IBW/d)
➢Take your multivitamins daily – you should be getting 200% of iron, zinc, and biotin.
Questions
Follow up
Appointments
Nutrition interventions were most commonly conducted as individual appointments (30
minutes) at:
➢1–2 weeks.
➢6-8 weeks.
➢3 months.
➢6 months.
➢9 months.
➢Every 6 months in second year.
➢Then, Annually.
Cont.
Weight should be recorded at every appointment, and physical activity should be discussed.
The short-term follow-up visits should focus on:
the graduated postoperative diet, tailoring of vitamin and mineral supplements, and how to deal with
common symptoms.
The long-term follow-up visits should include:
➢Screening for micronutrient deficiencies, bone health, and control of nutrition-related
noncommunicable diseases.
➢It is also recommended to reinforce healthy eating habits such as eating slowly, portion control, and
meeting protein requirements.
➢Unhealthy habits, such as the consumption of high-calorie liquids, puréed foods, and grazing, should
be discouraged.
➢In addition, it is important to be aware of the physical side effects, such as maladaptive eating,
return of hunger, eating disorders, and excessive skin, which may adversely affect surgery outcomes
Support group
All patients should be encouraged to participate in ongoing support groups after discharge from
the hospital (Grade B;BEL2).
45 – 60 minutes
Reaching a Plateau
In general, it is normal to have periods of plateaus through all phases of weight loss after
surgery.
It is important for the patient to recognize these plateaus as being normal.
Expecting these fluctuations in weight loss to occur can avert patient depression or
exasperation with the surgery.
Adhering to the basic rules of eating correctly and exercising regularly may shorten the
duration of a plateau and lead ultimately to greater long-term weight loss.
What is most important to remember is that weight loss surgery does not guarantee easy and
consistent weight loss. The operation is a tool that if used appropriately by the patient can help
one achieve successful weight loss.
 However, if used inappropriately, overall weight loss may fall below expectations.
Weight loss is less or more than expected!
Inadequate weight loss (<30% EWL) may be an indication of surgical or technical failure (e.g. loss
of integrity of gastric pouch), lack of proper adjustment to the LAGB, maladaptive eating
behaviours or psychological complications (e.g. depression, anxiety).
Excessive weight loss (>80% EWL) may indicate protein/calorie malnutrition, excessive
restriction of intake, excessive exercise or unintentional weight loss due to other reasons (i.e.
obstructions, cancer).
Investigations and referral to the appropriate health care provider or bariatric team are
recommended.
Regain weight lost after bariatric surgery!
➢No treatments are available to cure obesity, it is a chronic disease that needs to be monitored
and managed over time.
➢Weight re-gain is part of the typical pattern of weight change after bariatric surgery:
first there is a weight loss phase, followed by a weight regain phase, and then weight stability.
➢Weight regain after bariatric surgery most commonly occurs in 2 to 6 years after the procedure,
with about one-third of the initial weight lost regained within 5 years.
➢In spite of this, bariatric surgery remains the most effective treatment producing better and
sustained weight outcomes than any other treatment.
Factors contribute to weight re-gain
It is important to continue with nutrition, activity, behaviour modification and medical
interventions and provide clients with ongoing monitoring and support.
Behaviour and Self Monitoring
Decrease or discontinuation of self monitoring
Changes to physical or mental health impacting lifestyle behaviours (e.g. depression)
Cont.
Nutrition
Increased caloric intake
Selection of calorie-dense foods
Increased frequency of eating: more than 6 times per day: grazing pattern of intake
Consumption of caloric beverages above total daily calorie goal
Consumption of carbonated beverages - may contribute to decreased satiety over time
Consuming liquids within 30 minutes of a solid meal or snack.
Rate of eating is too slow (over 30 minutes for a meal)
Adaptation to feelings of fullness/satiety over time; able to eat increased portion of food.
Cont.
Activity
➢Increase in sedentary behaviour
➢Decrease or discontinuation of activity
Take home
messages
DRINK FLUIDS THROUGHOUT THE DAY
PRIORITIZE PROTEIN
TAKE BARIATRIC SPECIFIC MULTIVITAMIN DAILY AFTER SURGERY
CHEW FOODS EXTREMELY WELL AND EAT/DRINK SLOWLY
FOLLOW THE DIET PROGRESSION 100% (Do not jump ahead)
EXERCISE
FOLLOW-UP WITH YOUR SURGEON AND DIETITIAN REGULARLY
ATTEND SUPPORT GROUP MEETING REGULARLY

Bariatric Plate Model

Thank you
References
Parrot, J. et al, (2017). American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the Surgical
Weight Loss Patient 2016 Update: Micronutrients. Surgery for Obesity and Related Diseases,
http://dx.doi.org/10.1016/j.soard.2016.12.018
Mechanick, J. et al. (2013) AACE/TOS/ASMBS Guidelines Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and
Nonsurgical Support of the Bariatric Surgery Patient—2013 Update: Cosponsored by American Association of Clinical Endocrinologists,
The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surgery for Obesity and Related Diseases (9)pp.159–191.
Aills, L. et al (2018) ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surgery for Obesity and Related
Diseases (4) S73-S108.
Shannon, C. (2013) The Bariatric Surgery Patient, Nutrition considerations. Australian Family Physician, 42:(8) pp. 547-552.
Dagan, S. et al (2017), Nutritional Recommendations for Adult Bariatric Surgery Patients: Clinical Practice. American Society for Nutrition.
Adv Nutr (8) pp. 382–394.
Cambi, M. et al, (2018). Bariatric Diet Guide: Plate Model Template For Bariatric Surgery Patients. Arquivos Brasileiros de Cirurgia
Digestiva, 31(2):e1375.
ASBS Public/Professional Education Committee - Bariatric Surgery: Postoperative Concerns (2007).
Nutrition Guideline Bariatric Surgery for Adults. Alberta Health Services (2012).
Nutrition Guideline and Requirements. DeKalb Medical (2015).
Oxford Bariatric service, Pre Bariatric Surgery Diet. Oxford Radcliffe Hospitals, NHS Trust (2013).
Brigham and Woman’s Center for Metabolic and Bariatric Surgery. Nutrition Guidelines for Sleeve Gastrectomy and Gastric Bypass (2017)