6. The Practical Guide; Identification, Evaluation and treatment of
Overweight and Obesity in Adults, Oct 2000, NIH Pub No 00-4084
7. BARIATRIC SURGERY
Bariatric surgery is more effective
than nonsurgical treatment for weight
loss and control of some comorbid
conditions in MORBID OBESE patients
9. Prior to surgery candidates should be carefully
assessed by a specialized multidisciplinary team
including:
Bariatrician (MD specializing in the care of the obese)
Surgeon
PCP
Social Worker/ Psychologist
Dietitian
Nurse
10. • During active weight management,
multicomponent interventions that are
delivered through multidisciplinary care may
be more effective than interventions delivered
by individual health professionals (Flodgren et
al. 2010; Tsai & Wadden 2009).
12. Pre-Surgical Goals
Improvement of nutritional status
• Correct vitamin/nutrient deficiencies (most common include:
iron, vitamin B12 and vitamin D)
Achievement of better control of nutrition- related
comorbidities
Development of lifestyle and eating habits that will
promote positive post-weight loss surgery outcomes
and weight loss maintenance
Promote 5-10% weight loss to reduce surgical risks
13. Post-Surgery
Nutrition Guidelines
• Dietary consult ordered upon admit
– Complete nutrition assessment
– Review diet progression with patient
– Work with in-patient team to identify & minimize
complications post-op
• For all procedures patients will follow the
same diet
15. Diet advanced from NPO to Stage 1 Bariatric Diet on
Post op Day 1
• Stage 1 - Water
– Typically start day of surgery; Duration < 1 day
– Nursing staff to administer 1oz water per hour via
medicine cup
• Instruct patient to sip slowly & stop if feeling full or
nauseous
– All medications to be administered in liquid/chewable
form
– IV Fluid until tolerating liquids
– Patient to begin tracking fluid intake on Patient Intake
Diary (provided by healthcare team)
16. • Stage 2 - Bariatric Clear Liquids
– Starts Post op Day1; Duration 1-2 days
– Non-carbonated liquids without calories, sugar, or
caffeine; includes broth, sugar-free (SF) ice pops, SF
gelatin, water, & ice chips
– Priority is hydration
– Instruct to sip slowly & stop if feeling full or nauseous
(avoid straws)
– Will receive 3oz Bariatric Clear Liquids 3 times a day on
meal trays
– Instruct to sip 2-4 oz Bariatric Clear Fluids per hour
between meals
– Will be expected to track intake on Patient Intake Diary
17. Stage 3 - Bariatric Full Liquids
• Starts Post op Day 1-2; duration 2-4 weeks
• Will receive 3oz Bariatric Full Liquids 3 times a day on meal trays
• Low-fat protein-rich liquids with (exp. Low-fat (LF) broth, LF milk,
protein shakes; light/LF yogurt, LF cottage cheese; LF/SF
pudding) juven/beneprotein
• Priority on hydration and protein intake (minimize loss of lean
body mass)
• Instruct to sip slowly & stop if feeling full or nauseous
• Instruct to sip 2-4 oz fluids per hour between meals
• Note: Patients will go home on this stage. You may not see
other stages unless patients are re-admitted
18. Stage 4 - Soft and Moist Protein
• Start 2 weeks post-op; Duration 4-6 weeks
As tolerated replace full liquids with soft & moist protein
foods (avoid dry or tough meats); ~2-4oz per meal
• May need to continue with protein shakes to meet protein
needs
• Instruct not to drink fluids with meals; wait 30 min before &
after each meal to have beverages
• If meeting protein goals may add well-cooked soft fruits &
vegetables
• Will begin taking chewable vitamin & mineral supplements
19. Stage 5
• Low Fat, Low Sugar, High Protein
• Start 6-8 weeks post-op; Duration lifelong
• Balanced solid food diet with protein, fruits, vegetables, and
whole grains. Can add raw foods as tolerated.
• Goals:
– 60-80 grams protein /day
– 64+ ounces fluid/ day (including protein drinks) sipped
between meals.
• Continue to separate fluids from your meals
• Can advance to supplements in tablet form if tolerated
21. • Dehydration
– Monitor for signs and symptoms of dehydration as
patients are at greater risk given their dietary restrictions.
Patients should strive for 64 ounces of liquids per day.
• Nausea and Vomiting
– Eating too quickly or too much, drinking with meals or
drinking too close to meals, not chewing thoroughly, or
advancing the diet too quickly can all lead to nausea
and/or vomiting. Persistent vomiting can lead to thiamin
deficiency.
– Encourage patients to drink and eat slowly, stop if feeling
full or nauseous, and take small bites and chew their foods
thoroughly.
22. • Dumping Syndrome
– Usually occurs ~30 minutes following a meal.
– Symptoms may be similar to the flu and include nausea,
sweating, bloating, abdominal cramps, and diarrhea.
– To avoid these symptoms patients should avoid high fat and
high sugar foods. or example instead of 100% fruit juice; dilute
1:1 with water.
• Diarrhea
– Some patients can develop post-operative lactose intolerance.
Symptoms could include bloating, abdominal cramps, excessive
gas, and diarrhea.
– Treatment includes following a lactose-free diet.
24. • Stomach
– Water, ethyl alcohol, copper, iodide, fluoride,
molybdemum, intrinsic factor
• Duodenum
– Calcium, iron, phosphorus, magnesium, copper,
selenium, thiamin, riboflavin, niacin, biotin, folate,
vitamins A, D, E, K
Shikora SA, Kim JJ, Tarnoff ME. Nutrition and gastrointestinal complications of bariatric
surgery. Nutr Clin Pract. 2007;22(1):29-40.
25. • Jejunum
– Thiamin, riboflavin, niacin, pantothenate, biotin,
folate, vit B6, vit C, vit A, D, E, K, dipeptides,
tripeptides, calcium, phosphorus, magnesium,
iron, zinc, chromium, manganese, molybdenum,
amino acids
• Ileum
– Vit C, folate, vit B12, vit D, vit K, magnesium, bile
salts/acids
28. • Gastric Bypass:
– Most common: Iron, Vitamin B-12,
Folic acid, Fat soluble Vitamins A, D, & E
– Thiamin (seen in patients with frequent vomiting)
– Calcium
– Protein malnutrition
• Gastric Banding:
– Except for folate, nutrition deficiencies are less
commonly seen post gastric banding
• Sleeve Gastrectomy
– Possible B-12
29. Iron deficiency and anemia
• As high as 49% of patients
• Multifactorial cause
– Low gastric acid levels prohibit iron cleavage from food
– Absorption inhibited because no nutrient exposure to
duodenum or proximal jejunum
– Decrease in iron-rich food consumption due to
intolerance
• Treat with oral supplementation of ferrous sulfate
or ferrous gluconate
30. Vitamin B12 deficiency
• Up to 70% of patients
• Lack of hydrochloric acid and pepsin in stomach
– Prevents B12 cleavage from food
– Affects secretion of intrinsic factor, thus B12
absorption
• Intolerance to meat and milk
• Oral supplementation usually adequate,
otherwise, IM injections used
31. Folate Deficiency
• 40% of gastric bypass patients
• Complete absorption requires B12
• Absorption dependent on HCl and upper 1/3
stomach
• Deficiency generally caused by decreased
consumption
• Oral supplementation
32. Vitamin D and Calcium Deficiency
• Vitamin D deficiency is common among obese
people
• Calcium absorption decreased because duodenum is
bypassed
• Intolerance to dairy, foods high in calcium
• Vitamin D is required for Ca++ absorption
• Prolonged deficiencies lead to
– Bone resorption, osteomalacia, osteoporosis
• Treat with calcium citrate supplementation and 2
weekly doses of Vitamin D
36. • Lifelong compliance with vitamin/ mineral
supplementation is important to reduce the
risk of serious nutrient deficiencies
• Self-monitoring intake and avoiding high
calorie foods and beverages to prevent weight
re-gain
• Remaining connected with post bariatric
surgery support groups
37. • Prevention is likely to be the most efficient
and cost-effective approach for tackling
overweight and obesity.
• However, many people already require
treatment, may have comorbidities and are at
risk of further weight gain (NPHT 2009).
44. “There is nothing wrong with our
metabolism… the problem is the
Environment and the fact that
food is no longer a survival issue
but mostly a source of pleasure”…
uiza Kent-Smith, 2007