Bariatric Surgery: Postoperative Nutritional Management

Bariatric surgery: Postoperative nutritional management -... https://0-www.uptodate.com.millenium.itesm.mx/contents/...
Official reprint from UpToDate

www.uptodate.com 2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Bariatric surgery: Postoperative nutritional management
Authors: Robert F Kushner, MD, Susan Cummings, MS, RD, Daniel M Herron, MD, FACS, FASMBS
Section Editor: Daniel Jones, MD
Deputy Editor: Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2017. | This topic last updated: Oct 10, 2017.
INTRODUCTION The goals of bariatric operations include maximizing weight loss and maintaining or achieving nutritional
health while preventing micronutrient deficiencies and lean body mass loss [1,2]. Deficiencies of micronutrients following
bariatric surgery can arise from several mechanisms that include preoperative deficiency, reduced dietary intake,
malabsorption, and inadequate supplementation. Since obesity is a risk factor of malnutrition and micronutrient deficiencies,
all patients should be screened and deficiencies corrected prior to surgery. The postoperative diet and texture progression,
micronutrient deficiencies, and their management are reviewed here.
Bypass procedures, such as Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD/DS),
are known to cause micronutrient malabsorption [2-8]. The sleeve gastrectomy (SG), which is the most commonly performed
bariatric procedure in certain regions, does not involve intestinal bypass but can still lead to certain nutritional deficits. Any
bariatric procedure can result in malnutrition if a proper diet is not followed. The specific bariatric procedures, indications, and
outcomes are reviewed elsewhere and include the following topics:
(See "Bariatric procedures for the management of severe obesity: Descriptions".)
(See "Bariatric operations for management of obesity: Indications and preoperative preparation".)
(See "Bariatric operations: Perioperative morbidity and mortality".)
(See "Bariatric surgery: Postoperative and long-term management of the uncomplicated patient".)
(See "Medical outcomes following bariatric surgery".)
(See "Laparoscopic Roux-en-Y gastric bypass".)
(See "Laparoscopic sleeve gastrectomy".)
DIET AND TEXTURE PROGRESSION The diet after bariatric surgery is based upon a staged approach with emphasis on
nutritional needs at each stage of healing and weight loss. Additionally, consideration is given to the texture and volume of
food that patients can tolerate [1]. While all post-bariatric surgery patients will benefit from a well-planned dietary
advancement that ensures proper healing of the surgery and develops lifelong healthy eating habits, such plans have to take
into consideration a large variation in food tolerance depending upon the nature of the bariatric operation (eg, size of remnant
stomach, presence of gastrojejunostomy, etc.) (table 1 and table 2).
Early (postoperative) diet At each diet stage, nutrient needs and food texture should be emphasized. Although
postoperative diet plans are generally surgeon or institution specific, the following approach to the nutritional management of
the postoperative bariatric patient is generalizable to most patients (table 1 and table 2) [2,9]:
Stage 1 and 2 diet: Hydration and liquids The immediate postoperative diet should emphasize hydration and protein
intake. Patients are started on a clear liquid diet (stage 1) and, after a brief period, are advanced to full liquids and possibly
pureed foods, which they will consume for up to several weeks after the operation (stage 2 diet). Early hydration and
consumption of protein and carbohydrates to meet metabolic needs are essential, and the stage 2 diet helps to avoid irritation
to the surgical areas of the digestive tract.
1 of 32 10/29/17, 23:18
Many programs discharge patients from the hospital on a stage 2 diet that includes liquid sources of protein that also contain
small amounts of carbohydrate. Other programs discharge patients on a pureed diet. Patients should be taught to recognize
signs and symptoms of dehydration. All patients should receive preoperative education that focuses on their postoperative
nutritional needs, including guidelines regarding the consumption of an adequate amount of clear and full liquids daily to
maintain hydration and urine output. Surgical patients should be provided educational materials, shopping lists, and sample
meal plans of when they should be consuming clear and full liquids and how much. Such guidelines should be reinforced
through postoperative discharge instructions.
Stage 3 diet: Solid foods Approximately 10 to 14 days after surgery, as the gastrointestinal tract heals and patients are
able to tolerate more solid-textured foods, the diet is advanced to include soft solid foods with an emphasis on protein
sources, some carbohydrates, and fiber (eg, fruits and vegetables). Patients can advance their diet (texture and portions) as
tolerated as long as they follow guidelines for the stage 3 diet. Throughout all of the diet stages, patients should be counselled
to consume adequate fluid to prevent dehydration.
Food tolerance varies widely among patients. Patients are advised to eat slowly, chew food extensively, stop eating as soon
as they reach satiety, and avoid taking food and beverages at the same time. Vomiting and epigastric discomfort frequently
occur if food is ingested too quickly or when the patient eats more than the stomach pouch or sleeve can hold. During the first
few months after surgery, most patients learn to recognize the early satiety provided by a small gastric volume. Because
overeating can result in vomiting or nausea, most patients quickly learn to control portion sizes and food reactions. Guidance
by an experienced bariatric registered dietitian is strongly advised during the transition between diet stages, per the clinical
practice guidelines [10].
Stage 4 diet: Micronutrient supplementation Stage 4 is when patients reach a stable weight (maintenance weight).
Because of the wide variability in the rate of weight loss, healing, food tolerance, and the amount of food patients can
consume, it is unpredictable when a patient will reach this stage. Some programs do not have a stage 4 diet, as most patients
already tolerate regular foods by stage 3.
As patients are advancing their diet, they should be encouraged to consume a healthy, balanced diet. While some programs
start micronutrient supplementation as early as hospital discharge with chewable or liquid vitamins, all programs require daily
vitamin and mineral supplementation by the stage 4 diet. The recommended postoperative micronutrient supplementation
following a Roux-en-Y gastric bypass (RYGB) or gastric sleeve procedure is discussed separately (table 3) [1,9-12]. (See
'Micronutrient deficiency, supplementation, and repletion' below.)
In the past, patients were instructed to take one or two pills of multivitamin a day after bariatric surgery. However, there is wide
variability in the formulations of multivitamins, and most do not contain enough elemental iron or calcium to meet the needs of
bariatric patients. Thus, a "one size fits all" approach does not work for every bariatric surgical patient; supplementation needs
to be tailored to each individual's nutritional intake and status based upon regular review of blood chemistries. At a minimum,
the supplement should contain the recommended daily allowance (RDA) amounts for vitamin K, biotin, zinc, thiamin, vitamin
B12, folic acid, iron, and copper [13]. The minimum amounts of daily vitamins and minerals required to prevent deficiency are
summarized in this table (table 4). (See 'Postsurgical screening' below and 'Micronutrient management' below.)
Long-term diet Long-term eating habits are in part determined by the patient's motivation, willingness, and ability to
adhere to a healthy diet. Dietary intake longer-term is also dependent upon the type of bariatric procedure performed (see
"Bariatric procedures for the management of severe obesity: Descriptions"):
Roux-en-Y gastric bypass Due to the changes in both the pouch size and gut hormone signaling, patients may not feel
physical hunger early after RYGB, and, when they do eat, they experience early satiety. As weight stabilizes and the need for
external calories increases, sensations of hunger and satiety awareness will return; patients may also develop food
intolerances and aversions [14-16].
Learning how to choose healthy foods, avoid skipping meals, and prepare meals and snacks on a daily basis is part of the
new skills and goals all patients must learn. Patients may need continued reminders that the surgery has changed their body
but not the environment. Frequent education, emotional support, and counseling sessions with a registered dietitian
experienced with bariatric surgery are essential.
Food aversions Food aversions may develop during the transition phase from liquids to soft foods to a full diet,
especially if there is prolonged vomiting associated with eating. For patients who enjoyed food variety prior to the surgery,
the loss of food variety can result in anger and frustration. These patients will often complain that they experience anxiety
2 of 32 10/29/17, 23:18
and fear when eating. Reassurance and empathy is essential to help the patient overcome food intolerances.
By six months, most patients are able to tolerate most foods and tend to eat three small meals, with or without the
inclusion of planned snacks, per day. If vomiting persists or emerges, an evaluation should be performed for anatomical
etiologies (eg, ulcer, stricture) and/or pregnancy. Such patients with food aversions may express "buyer's remorse" and
may request extensive investigations for problems with the gastric pouch. Reassurance about the ability of the pouch to
tolerate a wide variety of foods with time is necessary.
Dumping syndrome This may occur to varying degrees, but it usually results in nausea, weakness, sweating,
faintness, and possibly diarrhea soon after eating within the first few years after surgery. These symptoms intensify when
highly refined foods with simple sugars (eg, sweets) are consumed, leading to feelings of weakness and extreme fatigue.
(See "Late complications of bariatric surgical operations", section on 'Dumping syndrome' and "Postgastrectomy
complications", section on 'Dumping syndrome'.)
Food intolerances Food intolerances may develop, especially to red meat, and patients may choose a more
vegetarian-based diet. However, fresh fruits and vegetables are generally well tolerated.
Vitamin and mineral supplementation Patients who have undergone bariatric surgery require lifelong vitamin and
mineral supplementation. Laboratory testing of nutritional status, scheduled at regular intervals based on the bariatric
procedure, is required to permit adjustments to the standard supplementation regimens [1]. (See 'Micronutrient
management' below.)
Long-term diet recommendations A well-balanced diet containing all of the essential nutrients is recommended for
continued good health and weight maintenance. Resources that may help patients with developing a lifelong healthy
postoperative diet include:
My Plate
DASH Diet
The Vegetarian Resource Group
Maintenance Obesity is a chronic condition, and although surgery has a strong influence on hunger and satiety, non-
hunger cues remain pervasive in today's environment. Patients should be advised that attending support groups and
having at least an annual check-in with their registered dietitian, especially if some weight gain is experienced, may
contribute to sustained weight loss.
Sleeve gastrectomy Sleeve gastrectomy (SG) resects the greater curvature of the stomach including the fundus and
promotes rapid gastric emptying, accelerated transit of nutrients into the duodenum and proximal intestine, and favorable
changes to gut microbiome [17]. SG also changes gut hormone signaling by reducing fasting and postprandial ghrelin and
augmenting nutrient-stimulated glucagon-like peptide-1 (GLP-1) and peptide YY (PYY) release [17-19]. The mechanism of
weight loss and resultant comorbidity improvement seen following SG may be related to gastric restriction or to neurohumoral
changes observed following the procedure due to the gastric resection or some other unidentified factors [20].
Since food tolerances vary greatly among individuals who have RYGB or SG, most programs follow the same diet
advancement and recommendations post-SG as for post-RYGB; close monitoring with a registered dietitian during the diet
stage transitions can be helpful to patients experiencing food intolerances or who may be struggling to stay adequately
hydrated.
Nutritional recommendations for macronutrients after SG are similar to those after RYGB, although exact needs are not
clearly defined and may need to be individually assessed [9].
Food aversions Following SG, patients may complain of acid reflux symptoms. Given the limited stomach volume, the
decreased motility of food through the sleeve during the healing process, and the preservation of stomach acid, patients
may experience acid reflux if they eat too fast or too much. Although reflux is a common complaint in the early
postoperative period after SG, by six months most patients have learned how to avoid it.
Food intolerances Food intolerances seem to be much less common after SG than after RYGB; however, as with the
bypass, postoperative food intolerances and/or aversions vary widely among patients.
Vitamin and mineral supplementation, long-term diet recommendations, and maintenance are the same as described for
3 of 32 10/29/17, 23:18
patients with an RYGB. (See 'Micronutrient management' below.)
Laparoscopic adjustable gastric band Laparoscopic adjustable gastric banding (LAGB) is much less commonly
performed at most bariatric centers compared with before. Patients who have undergone LAGB will generally resume a
normal diet soon after surgery since the initial band is placed deflated. Rarely, patients may experience vomiting before the
band is filled, if solid foods are ingested in large boluses or without adequate chewing.
The first band tightening usually occurs around six weeks after surgery. With gradual band tightening, which occurs at four- to
six-week intervals during the first one to two years after surgery, patients begin to feel satiety at smaller meal sizes and learn
to chew food more thoroughly.
Common determinants for a band fill include assessment of level of hunger before meals, level of satiety after meals, amount
of weight loss or gain, amount of food a patient is able to eat in one sitting, and if a patient is vomiting. A well-adjusted band,
in combination with exercise and appropriate food choices, will initially lead to weight loss of approximately 1 to 2 lbs per
week. Patients should be able to eat most solid foods; restriction should be just enough to allow smaller meals to cause and
maintain satiety.
Aggressive tightening of the band may result in frequent vomiting, which may ultimately steer the patient to maladaptive eating
behavior. Over time, significant dilation of the esophagus similar to that seen in achalasia can occur. Furthermore, patients
with an overly tight band may give up eating healthy solid foods and progressively rely on soft or liquid foods (eg, milkshakes)
or crunchy foods such as cookies or chips, which are better tolerated. Unfortunately, such foods tend to be calorie dense and
nutrient poor and often do not provide adequate satiety, as they rapidly empty from the pouch. When this occurs, weight loss
can be suboptimal, and patients become frustrated with their inability to eat substantial foods.
Removal of band fluid in a band that is too tight frequently allows patients to again eat healthy foods, and weight loss is often
observed despite loosening of the band. If esophageal dilation is noted, a follow-up study should be obtained six to eight
weeks later to confirm return of the esophagus to normal caliber. Persistence of nausea and vomiting after removal of fluid in
the band may indicate band slippage or gastric prolapse and should be investigated aggressively. (See "Late complications of
bariatric surgical operations".)
Although micronutrient deficiencies are not commonly seen after LAGB, folate deficiency has been observed. Thus, folate
should be routinely monitored, especially in women of childbearing age. Persistent vomiting in a band patient should be
aggressively treated with band deflation and surgical intervention if necessary, in order to reduce the risk of acute thiamin
deficiency or mechanical injury to the stomach or esophagus. (See 'Folate' below and 'Vitamin B1 (thiamine)' below and
"Fertility and pregnancy after bariatric surgery".)
Biliopancreatic diversion/duodenal switch The biliopancreatic diversion (BPD) with a duodenal switch (BPD/DS) is
the least commonly performed bariatric procedure and is associated with substantial malabsorption of macronutrients and
micronutrients.
This malabsorption leads to diarrhea and risks for protein and calorie malnutrition in addition to severe deficiencies in
micronutrients including fat-soluble vitamins. Again, vitamin and mineral laboratory evaluations should be performed annually
for life.
Some of the common complaints following BPDDS include:
Dumping syndrome This is rare after BPD/DS since the pylorus remains intact. However, it may occur after BPD
without DS, resulting in nausea, weakness, sweating, faintness, and possibly diarrhea soon after eating. These
symptoms get worse when highly refined foods with simple sugars (eg, sweets) are consumed, leading to feelings of
weakness and extreme fatigue. (See "Postprandial (reactive) hypoglycemia".)
Osteoporosis Osteoporosis is common due to malabsorption of calcium and vitamin D. (See "Pathogenesis of
osteoporosis" and "Prevention of osteoporosis" and "Screening for osteoporosis".)
Foul-smelling stools and diarrhea Foul-smelling stools and diarrhea that occur can result in malabsorption of protein;
fat; calcium; iron; and vitamins B12, A, D, E, and K. (See "Mechanisms of nutrient absorption and malabsorption" and
"Clinical features and diagnosis of malabsorption" and "Overview of the treatment of malabsorption".)
Kwashiorkor Severe malnutrition, kwashiorkor, is a potentially life-threatening form of protein malnutrition. While
4 of 32 10/29/17, 23:18
protein digestion is not impaired after RYGB, BPD/DS patients are at risk of protein malnutrition because of the great
degree of malabsorption; approximately 27 percent of protein is not absorbed at 24 to 36 months after BPD [21,22]. The
increased loss of endogenous nitrogen may play a significant role in the development of protein-energy malnutrition after
the procedure. Protein intake of 1.5 to 2.0 g of protein/kg ideal body weight per day may be required, making the average
protein requirement per day approximately 90 g/day [9]. The addition of the duodenal switch procedure to the BPD has
reduced protein malabsorption from 11 to 3 percent [23]. (See "Mechanisms of nutrient absorption and malabsorption",
section on 'Protein absorption'.)
Long-term dietary recommendations include consuming small, nutrient-dense meals that are high in protein, along with fruits,
vegetables, whole grains, and omega-3 fatty acids, and avoiding intake of concentrated sweets.
MACRONUTRIENT MANAGEMENT Early after bariatric surgery, patients use stored adipose tissue for energy needs;
there are approximately 3500 kcals in one pound of stored body fat. Thus, early postoperative diet stages are based upon
meeting essential nutrient needs and maintaining adequate hydration. However, as weight stabilizes, patients will begin to
obtain the bulk of their energy needs from dietary sources. By then, the macronutrient requirements of patients who have
undergone a sleeve gastrectomy (SG) or a Roux-en-Y-gastric-bypass (RYGB) do not differ from those of the general
population. Patients losing and maintaining weight should base their macronutrient intake on their total caloric intake [13].
Protein The recommended daily allowance for protein is 46 grams per day for women and 56 grams per day for men.
Protein intake should constitute at least 10 percent of daily caloric intake but not more than 35 percent, according to
recommendations from the Institute of Medicine. Protein needs in weight maintenance can also be calculated based on 0.8 to
1.2 grams/kg body weight per day, although exact needs are not clearly defined and may need to be individually assessed [9].
Protein needs during the active weight loss phase should be calculated as 1.2 grams/kg body weight for preservation of fat-
free mass [24]. Due to excess malabsorption that occurs with biliopancreatic diversion with duodenal switch (BPD/DS), protein
intake of 1.5 to 2.0 g of protein/kg body weight per day may be required, making the average protein requirement per day
approximately 90 g/day after that procedure [9].
Carbohydrates Carbohydrates are an essential macronutrient that should constitute approximately 50 percent of total
caloric intake. To meet that requirement, a minimum of 50 grams per day should be consumed early postoperatively,
advancing to 130 grams per day as diet intake increases. Patients should be educated to consume complex carbohydrates
from sources such as whole fruits, vegetables, and whole grains. Simple sugars should be limited to less than 10 percent of
daily caloric intake.
Fat Fat should constitute approximately 20 to 35 percent of the daily caloric intake. For a women on a 1600-kcal-per-day
diet, for example, daily fat intake should be approximately 35 to 60 grams. The bulk of the fat intake should be unsaturated fat.
MICRONUTRIENT MANAGEMENT Micronutrient deficiencies are quite prevalent in patients with obesity. While some
patients have baseline deficiencies before bariatric surgery, others may develop new deficiencies following the surgery, even
years after it has been performed [3,25].
Micronutrient deficiencies are a particular problem following malabsorptive or combination procedures because of inadequate
intake of nutrients and alterations in the digestive anatomy due to the operative procedures bypassing portions of the
stomach, duodenum, and/or proximal jejunum [26]. As examples, portions of the duodenum and the small bowel are excluded
from the alimentary path with Roux-en-Y gastric bypass (RYGB) (figure 1) and biliopancreatic diversion with duodenal switch
(BPD/DS) (figure 2) operations, thereby bypassing critical absorptive surfaces in the gastrointestinal tract for some fat- and
water-soluble vitamins (eg, folate, vitamin B12, and vitamin D) and minerals (eg, iron, calcium) [27]. (See "Bariatric
procedures for the management of severe obesity: Descriptions".)
The risk for developing nutritional deficiencies following a purely restrictive procedure, such as laparoscopic adjustable gastric
band (LAGB), is less compared with malabsorptive or combination procedures. However, the risk depends upon changes in
the patient's diet and eating habits. Nutritional deficiencies may occur in these patients due to low nutrient intake, poor food
choices, food intolerances, excessive vomiting, and limited portion sizes. As examples, excessive and/or persistent vomiting
due to a tight or displaced band can cause an acute deficiency of thiamin (see 'Vitamin B1 (thiamine)' below), and the overall
intake of dietary iron can be reduced due to decreased food volume, particularly with a reduction in meat intake. (See 'Iron'
below.)
Presurgical screening It is common for patients with obesity preparing for bariatric surgery to have at least one vitamin or
mineral deficiency preoperatively [28]. Thus, the American Society for Metabolic and Bariatric Surgery (ASMBS) intergraded
5 of 32 10/29/17, 23:18
health nutritional guides for the surgical weight loss patient recommend routine baseline presurgical screening for levels of
thiamin, vitamin B12, folate, iron, vitamin D and calcium, fat-soluble vitamins (A, E, K), zinc, and copper [29]. These screening
laboratory tests can be performed as an integral part of the preoperative clinical nutrition evaluation by a registered dietitian.
(See "Bariatric operations for management of obesity: Indications and preoperative preparation", section on 'Nutrition'.)
Postsurgical screening ASMBS guidelines further recommend nutrient assessments every three to six months in the first
year after bariatric surgery, and annually thereafter with laboratory tests [10,29]. During each follow-up visit, clinicians should
perform a review of systems to help identify symptoms of micronutrient malnutrition. Some of these symptoms may be subtle,
such as loss of night vision, memory issues, or impaired learning. The routine panel of laboratory tests is determined by
individual programs.
Micronutrient deficiency, supplementation, and repletion The ASMBS recommends micronutrient supplementation for
all patients after bariatric surgery. Patients who develop symptoms suggestive of a micronutrient deficiency, or who have a
micronutrient deficiency identified by screening laboratory tests, should be given appropriate repletion. Symptoms of specific
micronutrient deficiencies, requirements for routine supplementation according to bariatric procedures, and requirements for
repletion in case of deficiency are presented below for each micronutrient (table 3) [29].
Fat-soluble vitamins Fat-soluble vitamins include vitamins A, D, E, and K. The jejunum and ileum are the primary sites
of absorption for this class of vitamins [30,31]. Deficiencies in fat-soluble vitamins are more likely to occur following RYGB [27]
or BPD/DS [32-35]. Obesity is associated with vitamin D deficiency and secondary hyperparathyroidism, even in patients who
have not undergone bariatric surgery [36-38]. Clinical syndromes associated with fat-soluble vitamins are given in the table
(table 5).
The recommended daily allowance (RDA) for fat-soluble vitamins in the general population can be found in the included table
(table 6). The supplementation of fat-soluble vitamins following RYGB and SG is shown in the included table (table 3).
Supplementation with fat-soluble vitamin complexes is also advised after BPD/DS as the fat malabsorption caused by the
operation leads to frequent deficiencies of these vitamins.
Vitamin A A reported 14 percent of patients with obesity have vitamin A deficiency before bariatric surgery [39]. Eight
to 11 percent of patients develop vitamin A deficiency after RYGB; 70 percent develop vitamin A deficiency within four years of
BPD/DS [40,41]. Early symptoms of vitamin A deficiency include night blindness, Bitot's spots (picture 1), poor healing,
hyperkeratinization of the skin, and loss of taste. Late symptoms can include corneal damage, xerosis, or even blindness.
(See "Overview of vitamin A", section on 'Deficiency'.)
Patients should receive a vitamin A supplement of 5000 IU daily after LAGB, 5000 to 10,000 IU daily after RYGB or SG, and
10,000 IU daily after BPD/DS [33].
Patients with vitamin A deficiency but without corneal changes should receive 10,000 to 25,000 IU daily orally until clinical
improvement (one to two weeks); those with corneal changes should be given 50,000 to 100,000 IU daily intramuscularly for
three days, followed by 50,000 IU/day for two weeks [9].
Vitamin D Vitamin D deficiency has been reported in 90 percent of patients before and 100 percent of patients after
bariatric surgery [39]. Lack of vitamin D activity leads to reduced intestinal absorption of calcium and phosphorus. Early in
vitamin D deficiency, hypophosphatemia is more marked than hypocalcemia. With persistent vitamin D deficiency,
hypocalcemia occurs and causes secondary hyperparathyroidism, which leads to phosphaturia, demineralization of bones,
and, when prolonged and severe, to osteomalacia in adults and rickets and osteomalacia in children. (See "Vitamin D
deficiency in adults: Definition, clinical manifestations, and treatment", section on 'Clinical manifestations' and "Overview of
vitamin D", section on 'Deficiency and resistance' and "Causes of vitamin D deficiency and resistance", section on 'Gastric
bypass'.)
After bariatric surgery, patients should receive 3000 IU of D3 daily from all sources to maintain a 25(OH)D level of >30 ng/mL
[42]. (See 'Postsurgical screening' above.)
Patients with vitamin D deficiency should receive 3000 to 6000 IU of D3 daily (preferred), or 50,000 IU of D2 one to three
times per week [43]. Vitamin D deficiency must be corrected in order to achieve a normal calcium level. (See 'Calcium' below.)
Vitamin E A reported 2.2 percent of patients have a vitamin E deficiency before bariatric surgery [39]. Vitamin E
deficiency can cause neuromuscular disorders and hemolysis. Neuromuscular disorders associated with vitamin E deficiency
6 of 32 10/29/17, 23:18
are mostly of the neuropathic and myopathic type. Clinical manifestations include ataxia, hyporeflexia, and loss of
proprioceptive and vibratory sensation. (See "Overview of vitamin E", section on 'Deficiency'.)
After bariatric surgery, adult patients and adolescents ages 14 and over should receive vitamin E supplements of 15 mg (22.4
IU) per day [33]. Breastfeeding women should receive 19 mg, or 28.4 IU, per day. (See 'Postsurgical screening' above.)
Patients with vitamin E deficiency should receive 100 to 400 IU daily (90 to 300 mg), although the optimal dose is not well
established [9].
Vitamin K Clinical signs and symptoms of vitamin K deficiency include easy bruisability, mucosal bleeding, splinter
hemorrhages, melena, hematuria, or any other manifestations of impaired coagulation. (See "Overview of vitamin K", section
on 'Deficiency'.)
Patients should receive daily supplements of 90 to 120 mcg of vitamin K after LAGB, RYGB, or SG, or 300 mcg daily after
BPD/DS [33]. (See 'Postsurgical screening' above.)
The treatment for vitamin K deficiency due to acute malabsorption is 10 mg of parenteral vitamin K. The treatment for those
with chronic malabsorption is 1 to 2 mg per day orally or 1 to 2 mg per week parenterally [9].
Water-soluble vitamins The water-soluble vitamins and deficiency syndromes can be found in the included table (table
5). Long-term deficiencies in water-soluble vitamins have been reported [44]. (See "Overview of water-soluble vitamins".)
Vitamin B1 (thiamine) Vitamin B1 (thiamine) is absorbed through carrier-mediated active transport, primarily in the
duodenum and proximal jejunum [45]. RYGB and BPD/DS patients are at a particularly elevated risk since their alimentary
path bypasses the duodenum and proximal jejunum. Vitamin B1 deficiency may occur within three weeks after bariatric
surgery in the patient with persistent vomiting or severely diminished oral intake [46,47]. Thiamine deficiency may be caused
or exacerbated by alterations in gut flora following an RYGB [48].
Asymptomatic, abnormally low thiamine concentrations have been reported in 16 to 29 percent of preoperative patients
[49,50]. The most common manifestation of vitamin B1 deficiency in the post-bariatric bypass surgical population is Wernicke
encephalopathy (WE), a neurologic condition causing encephalopathy, oculomotor dysfunction, and gait ataxia [51]. WE
occurs in <1 to 49 percent of post-bariatric patients, depending on the type of surgery and length of follow-up [48,52].
Because neurologic deficits related to thiamine deficiency can become permanent if untreated, any bariatric patient who
presents with prolonged vomiting should have a neurologic exam and be given thiamine until it can be proven that the patient
does not have a thiamine deficiency. A laboratory test for thiamine level obtained at the initial encounter may take a few days
to come back. Patients with suspected WE should not be administered intravenous solutions containing glucose, as these
may deplete the remaining available thiamine and precipitate Korsakoff's syndrome, a chronic neurologic condition that
usually occurs as a consequence of WE. (See "Wernicke encephalopathy".)
Post-bariatric surgery patients should receive at least 12 mg of thiamin daily. Since over-the-counter multivitamins typically
contain less than that amount, it is preferable for patients to take a B-complex supplement containing 50 mg of thiamine one
or twice daily, in addition to a multivitamin [53].
Management of vitamin B1 deficiency includes:
Administer thiamine in one of the following three regimens:
Oral: 100 mg three times daily until symptoms resolve.
Intravenous: 200 mg three times daily to 500 mg once or twice daily for three to five days, followed by 250 mg daily
for three to five days, and subsequent oral maintenance (100 mg daily) indefinitely [43,54].
Intramuscular: 250 mg daily for three to five days [55,56] or 100 to 250 mg monthly [29,57,58].
Simultaneously replete magnesium, potassium, and phosphorus to prevent refeeding syndrome.
Immediate treatment of surgical causes of vomiting (eg, obstruction).
Vitamin B12 The prevalence of preoperative vitamin B12 deficiency has been reported to range from 0 to 18 percent
[49]. Bariatric procedures, including RYGB and SG, can result in vitamin B12 deficiency. Vitamin B12 deficiency is relatively
7 of 32 10/29/17, 23:18
common after RYGB, occurring in one-third or more of postoperative patients [59-62]. There are relatively few parietal cells
present in the small gastric pouch; therefore, inadequate gastric acid is available for the initial step, the cleavage of vitamin
B12 from dietary protein [63]. Additionally, a decreased amount of intrinsic factor may be available after RYGB [64]. Patients
who have undergone an RYGB are at a greater risk for vitamin B12 deficiency compared with patients managed with an SG
(42 versus 5 percent) [65]. The prevalence of B12 deficiency after SG ranges from 4 to 20 percent [66-69].
Vitamin B12 deficiency, which results in pernicious (megaloblastic) anemia, is permanent, and lifelong management is
warranted with oral or parenteral supplements [27]. (See "Treatment of vitamin B12 and folate deficiencies", section on
'Vitamin B12' and "Causes and pathophysiology of vitamin B12 and folate deficiencies", section on 'Causes of vitamin B12
deficiency'.)
We advise a daily oral dose of vitamin B12 of 350 to 500 mcg for postoperative bariatric surgery management [43].
Alternatively, patients can be treated with 1000 mcg of B12 intramuscularly or subcutaneously (monthly), or by nasal spray
preparations (dose per manufacturer) [29]. Peripheral neuropathy resulting from chronic vitamin B12 deficiency may not be
reversible and must be prevented by diligent laboratory monitoring and adequate replacement. Since the body has a 12- to
18-month storage of vitamin B12, B12 deficiency is identified approximately two years or more following surgery; therefore,
yearly long-term laboratory monitoring is essential. (See 'Postsurgical screening' above.)
Patients with B12 deficiency should receive 1000 mcg of B12 daily until the level is normalized before resuming maintenance
doses [70].
Folate Folate deficiency, which also induces megaloblastic anemia, is less common than vitamin B12 deficiency
since folic acid is absorbed throughout the entire small intestine. The preoperative prevalence of folate deficiency in patients
with obesity is 0 to 54 percent [71]. However, because folate is water soluble and there are no long-term stores in the body,
deficiencies may arise due to inadequate oral intake. Malabsorption of folate is less common following RYGB and SG since
the non-bypassed small bowel is usually adequate to absorb dietary folate [72,73]; deficiency is more common following BPD
due to limited absorption. (See "Clinical manifestations and diagnosis of vitamin B12 and folate deficiency" and "Causes and
pathophysiology of vitamin B12 and folate deficiencies".)
Supplementation is typically provided as a daily oral dose of 400 to 800 mcg, usually as a part of a multivitamin [74]. Women
of childbearing age should take 800 to 1000 mcg daily [75]. Prenatal vitamins, which generally contain 1 mg of folate per
tablet, can also be used [76].
Patients with B12 deficiency should receive 1000 mcg daily until the level is normalized before maintenance doses can be
resumed [29]. Folate supplementation above 1 mg per day is not recommended due to the potential masking of vitamin B12
deficiency [77].
Vitamin C Vitamin C (ascorbic acid) deficiency, which leads to scurvy, is uncommon following bariatric bypass
procedures, as long as the patient consumes fruits and vegetables. (See "Overview of water-soluble vitamins", section on
'Vitamin C (ascorbic acid)'.)
Supplementation of vitamin C may enhance absorption of iron from both dietary sources, and supplements should be
considered in patients who do not respond to oral iron therapy [78].
Trace minerals Minerals form only 5 percent of the typical human diet but are essential for normal health and function.
Macrominerals are defined as minerals that are required by adults in amounts greater than 100 mg/day or that make up less
than 1 percent of total body weight. Trace elements (or trace minerals) are usually defined as minerals that are required in
amounts between 1 to 100 mg/day by adults or make up less than 0.01 percent of total body weight. Ultra-trace minerals
generally are defined as minerals that are required in amounts less than 1 mg/day. Although the classification of mineral may
be controversial and somewhat arbitrary, one outline is given in the table (table 7). (See "Overview of dietary trace minerals".)
Iron Iron deficiency is one of the most common nutritional problems following bariatric surgery and results in
hypochromic and microcytic anemia. Iron is primarily absorbed in the duodenum and proximal jejunum; bariatric bypass
operations, namely RYGB and BPD/DS, exacerbate this problem. In addition, dietary iron is commonly bound to protein and
cleaved by the action of gastric acid in the stomach. Iron deficiency is identified in 0 to 58 percent of patients with obesity
preoperatively and 8 to 50 percent of postoperative bariatric patients, particularly in women who are still menstruating [29].
(See "Causes and diagnosis of iron deficiency and iron deficiency anemia in adults", section on 'Causes of iron deficiency'
and "Overview of dietary trace minerals", section on 'Deficiency'.)
8 of 32 10/29/17, 23:18
Because there is only a small amount of gastric acid-producing tissue in the RYGB pouch or SG remnant, iron absorption may
be further reduced [63,79-81]. In a retrospective review of 100 bariatric surgery patients undergoing an RYGB, abnormally low
levels were found in 16 percent of preoperative gastric bypass patients [82].
After bariatric surgery, males and patients without history of anemia should receive at least 18 mg of iron from a multivitamin.
Menstruating females and those who have undergone RYGB, SG, or BPD/DS should take at least 45 to 60 mg of elemental
iron daily [43]. Most multivitamins do not have enough iron in the elemental form to achieve this level of supplementation.
Taking vitamin C with iron increases absorption; calcium supplements and foods containing high amounts of calcium will
decrease absorption.
Management of iron deficiency anemia depends upon the acuity of the illness and includes oral and parenteral administration
of elemental iron. Post-bariatric surgery patients with iron deficiency should start with 150 to 300 mg of iron orally two to three
times daily [43,83]. Iron infusions may be indicated in postoperative patients who have chronic iron deficiency and/or cannot
tolerate the amount of oral iron supplements needed for repletion [10]. The treatment for iron deficiency is reviewed in detail
separately. (See "Treatment of iron deficiency anemia in adults".)
Zinc Zinc, like other divalent cations, is absorbed in the duodenum and proximal jejunum and linked to fat absorption.
Zinc deficiency results in growth retardation, delayed sexual maturity, impotence, and impaired immune function, among other
medical conditions. (See "Overview of dietary trace minerals", section on 'Zinc'.)
The prevalence of zinc deficiency ranged from 9 to 74 percent in patients seeking BPD/DS [82,84,85]. Zinc deficiency can
follow bypass or malabsorptive bariatric operations [86,87]. A retrospective review of 73 patients undergoing a BPD without
duodenal switch and 61 patients undergoing a BPD/DS found that 11 percent of all patients developed zinc deficiency two to
three years after surgery [88]. There was no difference between the patients undergoing a BPD versus a BPD/DS. Zinc
deficiency occurs in approximately 6 to 40 percent of patients after RYGB [4,5,28,86].
Post-bariatric surgery patients should receive zinc supplementation according to the type of procedure [43]:
BPD/DS: Multivitamin containing 200 percent of RDA for zinc (16 to 22 mg daily)
RYGB: Multivitamin containing 100 to 200 percent of RDA for zinc (8 to 22 mg daily)
LAGB: Multivitamin containing 100 percent of RDA for zinc (8 to 11 mg daily)
A ratio of 1 mg copper supplementation has been recommended for every 8 to 15 mg of elemental zinc to prevent copper
deficiency [43]. (See 'Copper' below.)
Management of a zinc deficiency is by oral administration of 60 mg of zinc twice daily [43]. The current optimal dose is
unknown [89]. Megadoses are associated with toxicity, including copper deficiency and gastrointestinal symptoms [29]. (See
"Overview of dietary trace minerals", section on 'Toxicity'.)
Copper Copper is absorbed in the stomach and proximal duodenum [90,91]. It is required for red and white blood
cell production and for normal functioning of the nervous system [92]. Copper deficiency results in microcytic anemia,
neutropenia, and ataxia and is worsened by iron supplements. (See "Overview of dietary trace minerals", section on 'Copper'.)
An acquired copper deficiency has been reported following bypass bariatric operations, such as RYGB and BPD/DS
operations [93]. In a retrospective review of records of 136 patients who had undergone RYGB, 13 (10 percent) were found to
have copper deficiency; a separate analysis from the same study followed 16 patients prospectively for two years, and three
developed copper deficiency [94]. The clinical presentation is often indistinguishable from subacute combined degeneration, a
condition found in patients with vitamin B12 deficiency [95]. (See "Copper deficiency myeloneuropathy", section on 'Clinical
manifestations'.)
Post-bariatric surgery patients should receive copper supplementation according to the type of procedure:
BPD/DS or RYGB: Multivitamin containing 200 percent of RDA for copper (2 mg daily)
SG or LAGB: Multivitamin containing 100 percent of RDA for copper (1 mg daily)
A ratio of 1 mg copper supplementation has been recommended for every 8 to 15 mg of elemental zinc to prevent copper
deficiency [43].
Management of copper deficiency depends on the severity of the deficiency [9,43]:
9 of 32 10/29/17, 23:18
Mild-to-moderate deficiency: 3 to 8 mg copper orally until levels normalize

Severe deficiency: 2 to 4 mg copper intravenously for six days or until symptoms resolve
Hematologic abnormalities may respond with two months of therapy while neurologic symptoms may persist long term. (See
"Copper deficiency myeloneuropathy", section on 'Treatment' and "Sideroblastic anemias: Diagnosis and management",
section on 'Copper deficiency'.)
Selenium Selenium is absorbed in the duodenum and proximal jejunum by the methionine pathway [92]. Selenium
deficiency results in skeletal muscle dysfunction and cardiomyopathy and has been implicated in mood disorders, impaired
immune function, and macrocytosis. (See "Overview of dietary trace minerals", section on 'Selenium'.)
Selenium deficiency has been reported in 14 to 22 percent of patients following an RYGB and BPD/DS procedure,
respectively [88,96]. The optimal range for dietary intake of selenium is narrow; potentially toxic intakes are closer to
recommended dietary intakes than for other dietary trace minerals. Management includes oral supplementation with an
estimated goal of over 100 mcg/day [97]. In a few studies, the use of 2 mcg/kg/day was used for repletion when patients
suffered cardiomyopathy from selenium depletion [98].
Calcium After bypass bariatric surgery, dietary intake of both calcium and vitamin D may be reduced. Dietary calcium is
best absorbed in the duodenum and proximal jejunum, where the highest concentration of calcium transporters is present.
Calcium is passively absorbed through the entire gastrointestinal tract. Additionally, calcium is better absorbed in an acidic
environment; since gastric acid exposure is reduced in RYGB, SG, and BPD/DS, these patients are at an increased risk of
calcium malabsorption. In one study, 3.6 percent of patients developed hypocalcemia after bariatric surgery, including 1.9
percent after RYGB, 9.3 percent after SG, and 10 percent after BPD/DS [99]. (See "Etiology of hypocalcemia in adults".)
The absorption of calcium is dependent upon vitamin D, which is absorbed in the jejunum and ileum and bypassed by bariatric
operations such as RYGB and BPD/DS [100]. BPD/DS patients are additionally at risk for vitamin D deficiency due to their fat
malabsorption [31]. The plasma level of vitamin D has been shown to decline over time after bariatric surgery [101]. (See 'Fat-
soluble vitamins' above.)
Calcium deficiency is associated with metabolic bone disease and secondary hyperparathyroidism. Management of
hypocalcemia depends upon the severity of disease and includes oral and parenteral administration of calcium and vitamin D.
(See "Treatment of hypocalcemia", section on 'Therapeutic approach' and "Treatment of hypocalcemia", section on 'Vitamin D
deficiency'.)
Secondary hyperparathyroidism can develop or persist postoperatively [102-104]. Affected patients will show elevated levels
of parathyroid hormone and normal-to-low serum calcium [104]. One study in 193 women in the United States found that
postmenopausal women, African-American women, and those with a higher body mass index (BMI) were at increased risk of
developing secondary hyperparathyroidism after RYGB [104].
Post-bariatric surgery patients should receive calcium supplementation according to the type of procedure [42]:
BPD/DS: 1800 to 2400 mg daily

RYGB, SG, or LAGB: 1200 to 1500 mg daily
The recommended doses of calcium repletion are identical to the doses of calcium supplementation described above. In order
to enhance absorption, calcium supplements should be given in divided doses, with meals for calcium carbonate, and with or
without meals for calcium citrate. Calcium carbonate, while more widely available, is not as well absorbed after RYGB due to
decreased acidity of the gastric pouch. Calcium citrate is better absorbed in an achlorhydric environment such as the post-
RYGB stomach pouch; however, calcium carbonate is less expensive and more readily available and may be recommended
in patients after an SG given that more gastric acid-producing cells are preserved. Cost, availability, and patient compliance
should all be taken into consideration when making supplementation recommendations.
EATING DISORDERS A significant number of individuals go into obesity surgery with preexisting disordered eating
behavior, such as binge eating disorder or food addictions [105]. Patients with disordered eating are unlikely to disclose these
behaviors to their clinician unless they are solicited. Asking the patient to describe what he/she ate during the past 24 hours in
a nonjudgmental and nonthreatening manner can often identify dysfunctional eating patterns. (See "Dietary assessment in
adults" and "Eating disorders: Overview of epidemiology, clinical features, and diagnosis".)
In order to maintain the weight loss that typically follows surgery, patients must significantly change their eating patterns.
10 of 32 10/29/17, 23:18
General normalization of eating behavior has been reported, characterized by fewer meals, less food consumed at each meal,
less eating between meals, and less eating in response to strong emotions [6,106,107]. Severe binge eating becomes virtually
impossible following Roux-en-Y gastric bypass (RYGB) due to the severely restricted stomach.
Despite this, patients with a preoperative history of eating disorders are more likely to have difficulty adjusting to the change in
eating habits, and some may continue to have disordered eating patterns. Referral to an experienced psychologist can help
unmask some of the underlying emotional issues associated with food.
SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Bariatric surgery".)
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they
answer the four or five key questions a patient might have about a given condition. These articles are best for patients who
want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer,
more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your
patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the
keyword(s) of interest.)
Basics topic (see "Patient education: Care after weight loss surgery (The Basics)")
Beyond the Basics topic (see "Patient education: Weight loss treatments (Beyond the Basics)").
SUMMARY AND RECOMMENDATIONS
The early diet advancement after bariatric surgery is based upon a staged approach with emphasis on nutritional needs
at each stage of healing and weight loss (table 1 and table 2) (see 'Early (postoperative) diet' above):
Postoperative weeks 1 and 2: Hydration and liquids.
Postoperative week 3 and beyond: Solid foods, advancing food texture and amounts as tolerated.
Once maintenance weight is achieved: Healthy, balanced diet and micronutrient supplements.
Long-term eating habits are in part determined by the patient's motivation, willingness, and ability to adhere to a healthy
diet. Dietary intake longer-term is also dependent upon the type of bariatric procedure performed. (See 'Long-term diet'
above.)
Early after bariatric surgery, patients use stored adipose tissue for energy needs. Thus, early postoperative diet stages
are based upon meeting essential nutrient needs and maintaining adequate hydration. As weight stabilizes and patients
are obtaining the bulk of their energy needs from dietary sources, the nutritional recommendations for macronutrients do
not differ from those of the general population. (See 'Macronutrient management' above.)
It is common for patients with obesity preparing for bariatric surgery to have at least one vitamin or mineral deficiency
preoperatively. Thus, patients should undergo routine baseline presurgical screening for levels of thiamin, vitamin B12,
folate, iron, vitamin D and calcium, fat-soluble vitamins (A, E, K), zinc, and copper. (See 'Presurgical screening' above.)
After bariatric surgery, patients should undergo nutrient assessments every three to six months in the first year, and
annually thereafter. Routine laboratory tests are determined by individual programs. (See 'Postsurgical screening' above.)
To prevent micronutrient deficiency, patients should receive daily vitamin and mineral supplementation determined by the
bariatric procedure after bariatric surgery (table 3). (See 'Micronutrient management' above.)
Patients with symptoms suggestive or a laboratory test diagnostic of a micronutrient deficiency should receive repletion of
that micronutrient (table 3). (See 'Micronutrient management' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
11 of 32 10/29/17, 23:18
REFERENCES
1. American Society for Metabolic and Bariatric Surgery position statement on sleeve gastrectomy as a bariatric procedure
2007. http://pugetsoundsurgicalcenter.com/sleeve_statement.pdf (Accessed on March 24, 2010).
2. Bosnic G. Nutritional requirements after bariatric surgery. Crit Care Nurs Clin North Am 2014; 26:255.
3. Tucker ON, Szomstein S, Rosenthal RJ. Nutritional consequences of weight-loss surgery. Med Clin North Am 2007;
91:499.
4. Gong K, Gagner M, Pomp A, et al. Micronutrient deficiencies after laparoscopic gastric bypass: recommendations. Obes
Surg 2008; 18:1062.
5. Dalcanale L, Oliveira CP, Faintuch J, et al. Long-term nutritional outcome after gastric bypass. Obes Surg 2010; 20:181.
6. Adami GF, Meneghelli A, Scopinaro N. Night eating and binge eating disorder in obese patients. Int J Eat Disord 1999;
25:335.
7. Topart P, Becouarn G, Sall A, Ritz P. Biliopancreatic diversion requires multiple vitamin and micronutrient adjustments
within 2 years of surgery. Surg Obes Relat Dis 2014; 10:936.
8. van Rutte PW, Aarts EO, Smulders JF, Nienhuijs SW. Nutrient deficiencies before and after sleeve gastrectomy. Obes
Surg 2014; 24:1639.
9. Allied Health Sciences Section Ad Hoc Nutrition Committee, Aills L, Blankenship J, et al. ASMBS Allied Health
Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis 2008; 4:S73.
10. Mechanick JI, Youdim A, Jones DB, et al. 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. Obesity (Silver Spring)
2013; 21 Suppl 1:S1.
11. Moore CE, Sherman V. Vitamin D supplementation efficacy: sleeve gastrectomy versus gastric bypass surgery. Obes
Surg 2014; 24:2055.
12. Ferrer R, Pardina E, Rossell J, et al. Haematological parameters and serum trace elements in "healthy" and "unhealthy"
morbidly obese patients before and after gastric bypass. Clin Nutr 2015; 34:276.
13. https://health.gov/dietaryguidelines/2015/guidelines/appendix-7/ (Accessed on July 26, 2017).
14. Ortega J, Ortega-Evangelio G, Cassinello N, Sebastia V. What are obese patients able to eat after Roux-en-Y gastric
bypass? Obes Facts 2012; 5:339.
15. Schweiger C, Weiss R, Keidar A. Effect of different bariatric operations on food tolerance and quality of eating. Obes
Surg 2010; 20:1393.
16. Nelson WK, Fatima J, Houghton SG, et al. The malabsorptive very, very long limb Roux-en-Y gastric bypass for super
obesity: results in 257 patients. Surgery 2006; 140:517.
17. Sweeney TE, Morton JM. Metabolic surgery: action via hormonal milieu changes, changes in bile acids or gut
microbiota? A summary of the literature. Best Pract Res Clin Gastroenterol 2014; 28:727.
18. Yousseif A, Emmanuel J, Karra E, et al. Differential effects of laparoscopic sleeve gastrectomy and laparoscopic gastric
bypass on appetite, circulating acyl-ghrelin, peptide YY3-36 and active GLP-1 levels in non-diabetic humans. Obes Surg
2014; 24:241.
19. Tremaroli V, Karlsson F, Werling M, et al. Roux-en-Y Gastric Bypass and Vertical Banded Gastroplasty Induce Long-
Term Changes on the Human Gut Microbiome Contributing to Fat Mass Regulation. Cell Metab 2015; 22:228.
20. American Society for Metabolic and Bariatric Surgery position statement on sleeve gastrectomy as a bariatric procedure
2007; http://pugetsoundsurgicalcenter.com/sleeve_statement.pdf (Accessed on March 24, 2010).
21. Scopinaro N, Gianetta E, Adami GF, et al. Biliopancreatic diversion for obesity at eighteen years. Surgery 1996; 119:261.
22. Bojsen-Mller KN, Jacobsen SH, Dirksen C, et al. Accelerated protein digestion and amino acid absorption after Roux-
en-Y gastric bypass. Am J Clin Nutr 2015; 102:600.
23. Gracia JA, Martnez M, Elia M, et al. Obesity surgery results depending on technique performed: long-term outcome.
Obes Surg 2009; 19:432.
24. Soenen S, Martens EA, Hochstenbach-Waelen A, et al. Normal protein intake is required for body weight loss and
12 of 32 10/29/17, 23:18
weight maintenance, and elevated protein intake for additional preservation of resting energy expenditure and fat free
mass. J Nutr 2013; 143:591.
25. Flancbaum L, Belsley S, Drake V, et al. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass
for morbid obesity. J Gastrointest Surg 2006; 10:1033.
26. Bloomberg RD, Fleishman A, Nalle JE, et al. Nutritional deficiencies following bariatric surgery: what have we learned?
Obes Surg 2005; 15:145.
27. Ledoux S, Msika S, Moussa F, et al. Comparison of nutritional consequences of conventional therapy of obesity,
adjustable gastric banding, and gastric bypass. Obes Surg 2006; 16:1041.
28. Gehrer S, Kern B, Peters T, et al. Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after
laparoscopic Roux-Y-gastric bypass (LRYGB)-a prospective study. Obes Surg 2010; 20:447.
29. Parrott J, Frank L, Rabena R, et al. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional
Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients. Surg Obes Relat Dis 2017; 13:727.
30. Davies DJ, Baxter JM, Baxter JN. Nutritional deficiencies after bariatric surgery. Obes Surg 2007; 17:1150.
31. Clements RH, Katasani VG, Palepu R, et al. Incidence of vitamin deficiency after laparoscopic Roux-en-Y gastric bypass
in a university hospital setting. Am Surg 2006; 72:1196.
32. Schweitzer DH, Posthuma EF. Prevention of vitamin and mineral deficiencies after bariatric surgery: evidence and
algorithms. Obes Surg 2008; 18:1485.
33. Aasheim ET, Bjrkman S, Svik TT, et al. Vitamin status after bariatric surgery: a randomized study of gastric bypass
and duodenal switch. Am J Clin Nutr 2009; 90:15.
34. Slater GH, Ren CJ, Siegel N, et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after
malabsorptive bariatric surgery. J Gastrointest Surg 2004; 8:48.
35. Pereira S, Saboya C, Chaves G, Ramalho A. Class III obesity and its relationship with the nutritional status of vitamin A
in pre- and postoperative gastric bypass. Obes Surg 2009; 19:738.
36. Hamoui N, Anthone G, Crookes PF. Calcium metabolism in the morbidly obese. Obes Surg 2004; 14:9.
37. Snchez-Hernndez J, Ybarra J, Gich I, et al. Effects of bariatric surgery on vitamin D status and secondary
hyperparathyroidism: a prospective study. Obes Surg 2005; 15:1389.
38. Hamoui N, Kim K, Anthone G, Crookes PF. The significance of elevated levels of parathyroid hormone in patients with
morbid obesity before and after bariatric surgery. Arch Surg 2003; 138:891.
39. Peterson LA, Cheskin LJ, Furtado M, et al. Malnutrition in Bariatric Surgery Candidates: Multiple Micronutrient
Deficiencies Prior to Surgery. Obes Surg 2016; 26:833.
40. Pereira SE, Saboya CJ, Saunders C, Ramalho A. Serum levels and liver store of retinol and their association with night
blindness in individuals with class III obesity. Obes Surg 2012; 22:602.
41. Zalesin KC, Miller WM, Franklin B, et al. Vitamin a deficiency after gastric bypass surgery: an underreported
postoperative complication. J Obes 2011; 2011.
42. Institute of Medicine, Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary Reference I
ntakes for Calcium and Vitamin D. National Academy of Sciences; Food and Nutrition Board, Institute of Medicine, Natio
nal Academy of Sciences, Washington, DC, DC.
43. Mechanick JI, Youdim A, Jones DB, et al. 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. Surg Obes Relat Dis
2013; 9:159.
44. Ledoux S, Calabrese D, Bogard C, et al. Long-term evolution of nutritional deficiencies after gastric bypass: an
assessment according to compliance to medical care. Ann Surg 2014; 259:1104.
45. Iannelli A, Addeo P, Novellas S, Gugenheim J. Wernicke's encephalopathy after laparoscopic Roux-en-Y gastric bypass:
a misdiagnosed complication. Obes Surg 2010; 20:1594.
46. Kaidar-Person O, Person B, Szomstein S, Rosenthal RJ. Nutritional deficiencies in morbidly obese patients: a new form
of malnutrition? Part A: vitamins. Obes Surg 2008; 18:870.
47. Sechi G, Serra A. Wernicke's encephalopathy: new clinical settings and recent advances in diagnosis and management.
13 of 32 10/29/17, 23:18
Lancet Neurol 2007; 6:442.

48. Lakhani SV, Shah HN, Alexander K, et al. Small intestinal bacterial overgrowth and thiamine deficiency after Roux-en-Y
gastric bypass surgery in obese patients. Nutr Res 2008; 28:293.
49. Saltzman E, Karl JP. Nutrient deficiencies after gastric bypass surgery. Annu Rev Nutr 2013; 33:183.
50. Carrodeguas L, Kaidar-Person O, Szomstein S, et al. Preoperative thiamine deficiency in obese population undergoing
laparoscopic bariatric surgery. Surg Obes Relat Dis 2005; 1:517.
51. Aasheim ET. Wernicke encephalopathy after bariatric surgery: a systematic review. Ann Surg 2008; 248:714.
52. Becker DA, Balcer LJ, Galetta SL. The Neurological Complications of Nutritional Deficiency following Bariatric Surgery. J
Obes 2012; 2012:608534.
53. Rudnicki SA. Prevention and treatment of peripheral neuropathy after bariatric surgery. Curr Treat Options Neurol 2010;
12:29.
54. Galvin R, Brthen G, Ivashynka A, et al. EFNS guidelines for diagnosis, therapy and prevention of Wernicke
encephalopathy. Eur J Neurol 2010; 17:1408.
55. Bal BS, Finelli FC, Shope TR, Koch TR. Nutritional deficiencies after bariatric surgery. Nat Rev Endocrinol 2012; 8:544.
56. Thomson AD, Marshall EJ. The treatment of patients at risk of developing Wernicke's encephalopathy in the community.
Alcohol Alcohol 2006; 41:159.
57. Foster D, Falah M, Kadom N, Mandler R. Wernicke encephalopathy after bariatric surgery: losing more than just weight.
Neurology 2005; 65:1987; discussion 1847.
58. Shah HN, Bal BS, Finelli FC, Koch TR. Constipation in patients with thiamine deficiency after Roux-en-Y gastric bypass
surgery. Digestion 2013; 88:119.
59. Skroubis G, Sakellaropoulos G, Pouggouras K, et al. Comparison of nutritional deficiencies after Roux-en-Y gastric
bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass. Obes Surg 2002; 12:551.
60. Brolin RE, LaMarca LB, Kenler HA, Cody RP. Malabsorptive gastric bypass in patients with superobesity. J Gastrointest
Surg 2002; 6:195.
61. Brolin RE, Leung M. Survey of vitamin and mineral supplementation after gastric bypass and biliopancreatic diversion for
morbid obesity. Obes Surg 1999; 9:150.
62. Juhasz-Pocsine K, Rudnicki SA, Archer RL, Harik SI. Neurologic complications of gastric bypass surgery for morbid
obesity. Neurology 2007; 68:1843.
63. Smith CD, Herkes SB, Behrns KE, et al. Gastric acid secretion and vitamin B12 absorption after vertical Roux-en-Y
gastric bypass for morbid obesity. Ann Surg 1993; 218:91.
64. Marcuard SP, Sinar DR, Swanson MS, et al. Absence of luminal intrinsic factor after gastric bypass surgery for morbid
obesity. Dig Dis Sci 1989; 34:1238.
65. Alexandrou A, Armeni E, Kouskouni E, et al. Cross-sectional long-term micronutrient deficiencies after sleeve
gastrectomy versus Roux-en-Y gastric bypass: a pilot study. Surg Obes Relat Dis 2014; 10:262.
66. Hakeam HA, O'Regan PJ, Salem AM, et al. Impact of laparoscopic sleeve gastrectomy on iron indices: 1 year follow-up.
Obes Surg 2009; 19:1491.
67. Kehagias I, Karamanakos SN, Argentou M, Kalfarentzos F. Randomized clinical trial of laparoscopic Roux-en-Y gastric
bypass versus laparoscopic sleeve gastrectomy for the management of patients with BMI<50 kg/m2. Obes Surg 2011;
21:1650.
68. Pech N, Meyer F, Lippert H, et al. Complications and nutrient deficiencies two years after sleeve gastrectomy. BMC Surg
2012; 12:13.
69. Eltweri AM, Bowrey DJ, Sutton CD, et al. An audit to determine if vitamin b12 supplementation is necessary after sleeve
gastrectomy. Springerplus 2013; 2:218.
70. Ben-Porat T, Elazary R, Yuval JB, et al. Nutritional deficiencies after sleeve gastrectomy: can they be predicted
preoperatively? Surg Obes Relat Dis 2015; 11:1029.
71. Caudill MA. Folate bioavailability: implications for establishing dietary recommendations and optimizing status. Am J Clin
Nutr 2010; 91:1455S.
14 of 32 10/29/17, 23:18
72. Ernst B, Thurnheer M, Schmid SM, Schultes B. Evidence for the necessity to systematically assess micronutrient status
prior to bariatric surgery. Obes Surg 2009; 19:66.
73. Brolin RE, Gorman RC, Milgrim LM, Kenler HA. Multivitamin prophylaxis in prevention of post-gastric bypass vitamin and
mineral deficiencies. Int J Obes 1991; 15:661.
74. National Institute of Health OoDS.2015.Folate Dietary Supplement Fact Sheet; https://ods.od.nih.gov/factsheets/list-all/F
olate/ (Accessed on July 27, 2017).
75. Force USPST.2015.Folic Acid for the Preventin of Neural Tube Defects: Preventive 2000 Medication Final Update Summ
ary: Folic Acid to Prevent Neural Tube Defects: Preventive Medication; https://www.uspreventiveservicestaskforce.org/P
age/Document/UpdateSummaryFinal/folic-acid-to-prevent-neural-tube-defects-preventive-medication (Accessed on July
27, 2017).
76. Saltzman E, Anderson W, Apovian CM, et al. Criteria for patient selection and multidisciplinary evaluation and treatment
of the weight loss surgery patient. Obes Res 2005; 13:234.
77. O'Leary F, Samman S. Vitamin B12 in health and disease. Nutrients 2010; 2:299.
78. Rhode BM, Shustik C, Christou NV, MacLean LD. Iron absorption and therapy after gastric bypass. Obes Surg 1999;
9:17.
79. Obinwanne KM, Fredrickson KA, Mathiason MA, et al. Incidence, treatment, and outcomes of iron deficiency after
laparoscopic Roux-en-Y gastric bypass: a 10-year analysis. J Am Coll Surg 2014; 218:246.
80. Salgado W Jr, Modotti C, Nonino CB, Ceneviva R. Anemia and iron deficiency before and after bariatric surgery. Surg
Obes Relat Dis 2014; 10:49.
81. Vargas-Ruiz AG, Hernndez-Rivera G, Herrera MF. Prevalence of iron, folate, and vitamin B12 deficiency anemia after
laparoscopic Roux-en-Y gastric bypass. Obes Surg 2008; 18:288.
82. Madan AK, Orth WS, Tichansky DS, Ternovits CA. Vitamin and trace mineral levels after laparoscopic gastric bypass.
Obes Surg 2006; 16:603.
83. Heber D, Greenway FL, Kaplan LM, et al. Endocrine and nutritional management of the post-bariatric surgery patient: an
Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2010; 95:4823.
84. Sall A, Demarsy D, Poirier AL, et al. Zinc deficiency: a frequent and underestimated complication after bariatric surgery.
Obes Surg 2010; 20:1660.
85. Di Martino G, Matera MG, De Martino B, et al. Relationship between zinc and obesity. J Med 1993; 24:177.
86. Balsa JA, Botella-Carretero JI, Gmez-Martn JM, et al. Copper and zinc serum levels after derivative bariatric surgery:
differences between Roux-en-Y Gastric bypass and biliopancreatic diversion. Obes Surg 2011; 21:744.
87. Kaidar-Person O, Person B, Szomstein S, Rosenthal RJ. Nutritional deficiencies in morbidly obese patients: a new form
of malnutrition? Part B: minerals. Obes Surg 2008; 18:1028.
88. Dolan K, Hatzifotis M, Newbury L, et al. A clinical and nutritional comparison of biliopancreatic diversion with and without
duodenal switch. Ann Surg 2004; 240:51.
89. Beers MH. The Merck Manual of Diagnosis and Therapy., Merck Research Laboratories; 2006, White Station, NJ 2006.
90. Mason KE. A conspectus of research on copper metabolism and requirements of man. J Nutr 1979; 109:1979.
91. Wapnir RA. Copper absorption and bioavailability. Am J Clin Nutr 1998; 67:1054S.
92. Shankar P, Boylan M, Sriram K. Micronutrient deficiencies after bariatric surgery. Nutrition 2010; 26:1031.
93. Griffith DP, Liff DA, Ziegler TR, et al. Acquired copper deficiency: a potentially serious and preventable complication
following gastric bypass surgery. Obesity (Silver Spring) 2009; 17:827.
94. Gletsu-Miller N, Broderius M, Frediani JK, et al. Incidence and prevalence of copper deficiency following roux-en-y
gastric bypass surgery. Int J Obes (Lond) 2012; 36:328.
95. Chhetri SK, Mills RJ, Shaunak S, Emsley HC. Copper deficiency. BMJ 2014; 348:g3691.
96. Lapointe-Gagner XA, Gagner M. Micronutrients deficiencies after laparoscopic gastric bypass and duodenal switch. A
comparative study. Surg Obes Rel Dis 2005; 1:285.
97. Institute of Medicine (U.S.). Panel on Dietary Antioxidants and Related Compounds. Dietary Reference Intakes for Vitam
in C, Vitamin E, Selenium, and Carotenoids, National Academy Press, Washington DC 2000.
15 of 32 10/29/17, 23:18
98. Al-Matary A, Hussain M, Ali J. Selenium: a brief review and a case report of selenium responsive cardiomyopathy. BMC
Pediatr 2013; 13:39.
99. Shah M, Sharma A, Wermers RA, et al. Hypocalcemia After Bariatric Surgery: Prevalence and Associated Risk Factors.
Obes Surg 2017; 27:2905.
100. Johnson JM, Maher JW, DeMaria EJ, et al. The long-term effects of gastric bypass on vitamin D metabolism. Ann Surg
2006; 243:701.
101. Chan LN, Neilson CH, Kirk EA, et al. Optimization of Vitamin D Status After Roux-en-Y Gastric Bypass Surgery in Obese
Patients Living in Northern Climate. Obes Surg 2015; 25:2321.
102. Coates PS, Fernstrom JD, Fernstrom MH, et al. Gastric bypass surgery for morbid obesity leads to an increase in bone
turnover and a decrease in bone mass. J Clin Endocrinol Metab 2004; 89:1061.
103. Ybarra J, Snchez-Hernndez J, Gich I, et al. Unchanged hypovitaminosis D and secondary hyperparathyroidism in
morbid obesity after bariatric surgery. Obes Surg 2005; 15:330.
104. Youssef Y, Richards WO, Sekhar N, et al. Risk of secondary hyperparathyroidism after laparoscopic gastric bypass
surgery in obese women. Surg Endosc 2007; 21:1393.
105. Pepino MY, Stein RI, Eagon JC, Klein S. Bariatric surgery-induced weight loss causes remission of food addiction in
extreme obesity. Obesity (Silver Spring) 2014; 22:1792.
106. Mills MJ, Stunkard AJ. Behavioral changes following surgery for obesity. Am J Psychiatry 1976; 133:527.
107. Crisp AH, Kalucy RS, Pilkington TR, Gazet JC. Some psychosocial consequences of ileojejunal bypass surgery. Am J
Clin Nutr 1977; 30:109.
Topic 587 Version 41.0
16 of 32 10/29/17, 23:18
GRAPHICS
Sample diet recommendations after Roux-en-Y gastric bypass and gastric sleeve procedures
Diet stage* Begin Fluids/food Guidelines
Stage 1
Postoperative days 1 and Clear liquids: Patients undergo a Gastrografin swallow

2 Non-carbonated; no calories test to rule out a leak on postoperative
day 1 after Roux-en-Y gastric bypass.
No sugar; no caffeine
Sips of clear liquids may be started after
the test.
Stage 2
Postoperative day 3 Clear liquids: Patients should consume a minimum of

(discharge diet) Variety of no-sugar liquids or artificially 48 to 64 ounces of total fluids per day, 24
sweetened liquids. to 32 ounces or more ounces of clear
liquids, plus 24 to 32 ounces of any
Encourage patients to have salty fluids at
combination of full liquids (meal
home.
replacement liquids):
Solid liquids: Sugar-free ice pops. 1% or skim milk, plain or mixed
Plus full liquids: with:
Less than 25 grams sugar per serving; Whey or soy protein powder
protein-rich liquids (limit 25 to 30 grams (limit 30 g protein per serving).
protein per serving of added powders). Whey isolates if lactose
intolerant.
Lactaid milk or soy milk mix with
soy protein powder.
Light yogurt, no fruit chunks;
less than 20 grams of sugar per
8 ounces.
Plain yogurt; Greek yogurt.
Stage 3
Postoperative days 10 to Increase clear liquids (total liquids 60 Protein food choices are encouraged for 3
14* plus ounces per day) and replace full to 6 small meals per day; patients may
liquids with soft, moist, diced, ground, or only be able to tolerate a couple of
pureed protein sources as tolerated. tablespoons of food at each meal/snack.
Soft solid foods including eggs; ground Protein should be moist and ground,
meats; poultry; soft, moist fish; added pureed, or diced.
gravy; bouillon; light mayonnaise to Encourage patients not to drink with
moisten; cooked beans; hearty bean meals and to wait 30 minutes after
soups; cottage cheese; low-fat cheese; each meal before resuming fluids.
yogurt. May continue to replace one meal or
snack with a nutritional shake.
Patients continue to Advance diet (amount and texture) as Adequate hydration is essential and a
advance diet as tolerated; patients should be priority for all patients during the rapid
tolerated; emphasis on incorporating well-cooked, soft vegetables weight loss phase.
slow, mindful eating; and soft and/or peeled fruit. Include
planning 5 to 6 small salads as tolerated.
meals/snacks and
adequate hydration
Stage 3 lasts for Continue to consume protein with some AVOID rice, bread, and pasta until
months; every patient is fruit or vegetable at each meal; some patient is comfortably consuming 60
different, and all patients people tolerate salads one month grams protein per day and 3 to 5 servings
should be encouraged to postoperatively. of fruits/vegetables per day. Since grains
advance diet (texture are a rapid source of energy, they are not
and portions) at their "essential" during the rapid weight loss
own pace phase, as caloric needs are met through
Frequent nutrition follow- utilizing body fat stores. The diet should
up during this phase is provide all "essential" nutrients through
imperative food choices and supplementation. May
switch to pill form of supplement.
Stage 4
17 of 32 10/29/17, 23:18
Stage 4 is a Healthy solid food diet, as hunger Healthy, balanced diet consisting of
"maintenance" diet, increases and more food is tolerated. adequate protein, fruits, vegetables, and
reached when patients' Vitamin and mineral supplement daily. whole grains. Calorie needs are
weights are stable determined based on height, weight, and
age of the patient.
* There is no standardization of diet stages; there is a wide variety of diet protocols varying from how long patients stay on each stage to
what types of fluids/foods are recommended. Dietary advancement is based on nutritional needs and increasing tolerance for dietary texture,
meaning that soft foods should be introduced successfully before any hard solids are allowed.
Nutritional labs should be drawn at 2, 6, and 12 months and yearly indefinitely; bone density test at baseline and every 2 years.
Table provided with permission: Sue Cummings, MS, RD, LDN; MGH Weight Center, Boston, MA.
Graphic 62266 Version 4.0
18 of 32 10/29/17, 23:18
Diet stages of laparoscopic adjustable gastric band
LAGB diet stage* Begin Fluids/food Guidelines
Stage I
Postoperative LAGB clear liquids: Postoperative LAGB day 1, patients may

days 1 and 2 Non-carbonated; no calories begin sips of water, ice chips, and no sugar
liquids; avoid carbonation
No sugar; no caffeine
Stage II
Begin Postoperative LAGB clear liquids: Patients should consume a minimum of

supplementation: days 2-3 Variety of no-sugar liquids or artificially 48-64 ounces of total fluids per day, 24-32
Chewable (discharge diet) sweetened liquids ounces or more ounces LAGB clear liquids,
multivitamin with plus 24-32 ounces of any combination of
Plus LAGB full liquids:
minerals x 2/day full liquids:
No more than 3 g fat per serving protein-
Chewable or liquid 1% or skim milk mixed with:
rich liquids
Calcium citrate with
Whey or soy protein powder if lactose
vitamin D intolerant
Lactaid milk or soy milk mix with soy

protein powder
Light yogurt, blended
Plain yogurt
Stage III
Week I Postoperative Increase LAGB clear liquids (total liquids NOTE: Patients should be reassured that
days 10-14* 48-64 plus ounces per day) and replace full hunger is common and normal after LAGB
liquids with soft, moist, diced, ground, or
Protein food (moist, ground) choices are
pureed protein sources as tolerated - as
encouraged for 3-6 small meals per day,
evidenced by the absence of excessive to help with satiety, since hunger is
fullness or bloating, nausea, or vomiting. common within a week or so of LAGB
Stage III week 1: Eggs, ground meats,
Mindful, slow eating is essential
poultry, soft, moist fish, added gravy,
bouillon, light mayo to moisten, cooked Encourage patients not to drink with
bean, hearty bean soups, cottage cheese, meals and to wait 30 minutes after each
low fat cheese, yogurt meal before resuming fluids
Week 2 4 weeks Advance diet as tolerated. Adequate hydration is essential and a

postoperatively Tofu is a good choice as it is soft. priority for all patients during the rapid
weight loss phase.
Dense, chewy foods such as tough meats
and doughy breads should be avoided as Protein at every meal and snack, especially
they may cause obstruction. if increased hunger noted prior to initial fill
or adjustment. Very well-cooked
Avoid high-calorie soft foods such as ice
vegetables may also help to increase
cream.
satiety.
Week 3 5 weeks Continue to consume protein with some

postoperatively fruit or vegetable at each meal.
Stage IV
Vitamin and mineral As hunger Healthy solid food diet. Healthy, balanced diet consisting of
supplementation increases and adequate protein, fruits, vegetables, and
daily more food is whole grains; calorie needs based on
tolerated height, weight, age.
Post-LAGB fill/adjustment
6 weeks Full liquids x 2 days post-fill; advance to Same as Stage II liquids above x 48 hours
postoperatively Stage III, week 1 guidelines above, as (and/or as otherwise advised by surgeon).
for LAGB, and tolerated. = x 4-5 days, then advance as NOTE: When diet advanced to soft solids,
possibly every 6 above. special attention to mindful eating and
weeks until chewing until liquid is key, since more
satiety reached restriction may increase risk for food
getting stuck above stoma of band if not
properly chewed (eg, if not chewed until
liquid).
19 of 32 10/29/17, 23:18
LAGB: laparoscopic adjustable gastric band.

* There is no standardization of diet stages; there are a wide variety of diet protocols varying from how long patients stay on each stage and
what types of fluids/foods are recommended.
Nutritional labs should be drawn at 2, 6, 12 months and yearly indefinitely; bone density test at baseline and every 2 years.
Table provided with permission: Sue Cummings, MS, RD, LDN; MGH Weight Center, Boston, MA.
20 of 32 10/29/17, 23:18
Micronutrient management after bariatric surgery [1]
Preoperative Postoperative Symptoms of

RDA [2] Supplementation Repletion
prevalence prevalence deficiency
Vitamin Up to 17% [3] 8 to 11% after Early signs: Men: 900 LAGB: 5000 IU daily Without corneal
A [1,3] RYGB Night blindness mcg (3000 RYGB or SG: 5000 to changes: 10,000
70% after BPD/DS Bitot's spots IU) 10,000 IU daily to 25,000 IU daily
Women: orally until clinical
Hyperkeratinization BPD/DS: 10,000 IU
700 mcg improvement (1 to
of skin daily
(2300 IU) 2 weeks)
Loss of taste
With corneal
changes: 50,000
Advanced signs:
to 100,000 IU
Corneal damage
daily IM for 3
Blindness
days, followed by
50,000 IU daily IM
for 2 weeks
Vitamin D 25 to 68% 25 to 80% Hypocalcemia, tetany, General: 3000 IU D3 daily from 3000 to 6000 IU
tingling, cramping, 600 IU all sources to maintain of D3 daily
metabolic bone disease, Pregnancy, a 25(OH)D level of (preferred), or
muscle pain lactation, >30 ng/mL 50,000 IU of D2 1
or over 71 to 3 times per
years of week
age: 800
IU
Vitamin E 2.2% Uncommon Neuromuscular disorders General: Adults and adolescents 90 to 300 mg (100
and hemolysis 15 mg 14 or older: 15 mg to 400 IU) daily
(22.4 IU) (22.4 IU) daily
Lactation: Lactation: 19 mg (28.4
19 mg IU) daily
(28.4 IU)
Vitamin K Uncommon Uncommon Impaired coagulation 90 to 120 LAGB, RYGB, or SG: Acute
mcg 90 to 120 mcg daily malabsorption: 10
BPD/DS: 300 mcg mg of parenteral
daily vitamin K
Chronic
malabsorption: 1
to 2 mg per day
orally or 1 to 2 mg
per week
parenterally
Vitamin B1 16 to 29% 1 to 49% Numbness, tingling in 1.5 mg >12 mg daily, Oral: 100 mg
(Thiamine) extremities, gait ataxia, preferably 50 to 100 three times daily
edema, vomiting, mg daily from a until symptoms
confusion B-complex supplement resolve
Wernicke-Korsakoff With IV hydration, 100 Intravenous: 200
syndrome: mg of thiamine should mg three times
Encephalopathy be added to the daily to 500 mg
Ataxia solution (should not once or twice daily
contain glucose if for 3 to 5 days,
Oculomotor
Wernicke followed by 250
dysfunction
encephalopathy is mg daily for 3 to 5
Confabulation
suspected) days, and
Impaired memory subsequent oral
Impaired learning maintenance (100
mg daily)
Beriberi: indefinitely
Neuropathy Intramuscular:
Pain 250 mg daily for 3
Paresthesia to 5 days, or 100
Loss of reflexes to 250 mg
monthly
21 of 32 10/29/17, 23:18
Vitamin 0 to 18% 33% after RYGB; Macrocytic 2.4 mcg Oral dose of 350 to 1000 to 2000 mcg
B12 4 to 20% after SG (megaloblastic) anemia, 500 mcg daily, or 1000 daily until the level
mild pancytopenia, mcg IM or SQ is normalized,
neuropsychiatric findings monthly, or by nasal then resume
(eg, depression, spray maintenance dose
neuropathy)
Folate 0 to 54% Up to 65% after Macrocytic 400 mcg General: 400 to 800 1000 mcg daily
RYGB; 18% after (megaloblastic) anemia, mcg daily until the level is
SG mild pancytopenia, Women of childbearing normalized, then
neural tube defects age: 800 to 1000 mcg resume
daily maintenance dose
Should not exceed 1

mg per day
Iron 0 to 58% LAGB 14%, SG Anemia Men ages Males, post- Oral: 150 to 300
<18%, RYGB 20 Pica 19 and menopausal women, mg 2 to 3 times a
to 55%, BPD 13 to older and and patients without day
Impaired learning
62%, DS 8 to 50% women history of anemia: 18 Parenteral iron for
ages 51 mg of iron from a those who do not
and older: multivitamin respond to oral
8 mg per Menstruating women supplementation
day and men or women
Women who have undergone
between RYGB, SG, or BPD/DS:
the ages >45 to 60 mg of
of 19 to elemental iron daily
50: 18 mg from all sources*
per day
Zinc 24 to 28% 70% after Growth retardation, Women: 8 BPD/DS: 16 to 22 mg Optimal repletion
overall; 9 to 74% BPD/DS, 40% delayed sexual maturity, mg (200% RDA) dose unknown
seeking BPD/DS after RYGB, 19% impotence, impaired Men: 11 RYGB: 8 to 22 mg Overdose can be
after SG, 34% immune function mg (100 to 200% RDA) associated with
after LAGB toxicity or copper
SG or LAGB: 8 to 11
mg (100% RDA) deficiency
Maintain a ratio of 8 to
15 mg of zinc per 1
mg of copper
Copper 68% in women 90% after Anemia, neutropenia, 900 mcg BPD/DS or RYGB: 2 Mild-to-moderate
seeking BPD BPD/DS, 10 to ataxia mg daily (200% RDA) deficiency: 3 to 8
20% after RYGB SG or LAGB: 1 mg mg copper orally
daily (100% RDA) until levels
normalize
Maintain a ratio of 8 to
15 mg of zinc per 1 Severe deficiency:
mg of copper 2 to 4 mg
intravenous
copper for 6 days
or until symptoms
resolve
Selenium 2% 14 to 22% after Skeletal muscle 55 mcg Unknown but likely 2 mcg/kg/day in
RYGB and BPD/DS dysfunction and higher than 100 patients who
cardiomyopathy, mood mcg/day [4] develop
disorder, impaired cardiomyopathy [5]
immune function,
macrocytosis
Calcium 1 to 10% [6] 3.6% after Bone disease, secondary 1000 to RYGB, SG, or LAGB: RYGB, SG, or
bariatric surgery hyperparathyroidism 1200 mg 1200 to 1500 mg daily LAGB: 1200 to
(1.9% after RYGB, in divided doses 1500 mg daily in
9.3% after SG, BPD/DS: 1800 to 2400 divided doses
and 10% after mg daily in divided BPD/DS: 1800 to
BPD/DS) doses 2400 mg daily in
divided doses
RDA: Recommended Daily Allowance; RYGB: Roux-en-Y gastric bypass; BPD/DS: biliopancreatic diversion with duodenal switch; IU:
22 of 32 10/29/17, 23:18
international unit; LAGB: laparoscopic adjustable gastric band; SG: sleeve gastrectomy; IM: intramuscular; IV: intravenous; SQ:
subcutaneous.
References:
1. Parrott J, Frank L, Rabena R, et al. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for
the Surgical Weight Loss Patient 2016 Update: Micronutrients. Surg Obes Relat Dis 2017; 13:727.
2. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 20152020 Dietary Guidelines for Americans, 8th
Edition, December 2015. Available at: http://health.gov/dietaryguidelines/2015/guidelines/ (Accessed on July 27, 2017).
3. Stein J, Stier C, Raab H, Weiner R. Review article: The nutritional and pharmacological consequences of obesity surgery. Aliment
Pharmacol Ther 2014; 40:582.
4. Institute of Medicine (U.S.). Panel on Dietary Antioxidants and Related Compounds. Dietary Reference Intakes for Vitamin C, Vitamin
E, Selenium, and Carotenoids, National Academy Press, Washington DC 2000.
5. Al-Matary A, Hussain M, Ali J. Selenium: a brief review and a case report of selenium responsive cardiomyopathy. BMC Pediatr 2013;
13:39.
6. Shah M, Sharma A, Wermers RA, et al. Hypocalcemia after bariatric surgery: Prevalence and associated risk factors. Obes Surg 2017.
23 of 32 10/29/17, 23:18
Post-bariatric surgery micronutrient supplementation
Post-bariatric surgery
Nutrient supplementation required to prevent Comments
deficiency (oral doses)
Iron 18 mg or 45 to 60 mg After all bariatric procedures

Women of childbearing age and individuals with
history of iron deficiency: 45 to 60 mg
Vitamin B12 350 to 500 mcg After all bariatric procedures
Folate 400 to 1000 mcg Women of childbearing age: 800 to 1000 mcg
Thiamin 12 to 100 mg After all bariatric procedures

Recommend a B-complex vitamin of 50 mg or more
in addition to a multivitamin
Calcium 1200 to 2400 mg (all sources) Supplement should include Vitamin D
Vitamin D 3000 IU (titrate to a serum 25(OH)D level of >30 Continue 3000 IU per day total, from all sources
ng/mL) (eg, multivitamin, calcium supplement)
Vitamin A 5000 to 10,000 IU 5000 to 10,000 IU after gastric bypass or sleeve

gastrectomy
10,000 IU after biliopancreatic diversion/duodenal
switch
Vitamins E/K 15 mg/90 to 300 mcg
Zinc/copper 8 to 22 mg/1 to 2 mg
Selenium Quantity contained in a "high potency" multivitamin
Magnesium Quantity contained in a multivitamin that "contains

magnesium"
Additional B vitamins 100 to 200% of daily value (DV)
Trace minerals Quantity contained in a multivitamin "complete in Molybdenum, manganese, chromium, etc
minerals"
IU: international unit.
24 of 32 10/29/17, 23:18
Roux-en-Y gastric bypass
This figure depicts the stomach's appearance after Roux-en-Y gastric bypass,
which creates a small stomach pouch by dividing the stomach and attaching it
to the small intestine. The pouch is only able to hold about an ounce of food,
causing a feeling of fullness after consuming a very small amount; over time,
the pouch stretches to hold about one cup. In addition, the body absorbs fewer
calories since food bypasses the majority of the stomach as well as the upper
small intestine (duodenum). This intestinal arrangement (Roux-en-Y) seems to
cause decreased appetite and improved metabolism by changing the release of
various hormones.
25 of 32 10/29/17, 23:18
Biliopancreatic diversion
The biliopancreatic diversion procedure consists of a partial gastrectomy and

gastroileostomy with a long segment of Roux limb and a short common channel (the part
of the small bowel that receives both food and biliopancreatic secretions), resulting in fat
and starch malabsorption. The use of this procedure results in high rates of protein
malnutrition, anemia, diarrhea, and stomal ulceration, limiting its use.
26 of 32 10/29/17, 23:18
Clinical symptoms of selected vitamin deficiencies
Vitamin Deficiency syndrome
Water-soluble vitamins
Vitamin B1 Beriberi Congestive heart failure (wet beriberi), aphonia, peripheral neuropathy, Wernicke
(thiamine) encephalopathy (nystagmus, ophthalmoplegia, ataxia), confusion, or coma
Vitamin B2 Nonspecific symptoms including edema of mucous membranes, angular stomatitis, glossitis, and seborrheic
(riboflavin) dermatitis (eg, nose, scrotum)
Niacin Pellagra Dermatitis on areas exposed to sunlight; diarrhea with vomiting, dysphagia, mouth inflammation
(nicotinic acid) (glossitis, angular stomatitis, cheilitis); headache, dementia, peripheral neuropathy, loss of memory,
psychosis, delirium, catatonia
Vitamin B6 Anemia, weakness, insomnia, difficulty walking, nasolabial seborrheic dermatitis, cheilosis, stomatitis
(pyridoxine,
pyridoxal)
Vitamin B12 Megaloblastic anemia (pernicious anemia), peripheral neuropathy with impaired proprioception and slowed
(cobalamin) mentation
Folate Megaloblastic anemia
Biotin Nonspecific symptoms including altered mental status, myalgia, dysesthesias, anorexia, maculosquamous
dermatitis
Pantothenate Nonspecific symptoms including paresthesias, dysesthesias ("burning feet"), anemia, gastrointestinal
symptoms
Vitamin C Scurvy fatigue, petechiae, ecchymoses, bleeding gums, depression, dry skin, impaired wound healing
(ascorbate)
Fat-soluble vitamins
Vitamin A Night blindness, xerophthalmia, keratomalacia, Bitot spot, follicular hyperkeratosis

(retinol, retinal,
retinoic acid)
Vitamin D Rickets, osteomalacia, craniotabes, rachitic rosary

(cholecalciferol,
ergocalciferol)
Vitamin E Sensory and motor neuropathy, ataxia, retinal degeneration, hemolytic anemia
(tocopherols)
Vitamin K Hemorrhagic disease

(phylloquinone,
menaquinone,
menadione)
27 of 32 10/29/17, 23:18
Dietary reference intakes for fat-soluble vitamins
Adverse effects of
Nutrient Age group RDA*/AI UL
excess
Vitamin A
1 mcg retinol activity Micrograms daily Micrograms daily Ataxia, alopecia,

equivalent = 3.3 unit hyperlipidemia,
Infants
vitamin A hepatotoxicity, bone and
0 to 6 months 400 600 muscle pain; teratogenic
7 to 12 months 500 600
Children
1 to 3 years 300 600
4 to 8 years 400 900
Males
9 to 13 years 600 1700
14 to 18 years 900 2800
19 years 900 3000
Females
9 to 13 years 600 1700
14 to 18 years 700 2800
19 years 700 3000
Pregnancy
<18 years 750 2800
19 years 770 3000
Lactation
<18 years 1200 2800
19 years 1300 3000
Vitamin D
(calciferol) Micrograms daily Micrograms daily Hypercalcemia,

1 mcg calciferol = 40 hypercalciuria,
Infants
int. unit polydipsia, polyuria,
0 to 12 months 10 (400 int. unit) 0 to 6 months: 25 (1000 confusion, anorexia,
int. unit) vomiting, bone
6 to 12 months: 37.5 (1500 demineralization
int. unit)
Children and adolescents
1 to 18 years 15 (600 int. unit) 1 to 3 years: 62.5 (2500

int. unit)
4 to 8 years: 75 (3000 int.

unit)
9 to 18 years: 100 (4000

int. unit)
Males and females (including pregnancy and lactation)
19 to 50 years 15 (600 int. unit) 100 (4000 int. unit)
50 to 70 years 15 100
>70 years 20 (800 int. unit) 100
Vitamin E
(alpha-tocopherol) Milligrams daily Milligrams daily Increased risk of

1 mg = 1.47 int. unit bleeding; possibly
Infants
"natural source" increased risk of
0 to 6 months 4 ND necrotizing enterocolitis
vitamin E, or 2.2 int.
unit synthetic vitamin 7 to 12 months 5 ND in infants
E Children
1 to 3 years 6 200
28 of 32 10/29/17, 23:18
4 to 8 years 7 300
Males and females (including pregnancy)
9 to 13 years 11 600
14 to 18 years 15 800
>18 years 15 1000
Lactation
18 years 19 800
>19 years 19 1000
Vitamin K
Micrograms daily Micrograms daily No adverse effects

associated with vitamin
Infants
K consumption from
0 to 6 months 2 ND food or supplements
7 to 12 months 2.5 ND have been reported;
however, data are
Children
limited
1 to 3 years 30 ND
4 to 8 years 55 ND
Males
9 to 13 years 60 ND
14 to 18 years 75 ND
>19 years 120 ND
Females (including pregnancy and lactation)
9 to 13 years 60 ND
14 to 18 years 75 ND
>19 years 90 ND
Vitamin A doses given as retinol activity equivalents (RAE). 1 RAE = 1 mcg retinol, 12 mcg beta-carotene, 14 mcg alpha-carotene,
or 24 mcg beta-cryptoxanthin.
RDA: recommended dietary allowance; AI: adequate intake; UL: upper tolerable level.
* Values in this column represent the recommended dietary allowance (RDA) unless otherwise indicated. The RDA is the level of dietary
intake that is sufficient to meet the daily nutrient requirements of 97 percent of the individuals in a specific life stage group.
These values represent an adequate intake (AI). The AI represents an approximation of the average nutrient intake that sustains a defined
nutritional state, based on observed or experimentally determined values in a defined population.
The UL is the maximum level of daily nutrient intake that is likely to pose no risk of adverse health effects in almost all individuals in the
specified life-stage or gender group.
Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Otten JJ, Hellwig JP, Meyers LD (Eds), The National Academies
Press, Washington, DC 2006. pp.530-541. Modified with permission from the National Academies Press, Copyright 2006, National Academy
of Sciences.
Sources: Dietary reference intakes for Thiamin, Riboflavin, Niacin, Vitamin B 6 , Folate, Vitamin B 12 , Panthothenic acid, Biotin, and Choline
(1998); Dietary reference intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intake reports of the Food
and Nutrition Board, Institute of Medicine (2010). These reports may be accessed via www.nap.edu.
29 of 32 10/29/17, 23:18
Bitot spot caused by vitamin A deficiency
Bitot spot (areas of abnormal squamous cell proliferation and keratinization of

the conjunctiva), caused by vitamin A deficiency. This picture was taken in
Lebanon and used as a clinical standard for examiners in international nutrition
surveys.
Reproduced from: Interdepartmental Committee on Nutrition for National Defense

(1963). Manual for Nutrition Surveys 2nd ed. Department of Health, Education and
Welfare, Public Health Service, NIH, US Government Printing Office, Washington DC
1963.
30 of 32 10/29/17, 23:18
Macro-, trace-, and ultra-trace minerals in man
Macro-minerals Trace minerals Ultra-trace minerals
Sodium Iron Arsenic
Potassium Zinc Boron
Chloride Copper Chromium
Calcium Manganese Iodine
Phosphate Fluoride Selenium
Magnesium Silicon
Nickel
Vanadium
31 of 32 10/29/17, 23:18
Contributor Disclosures
Robert F Kushner, MD Grant/Research/Clinical Trial Support: Aspire Bariatrics [Obesity (weight loss device)]. Susan
Cummings, MS, RD Nothing to disclose Daniel M Herron, MD, FACS, FASMBS Nothing to disclose Daniel Jones,
MD Consultant/Advisory Boards: Allurion Technologies [Weight loss device (Intragastric balloon)]. Wenliang Chen, MD,
PhD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by
vetting through a multi-level review process, and through requirements for references to be provided to support the content.
Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy
32 of 32 10/29/17, 23:18

Bariatric Surgery: Postoperative Nutritional Management - UpToDate

Загружено:

Сведения о документе

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Bariatric Surgery: Postoperative Nutritional Management - UpToDate

Загружено:

Авторское право:

Доступные форматы

Bariatric surgery: Postoperative nutritional management -... https://0-www.uptodate.com.millenium.itesm.mx/contents/...

Official reprint from UpToDate

(See "Bariatric procedures for the management of severe obesity: Descriptions".)

(See "Bariatric operations: Perioperative morbidity and mortality".)

(See "Medical outcomes following bariatric surgery".)

(See "Laparoscopic Roux-en-Y gastric bypass".)

(See "Laparoscopic sleeve gastrectomy".)

patients with an RYGB. (See 'Micronutrient management' below.)

Some of the common complaints following BPDDS include:

Management of vitamin B1 deficiency includes:

Administer thiamine in one of the following three regimens:

Oral: 100 mg three times daily until symptoms resolve.

Simultaneously replete magnesium, potassium, and phosphorus to prevent refeeding syndrome.

Immediate treatment of surgical causes of vomiting (eg, obstruction).

Management of copper deficiency depends on the severity of the deficiency [9,43]:

Mild-to-moderate deficiency: 3 to 8 mg copper orally until levels normalize

BPD/DS: 1800 to 2400 mg daily

SUMMARY AND RECOMMENDATIONS

Postoperative weeks 1 and 2: Hydration and liquids.

Use of UpToDate is subject to the Subscription and License Agreement.

Lancet Neurol 2007; 6:442.

Topic 587 Version 41.0

Diet stage* Begin Fluids/food Guidelines

Postoperative days 1 and Clear liquids: Patients undergo a Gastrografin swallow

Postoperative day 3 Clear liquids: Patients should consume a minimum of

Graphic 62266 Version 4.0

Diet stages of laparoscopic adjustable gastric band

LAGB diet stage* Begin Fluids/food Guidelines

Postoperative LAGB clear liquids: Postoperative LAGB day 1, patients may

Begin Postoperative LAGB clear liquids: Patients should consume a minimum of

Lactaid milk or soy milk mix with soy

Light yogurt, blended

Week 2 4 weeks Advance diet as tolerated. Adequate hydration is essential and a

Week 3 5 weeks Continue to consume protein with some

LAGB: laparoscopic adjustable gastric band.

Graphic 50516 Version 3.0

Micronutrient management after bariatric surgery [1]

Preoperative Postoperative Symptoms of

Should not exceed 1

Graphic 114101 Version 2.0

Post-bariatric surgery micronutrient supplementation

Iron 18 mg or 45 to 60 mg After all bariatric procedures

Vitamin B12 350 to 500 mcg After all bariatric procedures

Thiamin 12 to 100 mg After all bariatric procedures

Calcium 1200 to 2400 mg (all sources) Supplement should include Vitamin D

Vitamin A 5000 to 10,000 IU 5000 to 10,000 IU after gastric bypass or sleeve

Vitamins E/K 15 mg/90 to 300 mcg

Selenium Quantity contained in a "high potency" multivitamin

Magnesium Quantity contained in a multivitamin that "contains

Additional B vitamins 100 to 200% of daily value (DV)

IU: international unit.

Graphic 114815 Version 1.0

Roux-en-Y gastric bypass

Graphic 79256 Version 4.0

The biliopancreatic diversion procedure consists of a partial gastrectomy and

Graphic 67432 Version 2.0

Clinical symptoms of selected vitamin deficiencies

Vitamin Deficiency syndrome

Folate Megaloblastic anemia

Vitamin A Night blindness, xerophthalmia, keratomalacia, Bitot spot, follicular hyperkeratosis

Vitamin D Rickets, osteomalacia, craniotabes, rachitic rosary

Vitamin K Hemorrhagic disease

Graphic 63827 Version 11.0