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NutritionPracticeStandardsforBariatricSurgeryDanaEiesland,RD,LDNLisaC.Luz,RN,MSN,FNP-BCMountAuburnWeightManagementCenterObjectivesReviewcriteriaforsurgeryOutlinethepre-surgicalevaluationSummarizepre-surgicalnutritiongoalsReviewnutritionguidelines&dietprogressionfollowingsurgeryReviewimmediatepostoperativeandlongtermsurgicalcomplicationsGeneralCriteriaforWeightLossSurgery(WLS)BMI35-40withatleastoneco-morbidities(exp.DM,Obstructivesleepapnea)BMI>40withoutco-morbiditiesPreviousunsuccessfulattemptsatweightlossAge>18-65withfewexceptionsMedicallyclearedforsurgeryMentally&emotionallypreparedandmotivatedNosubstanceabuse,noactiveeatingdisorderSupportsysteminplaceRealisticexpectationregardingoutcomesHasgoodunderstandingoftheprocedureanddedicatedtolifestylechangePre-SurgicalEvaluationPriortosurgerycandidatesshouldbecarefullyassessedbyaspecializedmultidisciplinaryteamincluding:
Bariatrician(MDspecializinginthecareoftheobese)SurgeonPCPSocialWorker/PsychologistDietitianNurse
Pre-SurgicalGoalsImprovementofnutritionalstatusCorrectvitamin/nutrientdeficiencies(mostcommoninclude:iron,vitaminB12andvitaminD)Achievementofbettercontrolofnutrition-relatedcomorbiditiesDevelopmentoflifestyleandeatinghabitsthatwillpromotepositivepost-weightlosssurgeryoutcomesandweightlossmaintenancePromote5-10%weightlosstoreducesurgicalrisksPre-Surgery
NutritionEducationIntensiveEducationisprovidedduringgroup&one-on-onesessionsBehaviormodificationself-care&lifestylechoicesself-monitoring(keepingafoodjournal)healthyfoodselectionseatingbehaviors(speed,schedule)Fluid,calorie,andproteinrequirementsDietinstruction:Stages1-3LabelreadingSupplement/productinformationVitamin&mineralrequirementsExercisePost-Surgery
NutritionGuidelinesDietaryconsultordereduponadmitCompletenutritionassessmentReviewdietprogressionwithpatientWorkwithin-patientteamtoidentify&minimizecomplicationspost-opForallprocedurespatientswillfollowthesamedietDietadvancedfromNPOtoStage1BariatricDietonPostopDay1PostSurgical
DietProgressionStage1-WaterTypicallystartdayofsurgery;Duration<1dayNOSTRAWSNursingstafftoadminister1ozwaterperhourviamedicinecupInstructpatienttosipslowly&stopiffeelingfullornauseous
Note:DietofficewillbeinstructednottosendmealtraysAllmedicationstobeadministeredinliquid/chewableformIVFluiduntiltoleratingliquidsPatienttobegintrackingfluidintakeonPatientIntakeDiary(providedbyhealthcareteam)PostSurgical
DietProgressionStage2-BariatricClearLiquids
StartsPostopDay1;Duration1-2daysNon-carbonatedliquidswithoutcalories,sugar,orcaffeine;includesbroth,sugar-free(SF)icepops,SFgelatin,water,&icechipsPriorityishydrationInstructtosipslowly&stopiffeelingfullornauseous(avoidstraws)Willreceive3ozBariatricClearLiquids3timesadayonmealtraysInstructtosip2-4ozBariatricClearFluidsperhourbetweenmealsWillbeexpectedtotrackintakeonPatientIntakeDiaryPostSurgical
DietProgressionStage3-BariatricFullLiquids
StartsPostopDay1-2;duration2-4weeksWillreceive3ozBariatricFullLiquids3timesadayonmealtraysLow-fatprotein-richliquidswith(exp.Low-fat(LF)broth,LFmilk,proteinshakes;light/LFyogurt,LFcottagecheese;LF/SFpudding)juven/beneproteinPriorityonhydrationandproteinintake(minimizelossofleanbodymass)Instructtosipslowly&stopiffeelingfullornauseousInstructtosip2-4ozfluidsperhourbetweenmealsNote:Patientswillgohomeonthisstage.Youmaynotseeotherstagesunlesspatientsarere-admittedPostSurgical
DietProgressionStage4-SoftandMoistProteinStart2weekspost-op;Duration4-6weeks
Astoleratedreplacefullliquidswithsoft&moistproteinfoods(avoiddryortoughmeats);~2-4ozpermeal
Mayneedtocontinuewithproteinshakestomeetproteinneeds
Instructnottodrinkfluidswithmeals;wait30minbefore&aftereachmealtohavebeverages
Ifmeetingproteingoalsmayaddwell-cookedsoftfruits&vegetables
Willbegintakingchewablevitamin&mineralsupplementsPostSurgical
DietProgressionStage5LowFat,LowSugar,HighProteinStart6-8weekspost-op;Durationlifelong
Balancedsolidfooddietwithprotein,fruits,vegetables,andwholegrains.Canaddrawfoodsastolerated.
Goals:60-80gramsprotein/day64+ouncesfluid/day(includingproteindrinks)sippedbetweenmeals.
Continuetoseparatefluidsfromyourmeals
CanadvancetosupplementsintabletformiftoleratedThingstoConsiderPost-OpIfhavingpoordiettolerance:Temperature:Ifnottoleratingicechipsoricepopsconsiderwarmliquids.Beawarethattolerancemayvarybetweenpatients.
Speed:Drinkingtooquickly,gulping,ordrinkingtoomuchmaycausepainanddiscomfort.Patientsmustavoidusingstrawsandfocusontakingverysmallsipsfrommedicinecup.
AdministeringMedications:Noteallmedicationsgiveninthehospitalshouldbecrushedorinliquidform.Chewable/liquidvitaminswillbegin2weekspost-opImmediatePost-OpNutritionConsiderationsHydrationstatus
Foodtoleranceissues
Appropriatedietadvancement
AddressindividualcomplaintsCommonProblems
AfterAllWeightLossSurgeries
DehydrationMonitorforsignsandsymptomsofdehydrationaspatientsareatgreaterriskgiventheirdietaryrestrictions.Patientsshouldstrivefor64ouncesofliquidsperday.
NauseaandVomitingEatingtooquicklyortoomuch,drinkingwithmealsordrinkingtooclosetomeals,notchewingthoroughly,oradvancingthediettooquicklycanallleadtonauseaand/orvomiting.Persistentvomitingcanleadtothiamindeficiency.Encouragepatientstodrinkandeatslowly,stopiffeelingfullornauseous,andtakesmallbitesandchewtheirfoodsthoroughly.CommonProblems
AfterGastricBypassSurgeryDumpingSyndromeUsuallyoccurs~30minutesfollowingameal.Undigestedcontentsofthestomacharetransportedor"dumped"intothesmallintestinetoorapidly.Symptomsmaybesimilartothefluandincludenausea,sweating,bloating,abdominalcramps,anddiarrhea.Toavoidthesesymptomspatientsshouldavoidhighfatandhighsugarfoods.Forexampleinsteadof100%fruitjuice;dilute1:1withwater.
DiarrheaSomepatientscandeveloppost-operativelactoseintolerance.Symptomscouldincludebloating,abdominalcramps,excessivegas,anddiarrhea.Treatmentincludesfollowingalactose-freediet.
AnatomicalcomplicationsTheremaybereasontosuspectapossiblesurgicalcomplicationifapatienthaspersistentnausea,vomiting,andabdominalpain.CommonNutrientDeficienciesGastricBypass:Mostcommon:Iron,VitaminB-12,
Folicacid,FatsolubleVitaminsA,D,&EThiamin(seeninpatientswithfrequentvomiting)CalciumProteinmalnutritionGastricBanding:Exceptforfolate,nutritiondeficienciesarelesscommonlyseenpostgastricbandingSleeveGastrectomyPossibleB-12LongTermOutcomesLifelongcompliancewithvitamin/mineralsupplementationisimportanttoreducetheriskofseriousnutrientdeficiencies
Self-monitoringintakeandavoidinghighcaloriefoodsandbeveragestopreventweightre-gain
RemainingconnectedwithpostbariatricsurgerysupportgroupsResourcesAmericanSocietyforMetabolic&BariatricSurgery/L.Aillsetal.ASMBSAlliedHealthNutritionalGuidelinesfortheSurgicalWeightLossPatient.SurgObesRelatDis.2008;4:S73-S108.Ifyouhaveanyadditionalquestionscontact:LisaC.Luz,RN,MSN,FNP-BCBariatricProgramCoordinator,MountAuburnWeightManagementCenter(Phone):617-499-6769(Email):lcluz@
BariatricNutritionQuiz1.ItwouldbeappropriatetoallowapatientonStage2to
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