Nutritional Considerations After Bariatric Surgery

1. Nutritional Considerations After Bariatric Surgery Michelle Lee, PhD, RD, LDN Assistant Professor-Nutrition Department of Allied Health College of Clinical and Rehabilitative Sciences ETSU

2. Objectives: • What are the short-term nutritional implications for individuals receiving bariatric surgery? • What are the long-term nutritional implications for individuals receiving bariatric surgery?

3. Bariatric Surgery Trends • Between 2003 and 2008, bariatric surgeries peaked in 2004 and has remained steady(1) • Number of weight loss surgeries increased from 103,000 in 2003 to ~220,000 in 2008(2) • Bariatric surgery in NOT a quick fix for morbid obesity • There are nutritional implications for any bariatric surgery

4. Types of Bariatric Surgery • Restrictive • Laparoscopic adjustable gastric band (LAGB) • Vertical banded gastroplasty (VBG) • Intragastric balloon • Malabsorptive • Bilopancreatic diversion with duodenal switch (BPD/DS) • Jejunoileal bypass • Bilopancreatic diversion (BPD) • Primary Restrictive with a Malabsorptive Component • Roux-en-Y gastric bypass (RYGB)

5. Laparoscopic Adjustable Gastric Band

6. Roux-en-Y Gastric Bypass

7. Nutritional Implications of Various Bariatric Surgeries(3,4) • RYGB • Malabsorption of Vit B12, Vit B1 (thiamin), Vit D, Vit K, Folate, Iron, Calcium • LAGB • Folic Acid deficiency • BPD and BPD/DS • Vit A, D, E, and K deficiency, Protein-Calorie Malnutrition, Malabsorption of Calcium, Zinc, Selenium, Sodium, Potassium, Chloride, Phosphorus, Magnesium

8. Sites of Nutrient Absorption(4) • Stomach • Water, ethyl alcohol, copper, iodide, fluoride, molybdemum, intrinsic factor • Duodenum • Calcium, iron, phosphorus, magnesium, copper, selenium, thiamin, riboflavin, niacin, biotin, folate, vitamins A, D, E, K

9. Sites of Nutrient Absorption(4) • Jejunum • Thiamin, riboflavin, niacin, pantothenate, biotin, folate, vit B6, vit C, vit A, D, E, K, dipeptides, tripeptides, calcium, phosphorus, magnesium, iron, zinc, chromium, manganese, molybdenum, amino acids • Ileum • Vit C, folate, vit B12, vit D, vit K, magnesium, bile salts/acids

11. Macronutrient Concerns • Protein • Carbohydrates • Fat

12. Micronutrient Concerns • Iron • Calcium and Vitamin D • Vitamin B12 • Folic acid • Thiamin • Zinc

13. Recommended Daily Supplements(4) • Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid) • Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D) • Oral vitamin B12 (500-1000 mcg) • Iron (65 mg/day in elemental form) • Vitamin C (to increase absorption of Iron) • Thiamin (10 mg/day)

14. Diet Progression After Bariatric Surgery(5) • Clear Liquids • Full liquids • Pureed food • Mechanical soft food • Soft food • Regular diet

15. Diet Recommendations(3) • Reduce food volume • Chew food very well • Slow pace of eating • No liquids with meals • Encourage fruits and vegetables as diet progresses • Include high protein foods (at least 60g/day); may need protein supplements

16. References • Nguyen NT, Masoomi H, Magno CP, Nguyen XM, Laugenour K, Lane J. Trends in use of bariatric surgery. 2003-2008. J Am Coll Surg. 2011;213(2):261-266. • Weight-Control Information Network. Longitudinal assessment of bariatric surgery (LABS). NIH Publication No. 04-5573. http://win.niddk.nih.gov/publications/PDFs/LABS_FactSheet.pdf. Accessed February 25, 2012. • Tucker ON, Szomstein S, Rosenthal RJ. Nutritional consequences of weight-loss surgery. Med Clin N Am. 2007;91:499-514. • Shikora SA, Kim JJ, Tarnoff ME. Nutrition and gastrointestinal complications of bariatric surgery. NutrClinPract. 2007;22(1):29-40. • Furtado LC. Nutritional management after Roux-en-Y gastric bypass. Br J Nurs. 2010;19(7):428-436.

17. Questions