Manual of Clinical Nutrition

Nutrition Management in Bariatric Surgery

Manual of Clinical Nutrition Management B- 30 Copyright © 2013 Compass Group, Inc.

Strategies for Vitamin and Mineral Supplementation Following Bariatric Surgery
Vitamin and mineral supplementation is necessary for maintenance of nutritional stores and should be a part
of the patient’s life-long dietary strategies following bariatric surgery. A multiple vitamin and mineral tablet
usually given twice a day (one at breakfast and one at dinner) is recommended to meet the DRIs for most
patients (5). Chewable forms (or liquid forms) of supplements are recommended for at least 2 to 3 months,
after which the patient may switch to a form that they can swallow (5). Prenatal vitamins are good for
individuals who need extra iron (5). Allow at least 2 hours between iron and calcium supplements to avoid
interference and absorption (5). One option is to give the calcium supplement at lunch while providing the
iron supplements at breakfast and dinner (5). If iron is needed, it is recommended to be consumed with
vitamin C food sources (5). Signs and symptoms of nutritional deficiencies should be routinely evaluated and
monitored postoperatively to determine if additional vitamin or mineral supplementation is necessary (1).

Strategies for Behavior Modification Following Bariatric Surgery
Behavior modification is a critical element for short-term and long-term success following bariatric surgery,
as it directly affects for the Bariatric Diet. Behavior modification helps to improve tolerance during the initial
postoperative stages. The continued application of the behavior modification techniques described below
will also lead to improved long-term weight loss outcomes (1,8,23-25).

1. The patient should eat slowly, chewing foods completely before swallowing. The suggested average time
   to complete a meal is 20 to 30 minutes (8,23-25).


2. The patient should drink low-fat, low-sugar beverages including water between meals. The patient
   should avoid consuming fluids with meals and wait at least 30 minutes after meals to resume fluid intake
   (1).


3. The patient should consume protein foods first, vegetables and fruit second, and starch foods last to help
   ensure that adequate protein is consumed (5).


4. Portion control is critical. Foods should be cut, diced, and portioned to prevent overeating. The use of
   small serving plates may also be helpful with portion control (1).


5. The patient should become aware of satiety sensations and signs of pouch fullness. A feeling of pressure
   or nausea after consuming a food or beverage is a sign that the pouch may be full. The patient should
   avoid overeating or eating until fullness. There is a delay in response from when the pouch is full and
   when the brain signals fullness, so sticking with planned portions is important. Patients should be
   assured that hunger is common and normal postoperatively (1). The patient is encouraged to eat three to
   six servings of protein foods through the day to help satiety since hunger is common (especially within 1
   week postoperatively) (1). Chronic overeating may cause pouch dilation, ineffective weight loss, and
   premature weight gain (1,23,24).


6. If vomiting occurs after eating, the patient should eat more slowly at the next meal. The patient should
   properly chew food, wait at least 30 minutes after eating before drinking fluids, and avoid overeating (1).
   Lying down after eating may be helpful (23-25). Prolonged or protracted vomiting or intolerance to food
   consumption should be immediately reported to the physician to prevent complications of malnutrition,
   dehydration, and thiamin deficiency (1).


7. Food intolerances are common. The patient should keep detailed food records to determine how to
   achieve a high-quality meal plan that integrates a variety of nutrient-dense foods.

Medical Complications and Nutrition Evaluation and Monitoring Following Bariatric Surgery
Close medical monitoring is critical during the acute postoperative stages of weight loss (1 to 16 weeks) to
determine the adequacy of nutritional intake and the physiologic impact of rapid and substantial weight loss.
Vital signs, such as blood pressure and heart rate, should be routinely monitored, and the patient’s electrolyte
levels, hydration status, and cardiac status should be monitored with laboratory assessments. Risks
associated with rapid weight loss include the loss of potassium and body protein, which could lead to
ventricular arrhythmias (16). However, losses of body protein are less in severely obese patients, which may
provide protection from arrhythmias during rapid weight loss (15). Due to low-energy intake during the initial
stages of the Bariatric Diet, urinary ketone levels are generally increased. Urinary ketones interfere with the
renal clearance of uric acid, resulting in increased serum uric acid levels, which may lead to gout (19). Daily
consumption of more than 100 g of carbohydrates may help minimize ketosis and uric acid levels (15). Higher
serum cholesterol levels resulting from mobilization of adipose tissue may increase the risk of gallstone
formation (1).