Nutrition Implications of Bariatric Surgery
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Transcript Nutrition Implications of Bariatric Surgery
Nutrition Practice
Standards for
Bariatric Surgery
Dana Eiesland, RD, LDN
Lisa C. Luz, RN, MSN, FNP-BC
Mount Auburn Weight Management Center
Objectives
Review criteria for surgery
Outline the pre-surgical evaluation
Summarize pre-surgical nutrition goals
Review nutrition guidelines & diet progression
following surgery
Review immediate post operative and long term
surgical complications
General Criteria for Weight
Loss Surgery (WLS)
BMI 35-40 with at least one co-morbidities (exp. DM,
Obstructive sleep apnea)
BMI > 40 without co-morbidities
Previous unsuccessful attempts at weight loss
Age >18-65 with few exceptions
Medically cleared for surgery
Mentally & emotionally prepared and motivated
No substance abuse, no active eating disorder
Support system in place
Realistic expectation regarding outcomes
Has good understanding of the procedure and dedicated
to lifestyle change
Pre-Surgical Evaluation
Prior to surgery candidates should be carefully
assessed by a specialized multidisciplinary team
including:
Bariatrician (MD specializing in the care of the obese)
Surgeon
PCP
Social Worker/ Psychologist
Dietitian
Nurse
Pre-Surgical Goals
Improvement of nutritional status
Correct vitamin/nutrient deficiencies (most common
include: iron, vitamin B12 and vitamin D)
Achievement of better control of nutritionrelated comorbidities
Development of lifestyle and eating habits that
will promote positive post-weight loss surgery
outcomes and weight loss maintenance
Promote 5-10% weight loss to reduce surgical
risks
Pre-Surgery
Nutrition Education
Intensive Education is
provided during group & oneon-one sessions
Fluid, calorie, and
protein requirements
Diet instruction:
Behavior modification
Stages 1-3
self-care & lifestyle
Label reading
choices
self-monitoring (keeping a Supplement/product
information
food journal)
Vitamin & mineral
healthy food selections
requirements
eating behaviors (speed,
schedule)
Exercise
Post-Surgery
Nutrition Guidelines
Dietary consult ordered upon admit
Complete nutrition assessment
Review diet progression with patient
Work with in-patient team to identify &
minimize complications post-op
For all procedures patients will follow the
same diet
Diet advanced from NPO to Stage 1
Bariatric Diet on Post op Day 1
Post Surgical
Diet Progression
Stage 1 - Water
Typically start day of surgery; Duration < 1 day
NO STRAWS
Nursing staff to administer 1oz water per hour via medicine cup
Instruct patient to sip slowly & stop if feeling full or
nauseous
Note: Diet office will be instructed not to send meal trays
All medications to be administered in liquid/chewable form
IV Fluid until tolerating liquids
Patient to begin tracking fluid intake on Patient Intake Diary
(provided by healthcare team)
Post Surgical
Diet Progression
Stage 2 - Bariatric Clear Liquids
Starts Post op Day1; Duration 1-2 days
Non-carbonated liquids without calories, sugar, or caffeine;
includes broth, sugar-free (SF) ice pops, SF gelatin, water, &
ice chips
Priority is hydration
Instruct to sip slowly & stop if feeling full or nauseous
(avoid straws)
Will receive 3oz Bariatric Clear Liquids 3 times a day on meal
trays
Instruct to sip 2-4 oz Bariatric Clear Fluids per hour between
meals
Will be expected to track intake on Patient Intake Diary
Post Surgical
Diet Progression
Stage 3 - Bariatric Full Liquids
Starts Post op Day 1-2; duration 2-4 weeks
Will receive 3oz Bariatric Full Liquids 3 times a day on meal trays
Low-fat protein-rich liquids with (exp. Low-fat (LF) broth, LF milk, protein
shakes; light/LF yogurt, LF cottage cheese; LF/SF pudding)
juven/beneprotein
Priority on hydration and protein intake (minimize loss of lean body mass)
Instruct to sip slowly & stop if feeling full or nauseous
Instruct to sip 2-4 oz fluids per hour between meals
Note: Patients will go home on this stage. You may not see other
stages unless patients are re-admitted
Post Surgical
Diet Progression
Stage 4 - Soft and Moist Protein
Start 2 weeks post-op; Duration 4-6 weeks
As tolerated replace full liquids with soft & moist protein foods
(avoid dry or tough meats); ~2-4oz per meal
May need to continue with protein shakes to meet protein needs
Instruct not to drink fluids with meals; wait 30 min before & after
each meal to have beverages
If meeting protein goals may add well-cooked soft fruits &
vegetables
Will begin taking chewable vitamin & mineral supplements
Post Surgical
Diet Progression
Stage 5 Low Fat, Low Sugar, High Protein
Start 6-8 weeks post-op; Duration lifelong
Balanced solid food diet with protein, fruits, vegetables, and whole
grains. Can add raw foods as tolerated.
Goals:
60-80 grams protein /day
64+ ounces fluid/ day (including protein drinks) sipped between
meals.
Continue to separate fluids from your meals
Can advance to supplements in tablet form if tolerated
Things to Consider Post-Op
If having poor diet tolerance:
Temperature: If not tolerating ice chips or ice pops consider
warm liquids. Be aware that tolerance may vary between
patients.
Speed: Drinking too quickly, gulping, or drinking too much may
cause pain and discomfort. Patients must avoid using straws
and focus on taking very small sips from medicine cup.
Administering Medications:
Note all medications given in the hospital should be crushed or
in liquid form.
Chewable/liquid vitamins will begin 2weeks post-op
Immediate Post-Op
Nutrition Considerations
Hydration status
Food tolerance issues
Appropriate diet advancement
Address individual complaints
Common Problems
After All Weight Loss Surgeries
Dehydration
Monitor for signs and symptoms of dehydration as patients are
at greater risk given their dietary restrictions. Patients should
strive for 64 ounces of liquids per day.
Nausea and Vomiting
Eating too quickly or too much, drinking with meals or drinking
too close to meals, not chewing thoroughly, or advancing the
diet too quickly can all lead to nausea and/or vomiting.
Persistent vomiting can lead to thiamin deficiency. Encourage
patients to drink and eat slowly, stop if feeling full or nauseous,
and take small bites and chew their foods thoroughly.
Common Problems
After Gastric Bypass Surgery
Dumping Syndrome
Usually occurs ~30 minutes following a meal. Undigested contents of
the stomach are transported or "dumped" into the small intestine too
rapidly. Symptoms may be similar to the flu and include nausea,
sweating, bloating, abdominal cramps, and diarrhea. To avoid these
symptoms patients should avoid high fat and high sugar foods. For
example instead of 100% fruit juice; dilute 1:1 with water.
Diarrhea
Some patients can develop post-operative lactose intolerance.
Symptoms could include bloating, abdominal cramps, excessive gas,
and diarrhea. Treatment includes following a lactose-free diet.
Anatomical complications
There may be reason to suspect a possible surgical complication if a
patient has persistent nausea, vomiting, and abdominal pain.
Common Nutrient Deficiencies
Gastric Bypass:
Most common: Iron, Vitamin B-12,
Folic acid, Fat soluble Vitamins A, D, & E
Thiamin (seen in patients with frequent vomiting)
Calcium
Protein malnutrition
Gastric Banding:
Except for folate, nutrition deficiencies are less commonly seen
post gastric banding
Sleeve Gastrectomy
Possible B-12
Long Term Outcomes
Lifelong compliance with vitamin/ mineral
supplementation is important to reduce
the risk of serious nutrient deficiencies
Self-monitoring intake and avoiding high
calorie foods and beverages to prevent
weight re-gain
Remaining connected with post bariatric
surgery support groups
Resources
American Society for Metabolic & Bariatric Surgery
http://www.asmbs.org/
L. Aills et al. ASMBS Allied Health Nutritional Guidelines for the
Surgical Weight Loss Patient. Surg Obes Relat Dis. 2008; 4:S73S108.
If you have any additional questions contact:
Lisa C. Luz, RN, MSN, FNP-BC
Bariatric Program Coordinator, Mount Auburn Weight Management Center
(Phone) : 617-499-6769 (Email) : [email protected]
Bariatric Nutrition Quiz
1. It would be appropriate to allow a patient on Stage 2 to have
all of the following fluids except:
A.
B.
C.
D.
Water
Low sodium vegetable broth
Ginger ale
Crystal light
2. All medications & vitamin/mineral supplements should be
taken in which form after surgery?
A.
B.
C.
D.
Chewable
Liquid
Tablet
A&B
Bariatric Nutrition Quiz
3. Patients should wait 30 minutes before and after meals to drink
any fluids.
A. true
B. false
4. Which of the following are associated with Dumping Syndrome?
A. Drinking too much water
B. Flu like symptoms including nausea, sweating, bloating, abdominal
cramps, and diarrhea occurring ~30 minutes after a meal
C. Eating high fat or high sugar foods like 100% fruit juice or ice cream
D. B & C
Bariatric Nutrition Quiz
5. Following bariatric surgery it is important to monitor for:
A.
B.
C.
D.
Hydration status
Tolerance of oral intake (nausea/vomiting/diarrhea)
Diet to be advanced appropriately
All of the above