Nutrition Practice Standards for Bariatric

Surgery

Dana Eiesland, RD, LDNLisa 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 nutrition- related 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-SurgeryNutrition Education

Intensive Education is provided during group & one-on-one sessions

Behavior modificationself-care & lifestyle

choicesself-monitoring (keeping

a food journal)healthy food selectionseating behaviors

(speed, schedule)

Fluid, calorie, and protein requirements

Diet instruction: Stages 1-3

Label reading Supplement/product

information Vitamin & mineral

requirements 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 dietDiet 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

cupInstruct 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:S73-S108.

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) : lcluz@mah.harvard.edu

Bariatric Nutrition Quiz

1. It would be appropriate to allow a patient on Stage 2 to have all of the following fluids except: A. Water B. Low sodium vegetable broth C. Ginger ale D. Crystal light

2. All medications & vitamin/mineral supplements should be taken in which form after surgery? A. Chewable B. Liquid C. Tablet D. A&B

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

Bariatric Nutrition Quiz

5. Following bariatric surgery it is important to monitor for: A. Hydration status B. Tolerance of oral intake (nausea/vomiting/diarrhea) C. Diet to be advanced appropriately D. All of the above