Background • Obesity epidemic has increased

worldwide  Increased needs for

weight control measures.
• Bariatric surgery as part of weight
control has been popular in the last
decade  Need to adjust nutritional
needs for preoperative patients.
• We need to understand how to
screen, diagnose, and arrange
management plans for nutritional
needs of bariatric surgeries’ patients.

DR Dr Johana Titus, MS, SpGK

Types of • Purely Restrictive: affect Fe, Se & B12
Bariatric Surgery absorption
o Vertical Banded Gastroplasty
o Adjustable Gastric Band (AGB and LAGB)
o Vertical Sleeve Gastrectomy
• Mostly Restrictive (some
malabsorption):
o Roux-en-Y Gastric Bypass
• Mostly Malabsorptive (some
restriction):
o Jejuno-Ileal Bypass (not done anymore)
o Bilio-Pancreatic Diversion (anastomosis 50
cm from IC valve)
o Bilio-Pancreatic Diversion with Duodenal
switch (anastomosis 100 cm from IC valve)

DR Dr Johana Titus, MS, SpGK

Obesity and Bariatric Surgery

DR Dr Johana Titus, MS, SpGK

Malnutrition in Obesity before Bariatric Surgery
• CAUSES:
• Over ingestion of low-nutrient high-calorie foods.
• Low ingestion of high nutrient-density foods (vegetables, dairy, legumes,
whole grains, fish, nuts, etc.).
• High fat diets with low Vitamin A, C, and folate.
• Low sun-light exposure due to decreased activity causing low vitamin D.
• Low-grade chronic inflammatory state.
• Type-II DM increasing renal hyperfiltration with micronutrient loss.

References :
J Clin Endocrinol Metab 95:4823-4843,2010

DR Dr Johana Titus, MS, SpGK

Malnutrition in Obesity before Bariatric Surgery
• Fe deficiency found in 44% (female > male).
• Vitamin D deficiency (< 20ng/mL) in 91% on winter & 24% on
summer.
• Worse in African Americans & Hispanics.
• Low retinol & beta-carotene (vitamin A) in 12.5%
• Low vitamin E in 23%
• Low Folate in 0-6% in USA (folate enriched foods)
o but up to 54% in other parts of world.
References :
J Clin Endocrinol Metab 95:4823-4843,2010

DR Dr Johana Titus, MS, SpGK

Malnutrition in Obesity before Bariatric Surgery
• Low vitamin B12 in 18%.
• Low thiamin (Vitamin B1) in up to 7% in Caucasians, 31% in African
Americans, and 47% in Hispanics.
• Prevalence of low vitamins B2 (Riboflavin) and B6 (Pyridoxine) is not
known.
• Low vitamin C in 36%
• Low Zinc in up to 28%.
• Low Selenium was found in 6-58%.
• Copper deficiency has not been found. References :
J Clin Endocrinol Metab 95:4823-4843,2010

DR Dr Johana Titus, MS, SpGK

General Complications of Bariatric
Surgery

DR Dr Johana Titus, MS, SpGK

GI – Complications of Gastric Bypass

• Abdominal Pain / Nausea • Weight Gain

Marginal ulcer • Staple line disruption / gastro-
gastric fistula

• Obstruction (Nausea /
Vomitting/ Abdominal Pain) • Diarrhea
• Dumping syndrome
• Internal hernia
• Small bowel bacterial overgrowth
• Anastomotic stricture
• Bile acid diarrhea
• Adhesions

References : Nutr Clin Pract. 2007 Feb;22(1):29-40.

DR Dr Johana Titus, MS, SpGK

Internal Hernia

• Incidence 2%-5%.
• Intra-abdominal spaces are
created during surgery and
enlarge with weight loss.
• The intestine migrates into an
intra-abdominal space and
obstructs.
• Variety of presentations.
• Exploratory surgery.

DR Dr Johana Titus, MS, SpGK

Diarrhea

• Usual causes should be excluded.

• Dumping Syndrome: Postprandial lightheadedness, flushing, watery

diarrhea. Start meals with protein, avoid simple sugars. Octreotide for
refractory cases.
• Small Bowel Bacterial Overgrowth: Postprandial bloating. Breath test
or EGD with small bowel aspirate for quantitative culture. Rotating
antibiotics.
• Bile Salt Toxicity: Watery diarrhea. Cholestyramine.

DR Dr Johana Titus, MS, SpGK

Cholelithiasis

• 25% bariatric patients have had a prior cholecystectomy.

• 25% have cholelithiasis noted on their pre-operatively.
• 10%-42% of patients without gallstones will develop them.
• 32.5% of surgeons perform concomitant cholecystectomy.
• Ursodiol 600 mg daily for 6 months reduced postoperative gallstone
formation from 32% to 2%, but its use is limited by cost ($600 yearly)
and non-compliance.
• ERCP is difficult after gastric bypass and may require laparoscopic
access to the stomach.

DR Dr Johana Titus, MS, SpGK

Non-Alcoholic Fatty Liver Disease
• Incidence: NAFLD 91%
NASH 37%
unexpected cirrhosis 1.7% (1-7%)
• Hepatomegaly makes bariatric surgery technically difficult. A pre-operative
very low carbohydrate diet may reduce left lobe liver volume making
surgery easier.

• Bariatric surgery can potentially reverse fatty cirrhosis.

• However, the initial rapid weight loss following bariatric surgery can cause
hepatic decompensation in patients with NASH.
References :
J Hepatol.2006 Oct;45(4):600-6. SurgEndosc.2007 Mar 1.
J GastroenterolHepatol.2007 Apr;22(4):510-4. Dig DisSci. 2004 Oct;49(10):1563-8.
DR Dr Johana Titus, MS, SpGK
Nutritional Considerations for
Preoperative State

DR Dr Johana Titus, MS, SpGK

Nutritional Considerations
• Pre-operative
o Mandatory 6 month weight loss
programs
o VLCD
o Correction of nutritional deficiencies.
• Immediate Post-Operative
o Liquids--minimize trauma, maximize
healing
• Long term
o Food intake less than before
o Well balanced, small portions
o 64 oz. fluid daily
o 60-120 grams of protein daily

DR Dr Johana Titus, MS, SpGK

Preoperative Checklist and Diet Portion

DR Dr Johana Titus, MS, SpGK

 Clinical Practice Guidelines for the Perioperative
Nutritional, Metabolic, and Nonsurgical Support of the
Bariatric Surgery Patient—2013 Update*
• R11 - Preoperative glycemic control should be optimized using a
diabetes comprehensive care plan (Grade A, level of evidence 1)
 Targets : HbA1C ≤ 6.5%–7.0%, FBG ≤ 110 mg/dL, & 2-h PPBG ≤ 140
mg/dL.
 HbA1c 7%– 8%  advanced micro-/macrovascular complications,
extensive co-morbid conditions, or long-standing diabetes in which
the general goal has been difficult to attain.
• R31 – A low-sugar clear liquid meal program can usually be initiated
within 24 hours after any of the bariatric procedures, but this diet and
meal progression should be guided by the clinical nutritionists (Grade
C, level of evidence 3)
*These Guidelines are endorsed by the European Association for the Study of Obesity (EASO), International Association for the Study of Obesity (IASO), International Society for the Perioperative Care of the Obese
Patient (ISPCOP), Society American Gastrointestinal Endoscopic Surgeons (SAGES), American College of Surgery (ACS), and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO).
DR Dr Johana Titus, MS, SpGK
 Clinical Practice Guidelines for the Perioperative
Nutritional, Metabolic, and Nonsurgical Support of the
Bariatric Surgery Patient—2013 Update*
• R 31 - Patients should eat 3 small meals during the day and chew
small bites of food thoroughly before swallowing (Grade D)
• R 31 - Patients should adhere with principles of healthy eating,
including at least 5 daily servings of fresh fruits and vegetables (Grade
D)
• R31 - A minimal protein intake of 60g/day and up to 1.5g/kg ideal
body weight per day should be adequate; higher amounts of protein
intake—up to 2.1g/kg ideal body weight per day—need to be
assessed on an individualized basis (Grade D).
*These Guidelines are endorsed by the European Association for the Study of Obesity (EASO), International Association for the Study of Obesity (IASO), International Society for the Perioperative Care of the Obese
Patient (ISPCOP), Society American Gastrointestinal Endoscopic Surgeons (SAGES), American College of Surgery (ACS), and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO).
DR Dr Johana Titus, MS, SpGK
 Clinical Practice Guidelines for the Perioperative
Nutritional, Metabolic, and Nonsurgical Support of the
Bariatric Surgery Patient—2013 Update*
• R 31 - Concentrated sweets should be eliminated from the diet after RYBG to minimize
symptoms of the dumping syndrome, as well as after any bariatric procedure to reduce
caloric intake (Grade D).
• R32 – After consideration of risks and benefits, patients with or at risk for demonstrable
micronutrient insufficiencies or deficiencies should be treated with the respective
micronutrient (Grade A, level of evidence 2).
• R32 – Minimal daily nutritional supplementation for patients with RYGB and LSG all in
chewable form initially (i.e.,3 to 6 months), should include:
 2 adult multivitamin plus mineral (each containing iron, folic acid, and thiamine) supplements
(Grade B, level of evidence 2),
 1200 to 1500 mg of elemental calcium (in diet and as citrated supplement in divided doses) (Grade
B, level of evidence 2),
 At least 3000 IU of vitamin D (titrated to therapeutic 25- OH vitamin D levels of 430 ng/ml) (Grade
A, level of evidence 1),
 Vitamin B12 (parenterally as sublingual, subcutaneous, or intramuscular preparations, or orally, if
determined to be adequately absorbed) (Grade B, level of evidence 2).
*These Guidelines are endorsed by the European Association for the Study of Obesity (EASO), International Association for the Study of Obesity (IASO), International Society for the Perioperative Care of the Obese
Patient (ISPCOP), Society American Gastrointestinal Endoscopic Surgeons (SAGES), American College of Surgery (ACS), and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO).
DR Dr Johana Titus, MS, SpGK
 Clinical Practice Guidelines for the Perioperative
Nutritional, Metabolic, and Nonsurgical Support of the
Bariatric Surgery Patient—2013 Update*
• R 32 – Minimal daily nutritional supplementation for patients with
LAGB should include:
1 adult multivitamin plus mineral (including iron, folic acid, & thiamine) (Grade
B,level of evidence 2),
1200 to 1500 mg of elemental Ca (in diet and as citrated supplement in divided
doses) (Grade B,level of evidence 2),
At least 3000 IU of vitamin D (titrated to therapeutic 25-OH vitamin D levels)
• R 33 - Fluids should be consumed slowly, preferably at least 30
minutes after meals to prevent gastrointestinal symptoms, and in
sufficient amounts to maintain adequate hydration (more than 1.5
liters daily)
*These Guidelines are endorsed by the European Association for the Study of Obesity (EASO), International Association for the Study of Obesity (IASO), International Society for the Perioperative Care of the Obese
Patient (ISPCOP), Society American Gastrointestinal Endoscopic Surgeons (SAGES), American College of Surgery (ACS), and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO).
DR Dr Johana Titus, MS, SpGK
Nutritional Management of Surgical Patients
in the Perioperative (2017)
• Srivakumar (2017)  advisable to start with 6 months of VLCD, the
problems are it’s difficult to reduce BW 5-10% / mo., and decreased
immunity.
o Other researchers stated that 12 weeks with VLCD is enough.
o 2 weeks VLCD has been found reducing liver volume by 80%.
• Advised for 2 weeks with VLCD, 3 meals/day, no protein, 5 gr fat and
100 gr CHO with additional vitamins.

DR Dr Johana Titus, MS, SpGK

Examples of Preoperative Bariatric
Surgery Diet

DR Dr Johana Titus, MS, SpGK

DR Dr Johana Titus, MS, SpGK
DR Dr Johana Titus, MS, SpGK
DR Dr Johana Titus, MS, SpGK
Example of Patient
Education Leaflet

DR Dr Johana Titus, MS, SpGK

Conclusions

DR Dr Johana Titus, MS, SpGK

Conclusions
• The prevalence of obesity is still rising.
• The number of bariatric surgeries is rising accordingly.
• Gastrointestinal and nutritional complications of the surgeries are
common and may present years later.
• Given the multidiscipline model, the clinical nutritionist should be
prepared in association with other specialties to diagnose and treat
these problems.
• No matter what the presentation, always consider the possibility of
nutritional deficiency.

DR Dr Johana Titus, MS, SpGK

THANK YOU

DR Dr Johana Titus, MS, SpGK