Internal Medicine Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO


July 10, 2018

In This Article

Postbariatric Care

European Association for the Study of Obesity

The ingestion of solid foods in the first days after surgery is impossible, and a gradual change of food consistency in the first postoperative weeks is preferred in order to avoid or minimize regurgitation and vomiting, which can threaten the integrity and safety of the recent surgical procedure and result in severe vitamin B1 (thiamine) deficiency.

A low-sugar, clear-liquid meal program is usually initiated within 24 hours after surgery, and patients are then instructed to gradually and progressively change the food consistency, moving from clear liquids to soft or creamy foods and then to solid, chewable items over a period of 2-4 weeks.

After the end of the postoperative diet and thereafter, patients should receive periodic counseling by a registered dietitian about long-term dietary modifications in order to maximize the results of the bariatric procedure and reduce the risk of late weight regain.

Patients with gastric restriction should be counseled to eat 3 small meals during the day and chew small bites of food thoroughly before swallowing, without drinking beverages at the same time (more than 30 minutes apart).

Dietary counseling should address the problem of protein intake, particularly in the first months after surgery. Current guidelines suggest a minimal protein intake of 60 g/day and up to 1.5 g/kg ideal body weight per day, but higher amounts of protein intake (up to 2.1 g/kg ideal body weight per day) may be required in individual cases. The use of liquid protein supplements (30 g/day) can facilitate adequate protein intake in the first period after surgery.

In case of persistent (>6 months) and/or frequent vomiting, a physical cause should be suspected and a surgical diagnostic work-up considered. Persistent vomiting heavily disturbing normal eating and greatly reducing energy intake can precipitate the onset of an acute state of thiamine deficiency that needs to be considered and prevented.

Dumping refers to the postprandial occurrence of a constellation of symptoms elicited by the rapid transit of calorie-dense food to the small bowel. Nutritional manipulation is usually sufficient to control dumping. Nutritional tips comprise eating small but frequent meals, avoiding ingestion of liquids within 30 minutes of a solid-food meal, avoiding simple sugars, increasing intake of fiber and complex carbohydrates, and increasing protein intake.

The occurrence of vitamin and mineral deficiencies is one of the most common and compelling problems after bariatric surgery. Prevention, detection, and treatment of these deficiencies represent cornerstones of long-term follow-up in postbariatric patients.

Prophylactic empiric iron supplementation is recommended after gastric bypass, biliopancreatic diversion, duodenal switch, and sleeve gastrectomy.

Even in the absence of conclusive evidence concerning the long-term risk of fractures after bariatric surgery, calcium and vitamin D routine supplementation is strongly recommended after gastric bypass and malabsorptive procedures.

Routine fat-soluble vitamin supplementation is recommended in all patients having undergone biliopancreatic diversion or biliopancreatic diversion with duodenal switch.

Suggested daily supplementation for patients with gastric bypass and sleeve gastrectomy includes 2 adult multivitamin plus mineral supplements (containing iron, folic acid, and thiamine); 1,200-1,500 mg of elemental calcium (in diet and as citrated supplement in divided doses); at least 3,000 IU of vitamin D (titrated to therapeutic 25-hydroxyvitamin D levels >30 ng/ml); and vitamin B12 titrated to maintain normal levels. Routine supplementation with adequate amounts of fat-soluble vitamins should be added to this regimen after biliopancreatic diversion or duodenal switch. In the case of gastric banding, the suggested daily supplementation may be reduced to adult multivitamin plus mineral supplement and at least 3,000 IU of vitamin D (titrated to vitamin D levels) with or without 1,200-1,500 mg of elemental calcium (in diet and as citrated supplement in divided doses).

Ideally, metabolic control should be optimized in patients with obesity and type 2 diabetes in preparation for a bariatric procedure. HbA1c levels of 6.5-7%, fasting glucose levels <110 mg/dl, and 2-hour postload glucose <140 mg/dl should be targeted.

Nutritional deficiencies are more common in the first 12-18 months after surgery, when maximal weight loss occurs. A higher incidence of stillbirths has been reported when pregnancy occurs in the first year after surgery. Furthermore, obstetric complications after bariatric surgery are more frequent at higher BMI. Pregnancy is hence not recommended during 12-18 months following surgery.



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