Julianne Borba

April 5th, 2016

Nutritional Assessment of the Bariatric Patient

Nutritional Assessment of the Bariatric Patient

Rates of bariatric surgeries for the treatment of morbid obesity

are rising in the US and worldwide1. Bariatric surgery aims to help a
patient with extreme obesity lose weight. This is done by surgically
altering the stomach and/or intestines and changing the digestive
systems anatomy2. All bariatric surgeries restrict the amount of food a
patient can eat at one time, which promotes weight loss, some effect
secretion of gut hormones that decrease hunger/increase satiety as
well. However, these changes in gut anatomy can lead to
micronutrient malabsorption, placing patients at high risk for
nutritional deficiencies (short and long-term) 2.
Excess weight is defined as the number of pounds above a
persons ideal body weight (IBW), and percent excess weight loss
(%EWL) is a common metric for reporting weight loss and determining
success after bariatric surgery3. Although weight loss is generally the
focal point of success, decreasing and/or improving obesity-related
comorbidities and increasing quality of life are both important benefits
of bariatric surgery. The expenses of bariatric procedures, though
extensive, have been shown to be cost-effective when analyzed with
the healthcare costs associated with obesity-related comorbidities like
diabetes as well as improvements in patients quality of life4.
The most common types of bariatric surgery include gastric
bypass/Roux-en-Y, adjustable gastric banding/lap band, gastric
sleeve/vertical sleeve gastrectomy, biliopancreatic diversion with

duodenal switch (BPD/DS), and intragastric balloon/gastric balloon 1.

Good Samaritan treats a good number of bariatric patients each year.
The clinical nutrition manager has been updating the hospitals
Nutrition Assessment Toolkit, disease state by disease state, and felt
providing the dietetic team with an overview of bariatric surgeries,
considerations, and nutrition needs would be a helpful component in
the process.
Gastric bypass is the most common type of bariatric surgery
performed in the United States. Roux-en-Y (gastric bypass) is
considered the gold standard of weight loss surgery1. The procedure
is mainly restrictive but has malabsorptive elements as well. It has two
componentsfirst, a small pouch (~1oz in volume) is created by
dividing the top of the stomach from the rest of the stomach2. Next,
the first portion of the small intestine is divided, and the bottom end is
brought up and connected to the newly segmented small stomach
pouch. Once that is completed, the top portion of the divided small
intestine is connected to the small intestine further down resulting in
the stomach acids and digestive enzymes from the bypassed stomach
and first portion of the small intestine to mix with the food5. There are
several mechanisms at play that make this an effective weight loss
procedure. The newly created stomach pouch is much smaller which
requires significantly smaller meals, meaning less calories consumed.
In addition, there is less digestion of food by the smaller stomach

pouch and there is no longer food going through a segment of the

small intestine that would normally absorb food/calories, meaning
there is likely less absorption of calories and nutrients. The rerouting
of the food system produces hormonal gut changes that increase
satiety and suppress hunger. Patients lose 60-70% of excess weight on
average, which is higher and more consistent than other bariatric
surgeries5, 6.
The Gastric Sleeve, or Vertical Sleeve Gastrectomy, is the newest
addition to the accepted bariatric surgeries and is becoming
increasingly more popular1. It is more effective and safe than other
procedures and appears to be taking over as the Gold Standard of
bariatric surgeries1. The procedure involves dividing the stomach to
create a long pouch that connects the esophagus to the small
intestine. The pouch is stapled and the rest of the stomach is removed
(~80% of the stomach), drastically reducing the volume and amount of
food that can be consumed2. Like the gastric bypass, the vertical
sleeve causes beneficial changes in gut hormones leading to increased
satiety and decreased hunger. The risk of serious complications is low
(<10%) and the average excess weight loss for patients is 65-75%5,6.
The Adjustable Gastric Banding, or Lap Band, is a restrictive
surgery and is the second most popular bariatric surgery in the United
States1. It involves placing and inflatable band around the upper
portion of the stomach, creating a small pouch above the band with

the rest of the stomach below5. The idea is that since the stomach
pouch is much smaller, a small amount of food will make the patient
feel full and satisfy hunger2. The size of the opening between the
pouch and the rest of the stomach can be adjusted, or filled with
sterile saline, which is injected through a port, placed under the skin.
Reducing the size of the opening is done gradually over time5. Food is
digested and absorbed normally after this procedure, the major
mechanism of the adjustable gastric band is the reduction of hunger,
promoting less calorie intake by the patient5, 6.
Biliopancreatic Diversion with Duodenal Switch (BPD/DS) Gastric
Bypass involves two components. The first is similar to that of the
sleeve gastrectomyremoving a portion of the stomach creates a
small, tubular pouch. Then, a large portion of the small intestine is
bypassed. The first portion of the small intestinethe duodenumis
divided right past the outlet of the stomach5. A segment of the
end/distal portion of the small intestine is brought up and connected to
the outlet of the newly created stomach pouch.

Therefore, it is both a

restrictive and malabsorptive procedure. As a result, when the patient

eats, the food goes through the newly created tubular stomach and
empties into the last segment of the small intestine, bypassing about
of the small intestine6. The bypassed portion of the small intestine
is reconnected to the last portion so that the bile and pancreatic
enzymes necessary for the breakdown and absorption of protein and

fat can eventually mix with the redirected food stream7. Like the other
bariatric surgeries, the BPD/DS helps reduce the amount of food
consumed, though over time this effect lessens and patients are
eventually able to consume near normal amounts2. Since the food
does not mix with the bile and pancreatic enzymes until much further
down the small intestine, there is a significant decrease in the amount
of calories and nutrients absorbed7. Like the other gastric surgeries
mentioned, BPD/DS affects the gut hormones positively impacting
hunger and satiety2. On average BPD/DS results in more weight loss
than any other procedure but carries with it the highest risk of
complications6, 7.
The Intragastric Balloon, or Gastric Balloon procedure, is
considered a middle of the road weight loss strategy between a diet
and exercise regimen and the more aggressive bariatric procedures 2.
The procedure may or may not involve sedation and starts with
numbing the throat to insert a plastic mouth guard. Then a scope is
inserted and passed through the mouth and into the stomach. The
scope is then removed and a balloon is passed into the patients
stomach and inflated with air or saline (depending on the balloon type)
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. The procedure is temporary; the balloon must be removed within 6

months. It is meant to enhance weight loss and jump-start a longterm, medically supervised diet and lifestyle program5, 6.

Types of
Bariatric
Surgery

Category

Average
Longterm
Excess
Weight
Loss
(%EWL)

Complica
tion Rate

Average Cost

Gastric
Bypass;
Roux-en-Y
Gastric
Sleeve
Surgery;
Vertical
Sleeve
Gastrectom
y
Biliopancre
atic
Diversion
with
Duodenal
Switch
(BPD/DS)
Intragastric
Balloon;
Gastric
Balloon
Gastric
Banding;
Lap Band

Combinatio
n (primarily
restrictive)
Restrictive

50-70%

Up to 15%

$24,000

65-75%

Up to 10%

$19,000

Malabsorpt
ive

65-75%

Up to 24%

$27,000

Restrictive

26-46%

Very low

$8,000

Restrictive

~50%

Up to 33%

$15,000

2, 5, 6, 7
Although bariatric surgeries are accepted as a weight-loss
approach for patients with severe obesity and obesity-related
conditions, there are certain criteria that must be met in order to be an
appropriate candidate. The National Institute of Health (NIH) has
identified several bariatric surgery criteria for candidacy including:
severe obesity (BMI >40 or 100# over IBW), or BMI 35-40 with
significant obesity-related conditions (diabetes, high blood pressure,
sleep apnea, hyperlipidemia), patients must not have drug or alcohol
problems, patients must not have endocrine-related obesity, patients

must have adequate psychological status, and patients must accept

and understand all risks associated with the surgery8.
Pre-screening of potential patients should be a thorough process
to ensure patients are well aware with the associated risks,
complications, and implications that accompany these procedures 1. It
is important to assess each patients psychological status and
determine whether they are motivated and capable to make the
necessary lifestyle changes that accompany this decision8. Making
sure the patient is both well-educated and prepared regarding all
aspects of the procedure and their new dietary regimen pre and postsurgery will be vital in promoting success and maintenance of weight
loss8.
Common early complications associated with bariatric surgeries
include dumping syndrome, bleeding, anastomic leak, wound
infections, thromboembolism, anastomotic strictures, pneumonia, and
pulmonary embolism9. Longer-term complications seen in bariatric
patient include marginal ulcers, bowel obstruction, gallstones, stapleline breakdown, wound/incision hernia, weight regain, and nutrient
deficiencies9. Symptoms that are common among post-op bariatric
patients include nausea, vomiting, and dehydration; addressing these
problems as quickly as possible may prevent the patient from
developing more serious complications and improve their chances for
post-operative success10, 11.

Dumping syndrome is a common complication associated with

bariatric surgery, especially gastric bypass/Roux-en-Y10. With gastric
bypass surgery, the malabsorption resulting from bypassing part of the
intestine is what leads to dumping. It occurs when food, especially
sugar, moves too quickly through the stomach and are dumped into
the small intestinerapid gastric emptying6,10. The body has
difficulty processing and usually responds by adding large amounts of
fluid to the small intestine. This may result in symptoms like nausea,
stomach cramping, dizziness, diarrhea, light-headedness, hot flashes,
and cold sweats10, 11. Dumping syndrome can usually be resolved
without medical intervention. Dietary strategies to help prevent
dumping syndrome include: avoiding simple sugars, separating fluids
from meals, waiting at least 30 minutes after meals to consume
liquids, eating 5-6 small meals a day, choosing high fiber/complex
carbohydrate foods, including protein sources with each meal, lying
down 30 minutes after meals, and/or add fiber powder supplements to
dietary regimen10, 11.
Due to alterations in the gastrointestinal tract with bariatric
surgery, patients will require lifelong micronutrient monitoring and
supplementation2, 9. Vitamin B12 is of particular concern in RYGB
patients because the resection of the duodenum where B-12 attaches
to intrinsic factor for absorption is bypassed8, 11. B-12 should be
supplemented w/ 350mcg sublingual once a day, 500mcg intra-nasally

once a week, or 1000mcg intramuscularly once a month11. Calcium

and Vitamin D3 requirements are slightly higher in RYGB and SG
patients due to decreased dietary absorption8. Calcium citrate is the
preferred form of calcium supplementation because it does not require
a highly acidic environment for absorption11. Iron needs are higher
after RYGB and SG due to decreased stomach acid needed for
absorption8. With RYGB, the major sites of iron absorption (duodenum
and proximal jejunum) are bypassed11. If patients are taking a
multivitamin with at least 36mg iron, supplementation is likely
sufficient9. Pre-menopausal women may require 50-100mg/d more11.
Regular nutrient screenings and assessments are vital in the nutrition
care of bariatric patients; identifying possible deficiencies early and
addressing them appropriately is one of the dietitians key roles in the
bariatric surgery process.
Protein plays a crucial role in healing and in preservation of lean
body mass after bariatric surgery9, 12. The general protein goal for
bariatric patients is 60-120g of protein per day or 1-1.5g/kg of the
patients ideal body weight12. Generally, women should not consume
less than 60g protein per day and men should not consume less than
80g protein per day9, 12. This is thought to be a sufficient amount to
preserve lean body mass and promote healing after surgery12. High
protein foods like eggs, poultry, fish, lean and tender meats, beans,
lentils, etc are good dietary protein sources for post-op patients. Liquid

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protein supplements may be a helpful addition for many patients who

have a hard time consuming adequate protein.
Dietary changes should start as soon as bariatric surgery is
considered. Pre-operative changes can reduce the risk of bariatric
surgery complications and help maximize weight loss and
maintenance2. The patients pre-surgery diet should be one high in
protein and low in carbohydrates13. This will reduce bleeding, promote
healing, and shrink the liverall of which will be helpful during and
after the procedure11, 13. The post-operative diet is one that involves
many stages and strict adherence. The post-operative diet is also
based on high protein, low carbohydrates13. Stage 1, usually days 0-3,
patients will normally be put on a clear liquid diet drinking 1-3oz per
hour14. Water, broth, sugar-free gelatin, and non-carbonated
beverages are appropriate. Stage 2, usually days 4-14, patients are
advised to be on a full liquid diet. This may include the clear liquids as
well as sugar-free nutritional supplements to help provide adequate
protein14. Stage 3, usually weeks 2-5, slowly and gradually implements
pureed and soft foods. Patients are advised to eat 5-6 very small
meals per day with liquid protein supplements13, 14. These meals may
include blenderized soups, soft fruit and well-cooked vegetables,
oatmeal or cream of wheat, cottage cheese, yogurt, scrambled or softcooked eggs, and etc14. Stage 4, weeks 5 onward, patients should
gradually add regular foods13. They should continue to eat small,

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frequent meals and consume high amounts of protein, but they can
gradually decrease protein supplements as they begin to consume
more protein-rich foods10, 13.
Patients will need to adopt habits as part of a life-long weight
loss maintenance routine. Generally, post-op bariatric patients should
aim to consume less than 800-1000kcals/day in order to avoid
regaining their weight15. Though there is some variance and
discrepancy regarding the appropriate caloric ranges for post-op
bariatric patients, most scientific literature suggests patients consume
~800-1000kcals 6 months to a year after their procedure. For a year
onward, most resources suggest a range between 800-1400kcals
though some research literature ranges from 800-1800kcals between 3
months and 8 years post-op.15, 16 ASPENs 2009 guidelines have
identified the references of 11-14kcal/kg actual body weight for obese
patients with a BMI between 30-50 and 22-25kcal/kg ideal body weight
(IBW) for patients with a BMI >50.
Post-op bariatric patient are advised to adopt life-long habits to
reduce their complications risk and promote successful weight-loss
maintenance. Patients should avoid the consumption of liquids with
meals by aiming to separate them by at least 30-60min before and
after10. Patients should continue to avoid high fat, high calorie, and
sugary foods and should talk to their doctor or dietitian about
necessary vitamins and supplements they may require10, 15.

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Developing life-long habits of eating small portions, eating slowly, and

chewing thoroughly will be crucial in preventing complications and
promoting maintenance of weight loss15. Implementing physical
activity will be another key factor for success. Patients should perform
a minimum of 150 minutes weekly of moderate intensity exercise with
a goal of 30-45 minutes per day, as well as adding strengthening
workouts each week11, 12. Due to the fact that bariatric surgery comes
with such drastic lifestyle changes, patients should be thoroughly prescreened and assessed prior to surgery to indicate whether they are
truly prepared the commitment.
Weight loss and maintenance of weight loss is the main criteria
for successful bariatric surgery, though not the only one. Obesityrelated comorbidities include nearly every bodily system
cardiovascular, endocrine, pulmonary, hematopoietic, gastrointestinal,
genitourinary, gynecologic, musculoskeletal, and urologic 16, 17. Bariatric
surgery has been shown to improve and/or resolve these comorbidities
among obese patients17. Bariatric procedures treat more disease
conditions at once than any other single medical or surgical
intervention18. They have been shown to decrease patients risk for
coronary heart disease and overall mortality, and are playing an
increasingly more important role in helping control the obesity
epidemic18. Due to the increasing prevalence and increasing need for
bariatric procedures, dietitians and health care providers should

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continue to stay up-to-date on the latest research and

recommendations for bariatric patients in order to promote successful
outcomes for their patients.

References:

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1. 1st ed.; 2016. Available at:

https://asmbs.org/wp/uploads/2014/05/AACE_TOS_ASMBS_Clinical_Prac
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2. Gloy V, Briel M, Bhatt D et al. Bariatric surgery versus non-surgical
treatment for obesity: a systematic review and meta-analysis of
randomised controlled trials. BMJ. 2013;347(oct22 1):f5934-f5934.
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3. 1st ed.; 2016. Available at:
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4. Hoerger T, Zhang P, Segel J, Kahn H, Barker L, Couper S. CostEffectiveness of Bariatric Surgery for Severely Obese Adults With
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http://www.rippeinfoservices.com/conagra-foods-scienceinstitute/webinars/pdf/CFSI_webinar_050615_bariatric.pdf. Accessed
March 18, 2016.
6. Bariatric Surgery for Severe Obesity. Niddknihgov. 2016. Available
at: http://www.niddk.nih.gov/health-information/health-topics/weightcontrol/bariatric-surgery-severe-obesity/Pages/bariatric-surgery-forsevere-obesity.aspx. Accessed March 19, 2016.
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8. Types of Bariatric Surgery - Full Comparison. Bariatric Surgery
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Gastric Banding. PLOS ONE. 2016;11(2):e0149588.
doi:10.1371/journal.pone.0149588.
10. Noria S, Grantcharov T. Biological effects of bariatric surgery on
obesity-related comorbidities. Canadian Journal of Surgery.
2013;56(1):47-57. doi:10.1503/cjs.036111.

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11. Post-Op Bariatric Surgery Learn How to Identify Red Flags and
Triage Nutritional Deficiencies. Todaysdietitiancom. 2016. Available at:
http://www.todaysdietitian.com/newarchives/111412p50.shtml.
Accessed March 18, 2016.
12. Diet Following Bariatric Surgery - Health Library. Sworg. 2016.
Available at: http://www.sw.org/HealthLibrary?page=Diet%20%20Following%20Bariatric%20Surgery. Accessed March 19, 2016.
13. Bariatric Diet: What & How to Eat. Bariatric Surgery Source. 2016.
Available at: http://www.bariatric-surgery-source.com/bariatricdiet.html. Accessed March 19, 2016.
14. Life After Bariatric Surgery - American Society for Metabolic and
Bariatric Surgery. American Society for Metabolic and Bariatric Surgery.
2016. Available at: https://asmbs.org/patients/life-after-bariatricsurgery. Accessed March 20, 2016.
15. Mechanick J, Youdim A, Jones D et al. Clinical practice guidelines
for the perioperative nutritional, metabolic, and nonsurgical support of
the bariatric surgery patient-2013 update: Cosponsored by american
association of clinical endocrinologists, The obesity society, and
american society fo. Obesity. 2013;21(S1):S1-S27.
doi:10.1002/oby.20461.
16. Cummings S, Pratt J. Metabolic and bariatric surgery. The Journal of
the American Dental Association. 2015;146(10):767-772.
doi:10.1016/j.adaj.2015.06.004.
17. Editor B. Managing Weight Gain in a Bariatric Program | Bariatric
Times. Bariatrictimescom. 2016. Available at:
http://bariatrictimes.com/managing-weight-gain-in-a-bariatricprogram/. Accessed March 16, 2016.
18. Obesity epidemic means bariatric surgery rates continue to rise,
reports plastic and reconstructive surgery. ScienceDaily. 2016.
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Accessed March 19, 2016.

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