1. Nutrition and Weight Loss Surgery
Donna Logan, RD, LD
Maddie Orsak, MS, RD, LD

2. Objectives Preoperative protocol and liquid diet
Cover surgical procedures
Vitamin & mineral requirements Following bariatric surgery
Brief overview of postoperative diet progression
Common intolerances following surgery

3. Nutrition Protocol Before Surgery
Begin immediately
Daily multivitamin
Maintain or lose weight
Avoid the “Last Supper Syndrome”
Liquid Diet
Start 2 weeks prior to surgery

4. PreOp Liquid Diet Benefits –
Low calorie, low carb meal plan to induce ketosis
If you are diabetic, contact your physician monitoring your diabetes prior to starting the liquid diet. Your physician will need to provide recommendations to adjust your medications as needed.
Benefits –
Reduces size of liver for quicker, safer surgery
Additional weight loss
Familiarity with postoperative diet progression

6. Surgical Procedures Adjustable Gastric Banding Sleeve Gastrectomy
RNY Gastric Bypass
Duodenal Switch (DS)

7. Adjustable Gastric Banding (AGB)
Why Supplement?
Deficiency pre op
Restriction
Avoid certain foods
maladaptation

8. Vertical Sleeve Gastrectomy (VSG)
Why Supplement?
Deficiency pre op
Restriction
Maldigestion
Avoid certain foods
Often used as a first stage procedure that is followed by the DS.
Gastric resection, speedier gastric emptying, and neurohormonal changes

9. Roux-en-Y Gastric Bypass (RYGB)
Why Supplement?
Deficiency pre op
Combination
Restriction
Malabsorption
Maldigestion
Avoid certain foods
Describe Anatomy:
Upper part of stomach is dissected leaving behind a small proximal gastric pouch (10-30 mL)
Next, the intestines are divided at the jejunum ..the distal part is brought up to the pouch and stapled or stitched together (called the Roux limb)
This results in bypassing the remaining stomach, duodenum, and small portion of the jejunum.
and the rest of the intestines is then joined at the bottom of the roux limb .
Stomach continues to produce acids and digestive juices which mix flow from duodenum into jejunum and meet with food at the y junction
Why Supplement?
Restrictive – pts are eating less food and lower calorie diets
Malabsorption – passing area of the gut important for absorption of some nutrients
Maldigestive - Loss of pepsinogen, hcl, churning
Avoiding certain foods d/t instruction or personal preferences – meat intolerances, lactose intolerance, avoiding breads, pastas, rice (alotta folic acid fortification)

10. Duodenal Switch (DS) Deficiency pre op Combination Avoid certain foods
Why Supplement?
Deficiency pre op
Combination
Restriction
Malabsorption
Maldigestion
Avoid certain foods
DS wt loss caused by malabsorption primarily through macronutrients with a malabsorption of as much as 25% of protein and 72% of fat
preservation of the pylorus
Decreased transit time which means limited contact with the brush border d/t short common limb

11. Band Supplementation Calcium Elemental Iron Bariatric Multivitamin B12
100% Daily Value
2 a day
Chewable
B12
Sublingual ( mcg/day)
Nasal spray (500 mcg/week )
Intramuscular injection (1,000 mcg/month)
Calcium
1,500 mg/day
Calcium citrate
Chewable with vitamin D
Elemental Iron
30 mg premenopausal women

12. Bypass/Sleeve Supplementation
Calcium
1,000 mg/day
Calcium citrate
Chewable with vitamin D
Vitamin D3
5,000 IUs daily
Elemental Iron
30 mg premenopausal women
18 mg men and post menopausal women
Bariatric Multivitamin
% Daily Value
2 a day
Chewable
Until diet has
progressed to soft foods
B12
Sublingual ( mcg/day)
Nasal spray (500 mcg/week )
Intramuscular injection (1,000 mcg/month)

13. Duodenal Switch Supplementation
Bariatric Multivitamin
200% Daily Value
3 a day (per bottle)
Chewable
with ADEK
B12
Sublingual ( mcg/day)
Nasal spray (500 mcg/week )
Intramuscular injection (1,000 mcg/month)
Calcium
2,000 mg/day
Calcium citrate
Chewable with vitamin D
Vitamin D3
5,000 IUs daily
Elemental Iron
30 mg premenopausal women
18 mg men and post menopausal women

14. Medications
Discuss with TLC surgeons EVERY medication you are taking –
including over-the-counter and vitamin, mineral, and herbal supplements
You may be told to postpone, discontinue, or change the dosage of the medication
You may be instructed to change the form to liquid or chewable
Do not make medication changes or decisions without consulting the doctor

15. Postoperative Diet Progression
All procedures have
the same progression
Clear liquids
Full liquids
Pureed
Soft foods to Maintenance
Difference between procedures is how much time is spent on a stage
Why?
Safety
Avoid leaks
Avoid nausea and/or vomiting
Promote healing

16. Postoperative Diet Progression
The diet progression is gradual. Think about how you might progress with your nine-month old nephew…
TAKE BABY STEPS
Try new foods one at a time and gradually replace liquid calories.
If you aren’t progressing through the stages as expected, let us know.

17. Stage 1: Clear Liquids (Day 1-2)
Water
Sugar-free flavored water (crystal light)
Decaffeinated tea/coffee
Herbal tea
Sugar-free popsicles
Sugar-free gelatin
Broth and bouillon
64 oz a day
(48 oz minimum)
Sip 1 oz over minutes, then refill
Sugar-Free
Caffeine-Free
Carbonation-Free

18. adequate protein intake
Stage 2: Full Liquids
Goal
hydration
64 oz/day &
adequate protein intake
> 60 gms/day
Gastric Band:
Days 3-7
Bypass, Sleeve, DS:
Days 3-14
Start vitamin and mineral regimen (Day 3)
If your are having difficulty taking all supplements, start with the multivitamin (twice a day) and gradually add in all other supplements. You should be taking everything daily by 2 weeks postop

19. Stage 2: Full Liquids Clear liquids + Skim milk or light soy milk
Protein shakes
Use those recommended on the preop liquid diet
Bariatric Advantage or Unjury broth flavored powder
Isopure RTD
Vegetable juice (low sodium)
Strained cream soup (look for options low in fat & sugar)
Sugar free pudding
Lactose Intolerance – common following sleeve, bypass, and DS. May experience gas, bloating, diarrhea. Switch to lactose free options – light soy milk, low fat Lactaid, Mootopia (HEB)

20. Stage 2: Full Liquids Sip, sip, sip all day long
Avoid temperature extremes
extra hot or cold can cause discomfort/spasms
If you feel light headed, hungry, or dizzy… you may be dehydrated
Feeling nauseated?
Sip fluids slowly
As your diet progresses, take tiny bites (pencil eraser size), and chew well (apple sauce consistency)
Dab peppermint oil on a handkerchief – smell when nauseated

21. Stage 3: Pureed Gastric Band: Bypass, Sleeve, DS: Baby food
Days
Bypass, Sleeve, DS:
Days
All foods previously
allowed + food that
is the consistency
of baby food
or applesauce
Baby food
Add broth, skim milk, or water to meats, fruit, and well cooked vegetables and puree/blenderize
Light or plain yogurt
0% Greek yogurt
1% cottage cheese
Oatmeal
Fat free refried beans

22. Stage 4: Soft Gastric Band: Bypass, Sleeve, DS: Foods that you can
Ground chicken or turkey breast
Dairy
low fat
Eggs
Beans
Fish
Vegetables
over cooked
Fruit
soft without peel, canned
Gastric Band:
After Day 21
Bypass, Sleeve, DS:
After Day 30
Foods that you can
mash with a fork and
chew to the
consistency
of apple
sauce

23. Reactive Hypoglycemia Nausea & Vomiting Diarrhea & Constipation
Preventing and Alleviating Possible Food Intolerances and Issues Following Bariatric Surgery Handout
Dumping Syndrome
Reactive Hypoglycemia
Nausea & Vomiting
Diarrhea & Constipation
Excess gas
Pain
Dehydration
Lactose intolerance

24. Discuss in more detail at First Bite
Preventing and Alleviating Possible Food Intolerances and Issues Following Bariatric Surgery Handout
Alcohol
Avoid for the first year out from surgery or until you have reached goal weight
Short term hair loss
Discuss in more detail at First Bite
Bring handout to class
Tough meats
Raw fruit and vegetables
Starchy foods

25. Tips for Success Use small plates and utensils
Avoid eating past the point of fullness
Avoid skipping meals
Avoid drinking 30 minutes before, during, and 30 minutes after meal times
Continue to limit fats and avoid concentrated sweets
Eat your protein first

26. Your success depends on you!

27. Online Course - Documentation
Go to
Click on “Patients”
Then click on “Classes”
And finally, click on “Pre-Op Nutrition Class”
Follow the instructions and submit the form
IF YOU DO NOT COMPLETE THE FORM, WE WILL NOT HAVE RECORD OF YOUR CLASS ATTENDANCE.