Nutrition Practice
Standards for
Bariatric Surgery
Dana Eiesland, RD, LDN
Lisa 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
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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 nutritionrelated 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-Surgery
Nutrition Education
 Intensive Education is
provided during group & oneon-one sessions
Fluid, calorie, and
protein requirements
Diet instruction:
Behavior modification
Stages 1-3
self-care & lifestyle
Label reading
choices
self-monitoring (keeping a Supplement/product
information
food journal)
Vitamin & mineral
healthy food selections
requirements
eating behaviors (speed,
schedule)
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 diet
Diet 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 cup
Instruct 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:S73S108.
 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.
 B.
 C.
 D.
Water
Low sodium vegetable broth
Ginger ale
Crystal light
2. All medications & vitamin/mineral supplements should be
taken in which form after surgery?
 A.
 B.
 C.
 D.
Chewable
Liquid
Tablet
A&B
Bariatric Nutrition Quiz
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
5. Following bariatric surgery it is important to monitor for:
 A.
 B.
 C.
 D.
Hydration status
Tolerance of oral intake (nausea/vomiting/diarrhea)
Diet to be advanced appropriately
All of the above