Morbid obesity can be enfolded with many other non-communicable diseases and poor quality of life. To get the best possible results after bariatric surgery, it is important to optimize patients preoperatively.
5-10% of weight reduction pre-op bariatric surgery has a beneficial impact on overall health including physical, clinical and mental health.
Weight reduction through lifestyle management requires dedication, continuous effort and a lot of patience to see expected results. Everyone’s body responds differently to weight loss program. It is always better to compare your results with the amount of effort you put in instead comparing yourself with others.
We provide nutritional guidance with emphasis on lifestyle modification on the very first visit to Bariatric surgery OPD/Clinic. We expect a minimum of 2-3 kg weight reduction on the low – calorie diet. This diet is generally a normal diet with portion control. Our emphasis is always on eating a balanced meal in time and balancing it with daily physical activity.
……A tool to keep an eye on your health investment…….
This diet will promote moderate ketosis which aids fat loss without losing fat — -free mass, enhance satiety perception, reduces liver volume which provides
greater surgical access and reduces peri-operative complications. There is a general perception that liquid diet can cause constipation and require laxatives for the relief. We have not received any major complaint in this regard from patients who follow VLCD for two weeks. Possible reasons would be the initiation or inclusion of some degree of physical activity, drinking a large volume of fruits and vegetable juices with its pulp and a good amount of fluid intake.
Roux-Y-Gastric Bypass (RYGB)
Laproscopic Sleeve Gastrectomy (LSG)
Mini Gastric Bypass (MGB)
1) Within 24 hrs of surgery you are asked to start sipping water and coconut water with caution:
“Remember, a disciplined life approach required lifelong after bariatric surgery.
……..You are on your health journey, every challenge will make you special and wiser….
Except the challenges so that you can feel the exhilaration ofvictory – George S. Patton
Nutritional challenges after bariatric surgery, more or less remain the same only degree of severity varies. Most common short-term nutritional challenges are food intolerance and altered food perceptions which include gastritis, nausea, vomiting, diarrhoea, constipation, early satiety, dumping, changes in smell and taste perception. These long persisting symptoms may lead nutritional deficiencies in the long run which may be visible as hair loss, mineral and vitamin deficiencies like iron, vitaminB12, thiamine, zinc, calcium, vitamin D and other vitamins and minerals deficiencies, weakness, pica, muscle mass loss etc. Nutritional challenges can be subdivided as mentioned below:
A. Food intolerance:
I. Nausea/vomiting: Vomiting almost always occurs during the first few months after surgery and is often described as “spitting up food that is stuck6 ” It happens usually due to overeating or not chewing food adequately. The patient should be taught that bariatric surgery has diminished the stomach’s ability to grind food into small particles. If vomiting becomes more frequent, low potassium and/or low magnesium levels often occur, requiring oral replacement. Prolonged vomiting should be considered as an indication for empiric thiamine treatment, even without, biochemical deficiency. Vomiting can signal other problems and is associated with strictures and stomal stenosis.
II. Dumping syndrome: “Dumping Syndrome” occurs when food passes rapidly from the stomach into the small intestine. When high osmolarity food passes rapidly through the stomach can cause an osmotic overload upon entering the small intestine. This osmotic overload brings fluid from blood vessels into the lumen of the small intestine, resulting in a vagal reaction. Dumping can be provoked by ingestion of concentrated sweets, overeating, and consuming liquids with meals. There have been reports of symptoms after the ingestion of foods high in salt and fat. The following symptoms can be seen about ½ hour after eating: nausea, faintness, lightheadedness, fullness, cramping, pain, weakness, sweating, rapid heart rate(tachycardia), and possibly diarrhoea.
III. Constipation: Constipation is very common problem after bariatric surgery and is more likely to occur due to inadequate fluid intake, taking iron supplements and being physically inactive. The combination of too little fluid and no food intake can work against your body’s normal routine of elimination
IV. Dehydration: Dehydration occurs frequently and is due to multiple factors. The very small surgically created gastric pouch makes it extremely difficult for patients to hold much fluid, restriction of fluid at meals and snacks, diarrhoea, long persisting vomiting or Intolerance to water. Dehydration can be very dangerous to overall health, and it can lead to constipation and poor absorption of medications and nutrients.
V. Early satiety: Early satiety hinder with sufficient food consumption which badly affects total recommended protein allowances.
B. Malabsorption: Bariatric procedures that involve techniques to reduce gastric capacity or reroute the intestines to the gastric pouch may lead to micronutrient deficiencies. Vitamins and minerals that depend on fat absorption for optimal bioavailability, such as vitamins A, D, E, and K and zinc, won’t be fully absorbed. Food intolerance and poor eating practices can increase the chances of protein, vitamins and minerals deficiencies. Pre-existing nutritional deficiencies should be identified and treated before surgery to reduce the risk of nutritional deficiencies post operatively.
I. Protein Deficiency
It’s common for these patients not to feel hungry within the first six months after surgery because the hormones that regulate hunger cues have been dramatically altered. Protein is primarily absorbed in the mid ileum. This is commonly bypassed in malabsorptive bariatric procedures. This is augmented by an intolerance to protein rich food (dairy products, meat) which may lead to a net protein loss.The basic signs of protein malnutrition are hypoalbuminemia, oedema and alopecia (hair loss). A decrease in fatty/lean mass ration in certain restrictive procedures has been reported. The recommended daily intake of protein is 60 to 80 g or 1 to 1.5 g/kg of ideal body weight. Protein deficiency is less common in patients who have had gastric bypass, the sleeve, and adjustable gastric banding procedures; however, it’s a concern in those who have undergone BPD with or without duodenal switch.10 The incidence of protein malnutrition in all purely restrictive procedures is between 0-2%, gastric bypass procedures between 1-13% and in malabsorptive procedures between 13.4-18%.
II. Iron: The pathogenesis of iron deficiency is due to the following factors: The reduced capacity of the gastro intestinal tract (GIT) to reduce dietary Fe3+ into the more absorbable Fe2+ ion due to the reduction in gastric HCL secretion. Bypassing the duodenum and proximal jejunum contribute to iron deficiency because that is the main site of iron absorption.
Iron deficiency is perhaps the most common and earliest nutritional deficiency to occur following bariatric surgery. Menstruating and pregnant females are at greatest risk. Iron deficiency can lead to anaemia and fatigue and in severe cases, can present with pica. However, it is important to emphasize that baseline iron deficiency has also been reported in up to 44% of obese adults prior to bariatric surgery which may contribute to iron deficiency postoperatively if not identified and treated. Routine multi-vitamin supplementation does not always appear to be sufficient to prevent iron deficiency after RYGB, and in most cases supplemental iron is necessary. If refractory to oral iron supplementation and correction, parenteral iron therapy or even blood transfusions may be necessary.
25 to 80% of adult pre-bariatric patients may have baseline vitamin D deficiency. Overweight and obese individuals tend to have lower mean levels of 25-OH D compared with lean subjects. Potential explanations include decreased dietary intake of fortified milk products, more sedentary lifestyle and reduced exposure to bright sunlight as well as sequestration of the fat-soluble vitamin in increased adipose tissue stores. Low serum 25- OH D appears to be inversely proportional to increasing fat mass.
Fat-soluble vitamin deficiencies, including vitamin A,D,E,K are less common after sleeve and RYGB and MGB surgeries but should be considered for routine investigation after any bariatric surgery procedure if symptoms develop.
1. Vitamin B12: Vitamin B12 plays an integral role in metabolism and helps manufacture red blood cells and maintain the central nervous system. vitamin B12 deficiency is defined as a level below 200 pg/ml. Stomach acid is needed to release vitamin B12 from protein foods. It’s unclear how much intrinsic factor is produced in the new pouch after gastric bypass surgery or sleeve gastrectomy. Intrinsic factor binds with B12 in the duodenum for absorption in the lower intestines. Body stores of vitamin B12 are substantial at about 2000 µg, with the average daily requirement being only 2 µg.
Low vitamin B12 levels have been reported prior to bariatric surgery in up to 18% of severely obese adults. Vitamin B12 deficiency post-operatively is more commonly associated with RYGB (up to one- third of patients), but the rate is significantly reduced to approximately 4% of patients with vitamin B12 supplementation. Multivitamin supplementation alone is not sufficient to prevent the vitamin B12 deficiency. Daily oral vitamin B12 (350 – 600 ug per day) is effective in correcting deficiency in 81 to 95% of patients and intramuscular monthly vitamin B12 injections are another option in patients who have trouble adhering to daily oral supplements.
V. Folic Acid: Low prevalence of folate deficiency has been identified (0–6%) at baseline. Similarly, risk of folate deficiency appears to be very low after bariatric surgery and the addition of a routine multivitamin nearly always corrects any deficiencies. This is likely due to the absorption of folate along the entire length of the small intestine and bacterial synthesis of folate in the intestine. Low folate levels after bariatric surgery, therefore, can indicate a lack of adherence to multivitamin supplementation.
Thiamine is absorbed throughout the duodenum, although preferentially in the more acidic environment of the proximal portion. Body stores approximately 25-30 mg of thiamine, mainly in skeletal muscle, heart, brain, liver and kidneys. In a dietary deficient state, body stores can be depleted in 2-3 weeks. Thiamine is crucial in the metabolism of carbohydrate, and the administration of oral or parenteral carbohydrate is a precipitating factor for the complications of thiamine deficiency (Wernicke’s/Korsikoff’s). Thiamine status is best assessed by determining erythrocyte transketolase activity.
Zinc is a mineral that helps maintain the immune system and is associated with cell division, cell growth, wound healing, and carbohydrate metabolism. A zinc deficiency also may exacerbate hair loss, which is common within the first six months after bariatric surgery. Hair loss is most commonly associated with telogen effluvium, triggered by rapid weight loss and the stress of surgery on the body. Patients who are zinc deficient may experience a metallic taste in their mouths and hair loss on the arms, legs, and groin area. Research has shown that gastric bypass patients are more likely to be at risk of zinc deficiency because of zinc absorption heavily dependent on fat absorption. However, one study found that 34% of gastric sleeve patients experienced deficiency post-surgery.
These are rare deficiencies. None of these has significant clinical consequences. Heart failure following bariatric surgery should be screened carefully to rule out nutrient-deficient cardiomyopathy.
Copper is another important mineral that hasn’t been studied extensively in bariatric surgery patients despite the fact it’s absorbed by the stomach and proximal gut. This has particularly important ramifications for patients who had gastric bypass. A copper deficiency can cause anemia and myelopathy, decreased myelin in the spinal cord that may diminish function of the upper or lower extremities, similar to symptoms associated with a vitamin B12 deficiency. Copper status needs to be examined in gastric bypass patients presenting with signs and symptoms of neuropathy with normal vitamin B12 levels.
Life style associated: The vast majority of weight loss after bariatric surgery is accomplished at or around 1 year after surgery. Some patients continue to lose a small amount of weight while others begin to maintain their lower weight in 12 to 18 months after surgery. At 18 to 24 months after surgery, almost all patients stop losing weight and most patients either maintain or regain weight. During the first six to 12 months after surgery, patients generally consume 900 to 1000 calories. Calorie consumption slowly increases due to a change in the pouch size and stoma size, gastric emptying rate and intake of solid food. Flanagan observed a stabilization in pouch size at two years with the average size holding six ounces
a. Hair Loss: Temporary hair loss can occur from rapid weight loss, but may also be caused by inadequate protein in the diet. This situation is usually temporary and responds to protein supplements.
b. Gall stone disease: very low-calorie diet rapid weight loss more than three pounds or app. 1.5 kg per week may have a 10- to 25-percent chances of developing gallstones. Most of these are “silent” gallstones, meaning that the patient doesn’t have any symptoms. Those who have normal gall bladder emptying and a small stone may respond with oral dilution therapies. Most doctors prefer ursodeoxycholic acid one of the safest common drug. Some of them need surgery.
Support group meetings are a platform for you to share your apprehensions, weight loss success story and learn from another bariatric surgery fellow. YOU NEED TO LEARN AND UNLEARN MANY things related to lifestyle modification IN A SHORT SPAN OF TIME. SUPPORT GROUP MEETINGS HELP YOU IN YOUR PROGRESS.