An In-depth Discussion on Post-surgical “Rules”

Review of Procedures
SLEEVE GASTRECTOMY
MINI GASTRIC BYPASS (MGB)
DOUDENAL
SWITCH
Dr Kelvin Higa –
(referring to surgical techniques)
“THERE ARE NO RULES”
What he means:
Do what works!
THE RULE:
TAKE CARE OF YOUR WHOLE SELF!
Everything else is just a guideline
Walt’s rules
• Sleep is important – carb hunger
• Stress – exercise is only real cure for “toxicity”
• 6 feeding in a day is a red flag – easy to avoid with 45
min dry after each meal
• 2 treats in a day is red flag
• 3 days off exercise is a BURNING red flag
• 10 minute run when all is lost - is my gold star for
effort
• Muscle mass to avoid frailty – wanna be a butt kicking
80 year old
• Only liquid calorie is alcohol
What you see –
• Lots of Protein bars (LOTS), lots of deli meat, eggs,
cheese
• Lots of half-caf coffee, Fresca, Sprite Zero, NA beer
• Exercise socks on every day, some VERY short gym visits
• NEVER a sip for 45 minutes after a feeding
• Vitamin D, Devrom, others twice a day
Navigating Post Op Nutrition
Sarah Muntel, RD
Uncertainty of Bariatric Recommendations
Social Media
Bariatric
Websites
Program
Differences
Opinions
of others
What we know:
Bariatric Nutritional Recommendations based on:
ASMBS Nutritional Guidelines for the Surgical Weight Loss
Patient
Aills, et al, 2008
The ASMBS Textbook of Bariatric Surgery, Volume 2,
Integrated Health
Still, 2014
Protein: the building block nutrient used for
cell growth and development, healing and to
maintain muscle mass.
Why is protein a struggle?
• Decreased volume
• Malabsorption
• Decreased appetite
• Nausea
• Changes in taste
What is recommended?
• 60-90 Grams per day: Gastric
Bypass/Sleeve/Band
• 90-120 Grams per day: Duodenal Switch
Food Choice
Fish
Turkey Breast
Chicken
Lean Pork
Veal
Lean Beef
Tuna Fish
Canned Chicken
Canned Lean Ham
Canned Pink Salmon
Canned Lump Crab
Greek Yogurt
Low Fat Yogurt
Low Fat Cottage Cheese
Low Fat Natural Cheese
Low Fat Shredded Cheese
Low Fat Processed Cheese
Egg
Egg Beater
Tofu
Beans
Lentils
Baby Food Meat Item
Shrimp
Lobster
Grams of Protein per oz
7 grams
7 grams
7 grams
7 grams
7 grams
7 grams
7 grams
7 grams
5 grams
6 grams
3.5 grams
2-3 grams
1-2 grams
3-4 grams
6-8 grams
3-5 grams
5 grams
3.5 grams
3 grams
3 grams
2 grams
2-3 grams
3.5 grams
6 grams
6 grams
Supplement
Options
Whey Protein Isolate
is the best absorbed
protein supplement
Use with Caution
Supplements containing hydrolyzed collagen.
The Rest of the Plate
Carbohydrate Needs:
• Review needs with Registered
Dietitian
• Some recommend 100 grams
per day
• Consider your source
Dietary Fat Needs:
• Have not been published
• “Limit”
What about the Rules?
• Sip Slowly.
• Avoid using a straw.
• Avoid carbonation.
• Avoid caffeine.
• Separate liquids from
solids by 30 minutes.
Work within the guidelines to find
a plan that works for you. Every
bariatric patient is different.
Breaking Down Vitamin and
Nutritional Supplement
Recommendations
JACQUELINE JACQUES, ND, FTOS
Overview
 There’s a lot of “noise” out three when it comes to
nutrition
 I posed the question to a few of my FB groups asking
about things they were confused about or common
myths they heard and I had over 100 replies in 48
hours....
 So how do you sort out the truth?
Your Doctor and Guidelines
 Your program is a good place to start
 Your doctor/dietitian will have recommendations for patients
in his/her program with your procedure
 Your doctor should be informed of the guidelines 
 Guidelines
 Have been in place starting with the ASMBS Allied Health
Guidelines in 2008
 A joint committee of AACE/TOS/ASMBS have issued two sets
– most recently in 2013 which are the most recent
 Guidelines are good, but are not perfect
 We still lack a lot of evidence and much of what is in the
guidelines is still based on expert agreement
Snapshot of the Guidelines
Mutivitamins
 Recommended for ALL procedures (yes that includes
bands and sleeves and “restrictive” procedures)
 Why: Forget anything related to absorption for a
moment and just remember this:



Most of us don’t get enough nutrition from diet period
After surgery you eat less not more
Therefore the chance of getting all the nutrition you need from
food after surgery decreases
Multivitamins
 For RNY, VSG, BPD-DS
 Guidelines suggest using chewables for 3-6 months
 They do not list exact amounts of what should be in a multi
 They do state that for these procedures patients should take 2
adult multivitamin each containing iron, folic acid, and thiamine (B1)
 AGB
 Guidelines suggest 1 adult multivitamin including iron, folic
acid, and thiamine (B1)
Multivitamins
 Additional Guidance
 Iron can be in a multi or as a separate pill
 Folic acid should be at 400 mcg
 Copper should be at 2 mg
Multivitamins
 Common myths
 It’s ok for me to take any multivitamin after surgery
 I feel fine, why do I need vitamins
 I can stop taking vitamins after 2 years
Calcium
 The guidelines make the same recommendation for
ALL procedures:

1200 to 1500 mg of elemental calcium (from diet and as
citrated supplement) in divided doses
 Yes, that’s a recommendation for calcium as calcium
citrate in all procedures – even band.
 Yes, dietary calcium can count, but most programs
don’t count it because it’s very hard to keep track of
 Divided doses means to take it multiple times a day
(such as 500mg, 3 times daily)
Calcium
 Common myths
 It will give me kidney stones
 I’m a man – calcium is for girls
 My doctor said I could just take TUMs
Vitamin D
 The guidelines make the same recommendation for ALL
procedures:



At least 3000 international units of vitamin D (titrated to therapeutic
25- hydroxyvitamin D levels >30 ng/ml)
Vitamin D dosages of at least and as high as 6000 IU/d are safe and
necessary in many postbariatric surgery patients to achieve target
blood levels
In cases of severe vitamin D malabsorption, oral doses of vitamin D2
or D3 may need to be as high as 50,000 units 1 to 3 times weekly to
daily
 So essentially, the dosing is going to be based on a level
of vitamin D that keeps your blood levels healthy
 That could be very different from one person to another
and can vary over time
Vitamin D
 Common myths:
 More more more
B12
 For RNY, VSG and BPD-DS, the guidelines say the
following:




Vitamin B12 (as sublingual, subcutaneous, or intramuscular
preparations, or orally, if determined to be adequately absorbed) as
needed to maintain B12 levels in the normal range
Oral supplementation with crystalline vitamin B12 at a dosage of
1000 mcg daily or more may be used to maintain normal vitamin
B12 levels
Intranasally administered vitamin B12, 500 mcg weekly, may also be
considered
Parenteral (intramuscular or subcutaneous) B12 supplementation,
1000 mcg/mo to 1000- 3000 mcg every 6 to 12 months, is indicated
if B12 sufficiency cannot be maintained using oral or intranasal
routes
B12
 Common Myths
 My labs came back high so my PCP said I should stop taking it
 My energy is great, so why do I need B12
 I can only get it from an injection
Iron
 Total iron provided should be 45-60 mg via
multivitamins and additional supplements for
prevention
 This can be in a multi or separate


Vitamin C may improve absorption
Treatment may require 150-200mg elemental iron/day or
infusions
Iron
 Common myths
 I’m a man so I don’t need iron
 After menopause, women can stop taking it
 I have a sleeve so I don’t need iron
 I have a band so I don’t need iron
Why is there so much confusion
 Guidance is vague and not as specific as most people
need or desire



They don’t address many individual nutrients
They largely don’t address nutrient forms
In fact, the newer guidelines are, in some ways more vague and
general than the ones in the past...
 What is seen at the level of clinical practice often informs
your doctor or dietitian more than guidelines
 So people get together in a room like this or on FB and
find that what they have been told is not what’s in the
guidelines and is not what their friends have been told
 Oh...and one more thing...
Why is there so much confusion
...There is a LOT of
bad information on
the internet
What else have you heard?
 Biotin will keep my hair from falling out
 I can wear a patch to get my vitamins
 I can’t take X, Y and Z at the same time
 I have to take everything multiple times daily
 I’ve never been deficient so I must get everything I
need from food
 You can only take chewables forever after bariatric
surgery
 You can only absorb 30 grams of protein at a time