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Nutrition Overview

What determines weight loss results when you have bariatric surgery?

The answer is right there in plain sight, so close we almost look past it. The answer is “Nutrition”.

These are surgeries that alter your digestive tract. These are surgeries that directly change your nutrition intake. They also require that patients change their nutrition intake post-surgery to have good results.

Your weight loss surgery is a powerful tool to help you lose weight. It isn’t hard to do a good job getting in your protein and vitamins, but you do have to do it to be successful and stay healthy.

  • First and foremost, PROTEIN. high quality protein; 80 to 90 grams per day, depending on your surgery. It isn’t actually hard if you give it a little attention.
  • Nothing affects your weight loss success more than protein. Protein is critical BOTH during the first year, and for the rest of your life. It is a common and tragic mistake to ease off on the protein after you have had weight loss success.
  • Second, vitamins are essential to maintaining good health, particularly when your food consumption, and nutrient uptake is reduced and altered. Deficiencies are common among those weight loss surgery patients who don’t pay attention to their vitamins and minerals.
  • We talk with patients every week who have regained some, or even all of their weight because they quit paying attention to their protein.

The consequences of vitamin and mineral deficiencies can be quite severe. Examples include:

  • permanent damage to your nervous system
  • decreased immune function (reducing your resistance to viral and bacterial infections and other disorders)
  • irreparably weakened bones

In this section, we’ll tell you more about protein, more about vitamins: how much you need, how to get enough, how to recognize quality.



Considering Surgery

If you are considering surgery, here’s some of the best, most valuable advice we can give you: start getting enough protein and vitamins right now. Here’s why:

  • Start Protein Now: You cannot “store up” protein in your body the way a squirrel stores up nuts for the winter. If your protein status starts out low – if your body hasn’t been getting as much protein as you need – you can slowly improve your status.
  • What is “protein status”? It is measured several ways, but it is really whether your body has been getting enough protein to maintain the integrity and strength of each cell, as well as the many things your body does.

Here’s an example of low protein status:

  • An obstetrician we know works with a population of young women who chronically don’t eat enough high quality protein. Most of their protein comes from legumes – mostly beans and lentils and chick peas – and those are not top quality sources of protein. Even worse, they don’t get enough.
  • The obstetrician sometimes delivers their babies via Caesarian section, and she noted that when she has to do the sutures after the surgery, she said,
    "It's like sewing wet tissue paper."
  • So if you are considering surgery, start by getting 80 grams of high quality protein per day.

So if you are considering surgery, start by getting 80 grams of high quality protein per day. It can take months to improve your protein status and overall health if you have had a long term protein deficiency.

What is high quality protein?

High quality protein sources are mostly protein – undiluted by a lot of fat and carbohydrates. Even more important, the quality is determined by the mix of essential amino acids in the protein. The highest quality sources, with the highest first, are:

Highest Quality Protein Sources

  • Dairy protein, including whey protein isolate
  • Eggs
  • Beef, pork, fish, chicken and turkey
  • Soy

You will note that these are animal sources of protein except for soy. In general, all protein from animals is high quality protein except for collagen protein which has a (PDCAAS) protein quality score of zero


Start Taking a Quality Multi-Vitamin Now:

First, vitamins are important for many metabolic functions that regulate body size.

  • Getting more protein before surgery might help you heal faster after surgery.

Second, studies have found that obese individuals are at high risk for many vitamin and mineral deficiencies.

In short, they are very important to your heath, and you might well have deficiencies. Let’s look more closely at these important ingredients to your success:

Why are Vitamins and Mineral Important for Bariatric Patients?

  • They are important for many metabolic functions that regulate body size.
  • To prevent negative health conditions that can occur after surgery

Don’t Start with Deficiencies

  • Studies have found that obese individuals are at high risk for many vitamin and mineral deficiencies
  • Correcting vitamin deficiencies before surgery is important to reduce the risk of deficiencies after surgery
  • Taking a vitamin and mineral supplement and eating a balanced diet is important for any weight loss program, but it is especially important before weight loss surgery

Here are some common vitamin deficiencies that various medical studies have shown to be common among obese individuals before surgery.


Just Before and After

Just Before – Pre-Op Classes

Your surgeon’s office will have one or more education sessions before your surgery. These are very important. Pay close attention during the session, and review the written materials after you get back home.

Some of this information, such as the recommended grams of protein per day, is key to your success. It is key to reaching your goal weight, and key to maintaining your success afterward. Remember your grams of protein recommendation, and live by it for the rest of your life. Similarly, getting your vitamins after your surgery isn’t optional. You need them to prevent deficiencies – again, for the rest of your life.

You can benefit from the experience of people who have gone before you. The medical research has found that certain vitamin and mineral deficiencies are common after weight loss surgery.


Just Before - Pre-Surgical Diet

Protein and vitamin deficiencies before weight loss surgery are common. If you have been following the recommendations of BariBest since you began considering surgery, you are already getting in good levels of protein. BariBest recommends 80-90 grams of high quality protein per day.

If you haven’t been doing that start now, until the day when you begin your pre-surgery diet.


Special Diets Before and After

Your surgeon’s office will give you instructions for specific diets before and after surgery. Follow these closely.

It is a mistake to think that you can stop paying attention to nutrition when these diets are over. The patients who are successful commit to getting the right protein and vitamins for the rest of their lives.

  • Remember, the statistics show that not all patients are successful. Based on our many many conversations with weight loss surgery patients over the years, we are convinced that the big thing that determines success or failure is protein intake – both quantity and quality.

Patients who have followed our protein guidelines every day have had great success losing their excess body weight. Commonly, those who stop following the guidelines experience major or even complete weight regain, hair loss, deep fatigue and muscle weakness.

In short, while some weight loss surgery patients do not reach their weight loss goals, almost all who follow the guidelines do reach their goals. So get 80-90 grams of high quality protein per day (e.g. whey protein isolate) for the rest of your life, follow the other recommendations, and you will almost certainly be successful, both at losing the weight and keeping it off. Your success is in your hands.

Vitamins are essential to maintaining your health. Because of the changes to your digestive tract, you need to take vitamins appropriate for your surgery, and track your vitamin status through routine blood testing, for the rest of your life.

Specific Diets Before and After Surgery

Here are the diets you will follow before and after surgery:

  • Pre-Surgical Diet
  • Clear Liquid Diet, then
  • Full Liquid Diet, then
  • Pureed Diet, then
  • Solid Foods

Pre-Surgical Diet

  • High protein, low carbohydrate, low sugar, calorie-controlled diet
  • Time frame may vary by clinic, but is typically a minimum of 2 weeks before surgery
  • Purpose is to reduce the risk and difficulty of the surgery by reducing the liver size.
  • If you need more information, contact the dietitian at your surgeon’s office or email to Nutrition@BariBest.com

Post Surgery Diets: Overview

  • The time you stay on each post-surgical diet will vary by surgical practice and your surgeon’s assessment of your own specific needs
  • Consume liquids and solids separately, wait at least 30 minutes between eating and drinking -- to help leave space for nutrient-rich foods
  • Limit or avoid added sugar, fruit juice, fried foods, carbonation, caffeine, and alcohol.
  • Protein supplements are recommended at each stage of the diet following surgery

Clear Liquids

  • This stage of the diet typically lasts 1-2 days
  • Choose clear Liquids which are non-carbonated, caffeine free, low calorie, sugar-free or low-sugar
  • Examples of foods typically allowed on the clear liquid diet include:
    • Clear liquid high-quality protein supplements – (examples: these flavors of UNJURY® Protein: Chicken Soup flavor, Strawberry Sorbet flavor, Unflavored mixed in fruit-flavored Crystal Light. Caution: Lower quality protein supplements can be high in lactose, which could be dangerous.)
    • Sugar-Free Jell-O
    • Broth
    • Sugar-free popsicles
    • Artificially sweetened beverages
    • ecaf/herbal teas

Full Liquids

  • This stage of the diet typically lasts 10-14 days
  • Goals: 80 grams of high quality protein, 48-64 ounces of fluid
  • Allows everything on the clear liquid diet, PLUS Full liquids which are sugar-free or low-sugar. Examples include:
    • High Quality Protein Supplements, all flavors– important to meet protein needs
    • Skim Milk
    • Milk Alternatives (i.e. soy milk, almond milk)
    • Strained soups
    • Vegetable Juice
    • Plain or Artificially sweetened yogurt (Many fruit flavored yogurts have high sugar content. It is important for gastric bypass patients to avoid these.)

Pureed Foods

  • This stage of the diet typically lasts 10-14+ days
  • Goals: 80 grams of high quality protein, 48-64 ounces of fluid
  • Pureed foods which have been blended or liquefied
  • Allows everything on the full liquid diet, PLUS
    • Pureed meat or fish (using chicken broth UNJURY® Chicken Soup flavor instead of water provides flavor)
    • Scrambled eggs or egg substitute
    • Plain or Artificially sweetened yogurt
    • Sugar-free Pudding
    • Peeled pureed fruits or vegetables (chicken using broth instead of water provides flavor)
    • Oatmeal, cream of wheat

Soft Foods

  • This stage of the diet typically lasts 14 days or more.
  • Requires minimal chewing. Food can be chopped, ground, mashed, or pureed
  • Goals: 80 grams of high quality protein, 48-64 ounces of fluid
  • Allows everything on the pureed diet, PLUS
    • Ground chicken, turkey or lean meat
    • Cottage cheese or soft cheese such as low fat string cheese
    • Baked fish
    • Scrambled or poached eggs
    • Tuna with light mayonnaise
    • Soft canned fruit or vegetables

Solid Foods Diet

  • Balanced diet with protein, fruits, vegetables as tolerated
  • Goals: 80 grams of high quality protein, 48-64 ounces of fluid

Caution:

when the doctor’s office says you can move on to solid foods after surgery, that doesn’t automatically mean to stop using supplements. In fact, it can be difficult to meet protein goals without supplements. Here’s how to meet your protein goal:

Know how much quality protein is in foods. Many foods have 7 grams of protein per unit or per ounce. Examples:

  • 7 grams of protein per one egg
  • 7 grams of protein per ounce of beef, chicken, pork, fish
  • (1 ounce after cooking and shrinking)
  • (a common serving size is 3 ounces)
  • Skim milk has 1 gram per ounce of milk, so 8 grams per cup (almost 7)
  • Other dairy products will show the grams of protein on the label.

If you do a little arithmetic, you can see that getting enough protein from foods isn’t so easy. If you want 80 grams of quality protein, here are the amounts of one food you would need per day:

How much of this food

To get 80 grams of protein

2Beef, Pork, Chicken or Fish

12 ounces after cooking,
(almost a pound before cooking)

Eggs

12 eggs

Milk

10 cups of milk


Clearly you can combine some of each, but with much-reduced capacity after surgery, it isn’t easy.

That’s how protein supplements can help. One scoop of a high quality supplement powder typically provides about 20 grams of protein depending on the scoop size. If you mix the scoop of protein into 8 ounces of skim milk, that increases the total protein to about 28 grams.


Long-term Post-surgery Diet

  • Have lean protein or protein supplement with every meal/snack
    • Minimum protein needs 60-80 grams per day
    • Plan meals and snacks, eating 3 meals and 1-2 snacks per day.
    • Eat protein first at a meal or snack, then eat fruits, vegetables
  • Balanced diet as tolerated
  • 48-64 ounces of fluid per day (minimum)
  • Take small bites and chew, chew, chew
  • Daily vitamins and calcium citrate as directed by your bariatric clinic
  • Follow-up with your bariatric clinic or primary care physician every year to check your blood work and make sure you do not have any vitamin/mineral or protein deficiencies.


First Year Success

The first year is your most important year. Most of your weight loss will occur during that first year.

However, the following years – Year 2 onward for the rest of your life, are just as important. Why?

Because that’s when weight regain happens. It’s common and frustrating, but it does not have to happen. Eat right, get your protein and take your vitamins – every year – and we believe you will be successful, every year !

We have noted that our recommendation for protein, 80 to 90 grams per day, is somewhat higher than the ASMBS recommendation, which is 60 to 80 grams of protein per day. Here are some considerations when deciding which guideline to follow:

  • The ASMBS recommendations were made in 2007, when there was only limited research available on the optimal level of protein for weight loss surgery patients. There is still a need for more research.
  • We are not alone in recommending higher levels of protein. Other respected bariatric professionals recommend higher levels, some as high as 90 to 120 grams per day.
  • We agree that there is not enough research. So consider the risks from making a mistake. We believe getting in too little protein, by 20 grams per day, is far worse long term than getting too much protein by 20 grams per day.
    • There is little risk of too much protein: The National Academy of Sciences is quite reserved about any risk of too much protein. Part of what they say is that there is “insufficient data…to provide a Tolerable Upper Intake Level”. If there is a risk of too much protein, in the range of intakes being discussed, it either doesn’t exist or lacks research.
    • Risk of too little protein: The risks of too little protein are important and well established. When there is a protein deficiency, the body takes protein from the muscles and organs. Remember, your heart is a muscle. In one case reported in The New York Times, a man who got insufficient protein and insufficient calories over time was found to have severe thinning of his heart wall.
    • Importance of protein to weight loss: There is substantial research recommending protein intake in the range of 25% to 30% of calories for weight loss. Because this research was not conducted among bariatric patients, it is hard to say whether it applies to gastric bypass and gastric sleeve patients.

We do believe it applies to gastric band patients, based on our own experience with patients.


Protein Deficiencies

Why do I need protein?

Two important reasons weight loss surgery patients need protein are:

  • To give your body what it needs to replace and build cells and tissue
  • To give you that good feeling of satiety (satisfied, not hungry). This goes hand in hand with weight loss success. When you are hungry, you eat. Everyone does.
    Protein is the answer. Protein is good for satiety, and whey protein is great for satiety.

What happens when I don’t get enough protein?

When you don’t get enough protein bad things happen:

  • Weight loss plateau / Weight regain. We regularly hear of patients who hit weight loss plateaus during their first year, and others who are regaining weight years after their surgery. Most often, they tell us right away that they haven’t been getting enough protein.
    We have heard of surgeons who tell patients to stop using protein shakes and get their protein from solid food. They might be saying this in the mistaken belief that solid foods digest slower and thus provide satiety for a longer time.
    We haven’t found any medical research to support that, and in fact there is excellent research that shows that whey protein is excellent for satiety.

    Try this experiment for yourself at breakfast:

    have a protein shake made with high quality whey protein isolate from a trustworthy brand. See how long it takes until you get hungry. The next morning, have the same number of calories in solid food (probably about 190 calories) and see how long it takes for you to be hungry.
    Repeat two more days, just to see if the results are consistent. We are willing to bet you will make it to lunch with the protein shake, but not the solid food.
  • Hair loss. Sometimes patients lose some hair in the first three months after surgery. Often that is related to the shock of the surgery to the body.
    After that first three months, the hair loss can be caused by a many different reasons, and you should see a doctor.
    One prime suspect should be insufficient protein, particularly if you are not sure you have been getting enough protein, and actually tracking it – or if the protein has been of a low quality, such as collagen protein.
    The good news is that hair loss is due to protein deficiency is generally reversible – when you resume getting enough high quality protein.
  • Muscle loss. When you don’t consume enough protein, the body takes protein from the muscles and organs. You literally lose muscle tissue and get weaker.
    Remember, your heart is mostly muscle. In one case reported in The New York Times, a man who got insufficient protein and insufficient calories over time was found to have severe thinning of his heart wall.
  • Deep fatigue. Deep fatigue can be caused by many different reasons, and you should see a doctor. If you are not sure you have been getting enough protein, and actually tracking it, tell your doctor. That might be the cause.

How much protein is enough?

Protein recommendations for the general population

We noted at the top of the page that there are two reasons to get enough protein:

  • replacing and building cells, and
  • feeling satisfied, not hungry.

Sometimes, the advice you get about protein intake considers only a) rebuilding cells. The National Academy of Sciences recommends that you get .37 grams of protein per pound of body weight per day. For a person weighing 250 pounds, that formula would recommend 93 grams of protein per day.


Protein for weight loss:

Medical research strongly recommends that you will have better weight loss results if you get enough protein that it represents 25% to 30% of your calories – but that isn’t very practical. It’s too hard to do the math.

Here’s an easier way: Get 3 to 5 protein shakes a day, where most of the shakes are mixed into skim milk (or soy milk), and the protein powder gives you about 20 grams of protein. You still need to take a good multivitamin, and calcium and fiber.


Vitamin Deficiencies

Gastric Bypass & Gastric Sleeve

Here are some deficiencies that various medical studies have shown to occur after Gastric Bypass

  • There is limited research relating to nutritional deficiencies for Gastric Sleeve patients
  • Based on the limited research, medical studies have shown gastric sleeve patients to be deficient in Vitamin B12, Vitamin D, Folate, Iron, and Zinc.

Note: Some people may not experience physical symptoms of deficiency which is why it is important to have frequent follow-up with your surgeon or primary care physician. Many of these symptoms can be present in a variety of medical conditions so it is important to have your physician evaluate any symptoms. Lifelong vitamin supplementation is recommended to help prevent deficiencies.

Nutrient

Symptoms of Deficiency

Thiamin (B1)

  • Vomiting
  • High risk of thiamin deficiency with severe vomiting, especially when unable to eat adequate amount of food
  • Loss of muscle function
  • Tingling in the hands and feet pain
  • Difficulty walking
  • Memory loss or confusion
  • Strange or jerky eye movements

Vitamin B6

  • Certain types of anemia
  • Scaling on the lips and cracks at the corners of the mouth
  • Swollen tongue
  • Confusion

Folic Acid

  • Certain types of anemia
  • Weakness, fatigue
  • Poor growth
  • Sore or Swollen Tongue

Vitamin B12

  • Lemon-yellow tint to skin and eyes
  • Smooth, beefy red tongue, or sore mouth
  • Confusion and difficulty concentrating
  • Fatigue, light-headedness, or vertigo
  • Nerve problem, such as numbness or tingling in hands and feet
  • Loss of appetite
  • Deficiency can cause certain types of Anemia
  • Balance Problems
  • Diarrhea

Vitamin C

  • Impaired wound healing
  • Edema (swelling)
  • Weakness in bone, cartilage and teeth
  • Skin lesions
  • Anemia

Vitamin A

  • Night blindness
  • Dry scaly, rough, bumpy skin commonly called "goose flesh" or "toad skin"
  • Deficiency can also impair immunity, increasing risk for infection, especially respiratory infection.

Vitamin D

  • Decreased bone density
  • Muscular weakness
  • Bone tenderness
  • High fracture risk, especially of the wrist and pelvis

Calcium

  • Cramping in legs
  • Osteoporosis
  • Increased parathyroid hormone

Vitamin E

  • Changes in balance and coordination
  • Muscle weakness
  • Visual disturbances
  • Poor transmission of nerve impulses

Iron

  • The world’s most common nutritional deficiency
  • Early stages of iron deficiency may have no symptoms.
  • Thin nails that curve inward with raised edges
  • Feeling tired and weak
  • Decreased work or school performance
  • Inflamed tongue
  • Decreased immune function
  • Anemia

Zinc

  • Decreased ability to taste food
  • Poor wound healing
  • Hair loss
  • Diarrhea
  • Skin and eye lesions
  • Poor appetite

Selenium

  • Not likely to cause observable physical symptoms

Protein

  • Changes in hair (thin, brittle, pulls out easily) or hair loss
  • Edema
  • Central ridges in nails
  • Thin, brittle nails
  • Breakdown of muscle tissue
  • Weakness
  • Neurologic changes
  • High risk of infection
  • Poor wound healing

(Strohmayer 2010), (Gerher 2010) (Manual of clinical dietetics) (ASMBS), NIH Fact Sheets, Krause 11th edition, DRI Reference

Gastric Band

Here are some deficiencies that various medical studies have shown to occur after Gastric Band.

  • Low-nutrient dense food choices, intolerance to certain foods, and decreased portion size can contribute to possible deficiencies.

Note: Some people may not experience physical symptoms of deficiency which is why it is important to have frequent follow-up with your surgeon or primary care physician. Many of these symptoms can be present in a variety of medical conditions so it is important to have your physician evaluate any symptoms. Lifelong vitamin supplementation is recommended to help prevent deficiencies.

Nutrient

Symptoms of Deficiency

Thiamin (B1)

  • Vomiting
  • High risk of thiamin deficiency with severe vomiting, especially when unable to eat adequate amount of food
  • Loss of muscle function
  • Tingling in the hands and feet pain
  • Difficulty walking
  • Memory loss or confusion
  • Strange or jerky eye movements

Vitamin B6

  • Certain types of anemia
  • Scaling on the lips and cracks at the corners of the mouth
  • Swollen tongue
  • Confusion

Folic Acid

  • Certain types of anemia
  • Weakness, fatigue
  • Poor growth
  • Sore or Swollen Tongue

Vitamin B12

  • Lemon-yellow tint to skin and eyes
  • Smooth, beefy red tongue, or sore mouth
  • Confusion and difficulty concentrating
  • Fatigue, light-headedness, or vertigo
  • Nerve problem, such as numbness or tingling in hands and feet
  • Loss of appetite
  • Deficiency can cause certain types of Anemia
  • Balance Problems
  • Diarrhea

Vitamin C

  • Impaired wound healing
  • Edema (swelling)
  • Weakness in bone, cartilage and teeth
  • Skin lesions
  • Anemia

Vitamin A

  • Night blindness
  • Dry scaly, rough, bumpy skin commonly called "goose flesh" or "toad skin"
  • Deficiency can also impair immunity, increasing risk for infection, especially respiratory infection.

Vitamin D

  • Decreased bone density
  • Muscular weakness
  • Bone tenderness
  • High fracture risk, especially of the wrist and pelvis

Vitamin E

  • Changes in balance and coordination
  • Muscle weakness
  • Visual disturbances
  • Poor transmission of nerve impulses

Iron

  • The world’s most common nutritional deficiency
  • Early stages of iron deficiency may have no symptoms.
  • Thin nails that curve inward with raised edges
  • Feeling tired and weak
  • Decreased work or school performance
  • Inflamed tongue
  • Decreased immune function
  • Anemia


Long Term Success

Protein, Vitamins and Calorie Levels

BariBest does not recommend that you track calories. It can be easy with computer and smartphone applications, but a focus on calories can distract you for more important goals.

If you want to use those applications, use them to track protein and vitamins. Those are most important. If you are getting enough lean protein (including high quality protein shakes), you won’t be hungry, and the calorie intake takes care of itself.

First, refer to our Long Term Success section - click here. You can also find it on the navigation across the top of every page. It has three sections full of tips and advice:


Long Term Success: Protein

During your first year, you will likely be experiencing rapid weight loss. If you don’t get enough protein during that time, your body will take protein from your muscles, even you heart muscle. The research indicates that about 1% of gastric bypass patients are hospitalized during their first year for protein malnutrition and related complications. If you are having trouble getting in your protein for more than a week, get help from someone; start with the Registered Dietitian at your surgeon’s office.

Breakfast is key. You need approximately 30 grams of protein with breakfast to resupply and restore body protein in the morning. That will also help you stay satisfied (not hungry). If you aren’t hungry, you won’t want to eat that unhealthy snack.

When you get your scheduled check-ups and they do lab work, ask if they check your protein status.

Our experience talking with many many patients clearly shows that success keeping the weight off depends on staying on track with protein – 80 grams per day – forever. If you cannot find the help you need with protein, please email Nutrition@BariBest.com.


Long Term Success: Vitamins

First, take your vitamins, every day, for the rest of your life. Otherwise, the risks of health-damaging deficiencies are high.

BariBest recommends OPURITY® Multivitamins and OPURITY® Calcium Citrate Plus. The multivitamins require only 1 tablet per day, even for Bypass and Sleeve patients. Each formula is carefully designed to be optimal for your surgery. (You don’t want a vitamin that promises mega-doses of each vitamin because too much of some vitamins can cause major problems, and you don’t want too-small a dosage either.) OPURITY is unique in being the only complete multivitamins (among both bariatric and non-bariatric multivitamins) that contains nothing from China. Top hospitals trust their quality.

To avoid deficiencies, at minimum we recommend:

  • A complete high quality multi-vitamin multi-mineral supplement for bariatric patients
  • Calcium citrate that provides 1200 to 1500 mg of calcium each day. If possible, separate taking your calcium from your multivitamin by two hours. A high dose of calcium will interfere with your getting the iron in your multivitamin. Also, it is best to split your calcium into two doses, one in the morning, one later in the day.
  • Vitamin B-12 -- for Bypass and Sleeve patients. We recommend either a sublingual (under the tongue) tablet, or a monthly injection. While many bariatric multivitamins have very high doses of B-12, we don’t believe that that approach is sufficiently proven by the limited research available. The health effects of a Vitamin B-12 deficiency are quite serious, including potential nerve damage.

You need to have your vitamin status monitored at least annually. Know the deficiency risks for each vitamin.


Long Term Success: Common Vitamin Deficiencies After Surgery

Vitamin D

Why is it Important?

Vitamin D is important for calcium absorption, bone health and plays a role in prevention of certain types of cancer, heart disease and other chronic disorders. Supplemental Vitamin D, combined with calcium, is essential because bone loss is a common problem following weight loss surgery.

Studies have found that 60% to 80% of bariatric pre-op candidates have low Vitamin D.

Vitamin B12

Vitamin B12 is an essential nutrient required for healthy blood cells and to preserve normal nerve function. Changes created in the gut by gastric bypass surgery result in depleted Vitamin stores because absorption from food is limited and ultimately results in a Vitamin B12 deficiency.

There are two key steps necessary to absorb Vitamin B12:

  • Vitamin B12 in food is always bound to a carrier. Once food containing Vitamin B12 reaches the stomach, the acidic environment is ideal to break the Vitamin B12 from the carrier.
  • Also, intrinsic factor, a compound needed for active absorption of Vitamin B12, is synthesized in the stomach. Both of these steps in Vitamin B12 absorption are hindered because weight loss surgery reduces the size of the stomach, the acidity of the stomach and the ability to produce enough intrinsic factor.

It is possible to absorb Vitamin B12 without intrinsic factor if intakes are very high. A limited set of studies have shown that individuals given high levels of Vitamin B12 can absorb about 1%-2% even in a low acid environment and without intrinsic factor.

Vitamin B12 deficiency can result in permanent damage to the nervous system.

Thiamin, Riboflavin, Niacin and Vitamin B6

All of these “B” vitamins have important roles.

It is particularly important to supplement with Thiamin because the “reserves” in the body are small, and need daily replacement. In one study, 15% of pre-bariatric surgery patients were low in thiamin.

Folic Acid

Folic acid is an important B-complex vitamin. Deficiencies can lead to weakness, fatigue, difficulty with concentration, and irritability. However, overdoses have risks as well. Overdoses can mask B12 deficiency.

Iron

Iron deficiency anemia is the most common nutritional deficiency in the world.

Your entire body needs oxygen, and every cell depends on red blood cells to deliver that oxygen. To build red blood cells, iron is essential. Supplemental iron is needed to prevent anemia, a common side effect of weight loss surgery.

Common symptoms of anemia are fatigue, and reduced capacity to exercise. Getting enough iron is difficult because the body normally absorbs only 10% of iron from foods. Iron absorption is greatest in an acidic environment. Weight loss surgery reduces the size of the stomach and its ability to make enough acid for the best iron absorption. Plus, gastric bypass usually bypasses the duodenum and proximal jejunum, the most efficient absorption sites.

A note about Iron in multivitamins, and calcium: Calcium blocks iron absorption depending on how much calcium is present.

Vitamin A

Vitamin A is important to maintaining good vision, gene expression, growth and immune function and more. At the same time, excessive Vitamin A can be toxic as well; chronic toxicity can cause reduced bone density, disorders of the brain and spinal cord, and liver abnormalities. For these reasons, it is most important to get Vitamin A dosage right.

Vitamin C

A 2009 study in Obesity Surgery reports that almost 50% of pre-surgery patients are deficient in Vitamin C. Vitamin C deficiency has also been reported after gastric bypass surgery.

Calcium

Sufficient calcium is essential to maintenance of healthy strong bones. The duodenum and proximal jejunum are important sites for calcium absorption, and these are usually bypassed in RNY Gastric Bypass Surgery. As a result, because bone loss is a common problem following weight loss surgery, use of a calcium plus Vitamin D supplement is essential.

Because higher doses of calcium inhibit iron absorption which is why Calcium and Iron should be taken at separate times of the day.


Long Term Success: Surgery Diets

As you get closer to your surgery date, your surgeon’s office will advise when to begin your pre-surgical diet. Usually it starts about two before your surgery date. There is a set of diets you will follow after your surgery date as well, commonly starting with:

  • Pre-Surgical Diet
  • Clear Liquid Diet, then
  • Full Liquid Diet, then
  • Pureed Diet, then
  • Solid Foods

Pre-Surgical Diet

  • High protein, low carbohydrate, low sugar, calorie-controlled diet
  • Time frame may vary by clinic, but is typically a minimum of 2 weeks before surgery
  • Purpose is to reduce the risk and difficulty of the surgery by reducing the liver size.
  • If you need more information, contact the dietitian at your surgeon’s office or email to Nutrition@BariBest.com

Post Surgery Diets: Overview

  • The time you stay on each post-surgical diet will vary by surgical practice and your surgeon’s assessment of your own specific needs
  • Consume liquids and solids separately, wait at least 30 minutes between eating and drinking -- to help leave space for nutrient-rich foods
  • Limit or avoid added sugar, fruit juice, fried foods, carbonation, caffeine, and alcohol.
  • Protein supplements are recommended at each stage of the diet following surgery

Clear Liquids

  • This stage of the diet typically lasts 1-2 days
  • Choose clear Liquids which are non-carbonated, caffeine free, low calorie, sugar-free or low-sugar
  • Examples of foods typically allowed on the clear liquid diet include:
    • Clear liquid high-quality protein supplements – (examples: these flavors of UNJURY® Protein: Chicken Soup flavor, Strawberry Sorbet flavor, Unflavored mixed in fruit-flavored Crystal Light. Caution: Lower quality protein supplements can be high in lactose, which could be dangerous.)
    • Sugar-Free Jell-O
    • Broth
    • Sugar-free popsicles
    • Artificially sweetened beverages
    • ecaf/herbal teas

Full Liquids

  • This stage of the diet typically lasts 10-14 days
  • Goals: 80 grams of high quality protein, 48-64 ounces of fluid
  • Allows everything on the clear liquid diet, PLUS Full liquids which are sugar-free or low-sugar. Examples include:
    • High Quality Protein Supplements, all flavors– important to meet protein needs
    • Skim Milk
    • Milk Alternatives (i.e. soy milk, almond milk)
    • Strained soups
    • Vegetable Juice
    • Plain or Artificially sweetened yogurt (Many fruit flavored yogurts have high sugar content. It is important for gastric bypass patients to avoid these.)

Pureed Foods

  • This stage of the diet typically lasts 10-14+ days
  • Goals: 80 grams of high quality protein, 48-64 ounces of fluid
  • Pureed foods which have been blended or liquefied
  • Allows everything on the full liquid diet, PLUS
    • Pureed meat or fish (using chicken broth UNJURY® Chicken Soup flavor instead of water provides flavor)
    • Scrambled eggs or egg substitute
    • Plain or Artificially sweetened yogurt
    • Sugar-free Pudding
    • Peeled pureed fruits or vegetables (chicken using broth instead of water provides flavor)
    • Oatmeal, cream of wheat

Soft Foods

  • This stage of the diet typically lasts 14 days or more.
  • Requires minimal chewing. Food can be chopped, ground, mashed, or pureed
  • Goals: 80 grams of high quality protein, 48-64 ounces of fluid
  • Allows everything on the pureed diet, PLUS
    • Ground chicken, turkey or lean meat
    • Cottage cheese or soft cheese such as low fat string cheese
    • Baked fish
    • Scrambled or poached eggs
    • Tuna with light mayonnaise
    • Soft canned fruit or vegetables

Solid Foods Diet

  • Balanced diet with protein, fruits, vegetables as tolerated
  • Goals: 80 grams of high quality protein, 48-64 ounces of fluid

Caution:

when the doctor’s office says you can move on to solid foods after surgery, that doesn’t automatically mean to stop using supplements. In fact, it can be difficult to meet protein goals without supplements. Here’s how to meet your protein goal:

Know how much quality protein is in foods. Many foods have 7 grams of protein per unit or per ounce. Examples:

  • 7 grams of protein per one egg
  • 7 grams of protein per ounce of beef, chicken, pork, fish
  • (1 ounce after cooking and shrinking)
  • (a common serving size is 3 ounces)
  • Skim milk has 1 gram per ounce of milk, so 8 grams per cup (almost 7)
  • Other dairy products will show the grams of protein on the label.

If you do a little arithmetic, you can see that getting enough protein from foods isn’t so easy. If you want 80 grams of quality protein, here are the amounts of one food you would need per day:

How much of this food

To get 80 grams of protein

2Beef, Pork, Chicken or Fish

12 ounces after cooking,
(almost a pound before cooking)

Eggs

12 eggs

Milk

10 cups of milk


Clearly you can combine some of each, but with much-reduced capacity after surgery, it isn’t easy.

That’s how protein supplements can help. One scoop of a high quality supplement powder typically provides about 20 grams of protein depending on the scoop size. If you mix the scoop of protein into 8 ounces of skim milk, that increases the total protein to about 28 grams.


Long-term Post-surgery Diet

  • Have lean protein or protein supplement with every meal/snack
    • Minimum protein needs 60-80 grams per day
    • Plan meals and snacks, eating 3 meals and 1-2 snacks per day.
    • Eat protein first at a meal or snack, then eat fruits, vegetables
  • Balanced diet as tolerated
  • 48-64 ounces of fluid per day (minimum)
  • Take small bites and chew, chew, chew
  • Daily vitamins and calcium citrate as directed by your bariatric clinic
  • Follow-up with your bariatric clinic or primary care physician every year to check your blood work and make sure you do not have any vitamin/mineral or protein deficiencies.