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• W2170189584 abstract "This document is intended to provide an overview of the elements that are important to the nutritional care of the bariatric patient. It is not intended to serve as training, a statement of standardization, or scientific consensus. It should be viewed as an educational tool to increase awareness among medical professionals of the potential risk of nutritional deficiencies common to bariatric surgery patients. The goal of this document is to provide suggestions for conducting a nutrition assessment, education, supplementation, and follow-up care. These suggestions are not mandates and should be treated with common sense. When needed, exceptions should be made according to individual variations and the evaluation findings. It is intended to present a reasonable approach to patient nutrition care and at the same time allow for flexibility among individual practice-based protocols, procedures, and policies. Amendments to this document are anticipated as more research, scientific evidence, resources, and information become available. The Dietitian's role is a vital component of the bariatric surgery process. Nutrition assessment and dietary management in surgical weight loss have been shown to be an important correlate with success [1Cottam D.R. Atkinson J.A. Anderson A. Grace B. Fisher B. A case-controlled matched-pair cohort study of laparoscopic Roux-en-Y gastric bypass and Lap-Band® patients in a single U.S. center with three-year follow-up.Obes Surg. 2006; 16: 534-540Crossref PubMed Scopus (64) Google Scholar, 2Cummings D.E. Shannon M.H. Ghrelin and gastric bypass: is there a hormonal contribution to surgical weight loss?.J Clin Endocrinol Metab. 2003; 88: 2999-3002Crossref PubMed Scopus (132) Google Scholar]. A comprehensive nutrition assessment should be conducted preoperatively by a dietitian, physician, and/or well-informed, qualified multidisciplinary team to identify the patient's nutritional and educational needs. It is essential to determine any pre-existing nutritional deficiencies, develop appropriate dietary interventions for correction, and create a plan for postoperative dietary intake that will enhance the likelihood of success. The management of postoperative nutrition begins preoperatively with a thorough assessment of nutrient status, a strong educational program, and follow-up to reinforce important principals associated with long-term weight loss maintenance. A comprehensive nutrition evaluation goes far beyond assessing the actual dietary intake of the bariatric patient. It takes into account the whole person, encompassing several multidisciplinary facets. Not only should the practitioner review the standard assessment components (i.e., medical co-morbidities, weight history, laboratory values, and nutritional intake), it is also important to evaluate other issues that could affect nutrient status, including readiness for change, realistic goal setting, general nutrition knowledge, as well as behavioral, cultural, psychosocial, and economic issues. The role of nutrition education and medical nutrition therapy in bariatric surgery will continue to grow as tools to enhance surgical outcome and long-term weight loss maintenance are explored further and identified. The following tables suggest the possible components of bariatric nutrition care:Table 1: Suggested preoperative nutrition assessmentTable 1Suggested Preoperative Nutrition AssessmentRecommendedSuggestedOther considerationsAnthropometrics Age, sex, race, accurate height and weight, BMI, excess body weightVisual inspection of hair, skin, and nailsWaist circumferenceOther body measurementsWeight history Failed weight loss attempts Recent preoperative weight loss attempt (if required by program)Life events that may have caused weight changePersonal weight loss goalsMedical history Current co-morbidities Current medications Vitamin/mineral/herbal supplements Food allergies/intolerancesPast medical historyIf available: % body fat using bioelectrical impedance; resting metabolic rate (volume of oxygen uptake); respiratory quotientObservation of body fat distributionConsideration of patients who are athletic or muscular and BMI classificationsAvailable laboratory valuesPsychological history History of eating disorder Current/past psychiatric diagnosisOther Alcohol/tobacco/drug use Problems with eyesight Problems with dentition Literacy level Language barrierDietary intake: food/fluid 24-hr recall (weekday/weekend), Food frequency record, or Food, mood, and activity log (helps identify food group omission or dietary practices that increase nutritional risk) Restaurant meal intake Disordered eating patternsCultural diet influencesReligious diet restrictionsMeal preparation skill levelCraving/trigger foodsEats while engaged in other activitiesComputerized nutrient analysis (if available)Food preferencesAttitudes toward foodPhysical activity Physical conditions limiting activity Current level of activityTypes of activities enjoyed in the pastAmount of time spent in daily sedentary activitiesActivity preference for the futureAttitude toward physical activityPsychosocial Motivation/reasons for seeking surgical intervention Readiness to make behavioral, diet, exercise, and lifestyle changes Previous application of above principles listed to demonstrate ability to make lifestyle change Willingness to comply with program protocol Emotional connection with food Stress level and coping mechanisms Identify personal barriers to postoperative successConfidence to maintain weight lossAnticipated life changesMarital status/childrenSupport systemWork scheduleFinancial constraintsReferral to appropriate professionals for specialized physical activity instruction and/or mental health evaluationAttitude toward lifestyle changeAttitude toward taking life-long vitamin supplementationBMI = body mass index. Open table in a new tab Table 2: Suggested preoperative nutrition educationTable 2Suggested Preoperative Nutrition EducationRecommendedSuggestedOther considerationsDiscuss/include Importance of taking personal responsibility for self-care and lifestyle choices Techniques for self-monitoring and keeping daily food journal Preoperative diet preparation (if required by program)Realistic goal settingBenefits of physical activityAppropriate monitoring of weight lossPostoperative intakeCommon complaintsLong-term maintenance Adequate hydration Texture progression Vitamin/mineral supplements Protein supplements Meal planning and spacing Appropriate carbohydrate, protein, and fat intake, and food/fluid choices to maximize safe weight loss, nutrient intake, and tolerance Concepts of intuitive eating Techniques and tips to maximize food and fluid tolerance Possibility of nutrient malabsorption and importance of supplement compliance Possibility of weight regainDehydrationNausea/vomitingAnorexiaEffects of ketosisReturn of hungerStomal obstruction from foodDumping syndromeReactive hypoglycemiaConstipationDiarrhea/steatorrheaFlatulence/bowel soundsLactose intoleranceAlopeciaSelf-monitoringNutrient dense food choices for disease preventionRestaurantsLabel readingHealthy cooking techniquesRelapse management Open table in a new tab Table 3: Suggested postoperative follow-upTable 3Suggested Postoperative Nutrition Follow-upRecommendedSuggestedOther considerationsAnthropometric Current and accurate height, weight, BMI, and percentage of excess body weightOverall sense of well-beingUse of contraception to avoid pregnancyBiochemicalActivity levelPsychosocial Review laboratory findings when availableAmount, type, intensity, and frequency of activityChanging relationship with foodChanges in support systemStress managementBody imageMedication review Encourage patients to follow-up with PCP regarding medications that treat rapidly resolving co-morbidities (e.g., hypertension, diabetes mellitus)Vitamin/mineral supplements Adherence to protocolDietary intake Usual or actual daily intake Protein intake Fluid intake Assess intake of anti-obesity foods Food texture compliance Food tolerance issues (e.g., nausea/vomiting, “dumping”) Appropriate diet advance Address individual patient complaints Address lifestyle and educational needs for long term weight loss maintenanceEstimated caloric intake of usual or actual intakeReinforce intuitive eating style to improve food toleranceAppropriate meal planningPromote anti-obesity foods containing:Omega-3 fatty acidsHigh fiberLean quality protein sourcesWhole fruits and vegetablesFoods rich in phytochemicals and antioxidantsLow-fat dairy (calcium)Discourage pro-obesity processed foods containing:Refined carbohydratesTrans and saturated fatty acidsBMI = body mass index; PCP = primary care physician. Open table in a new tab Table 4: Suggested biochemical monitoring tools for nutrition statusTable 4Suggested Biochemical Monitoring Tools for Nutrition StatusVitamin/mineralScreeningNormal rangeAdditional laboratory indexesCritical rangePreoperative deficiencyPostoperative deficiencyCommentsB1 (thiamin)Serum thiamin10–64 ng/mL↓RBC transketolase↑PyruvateTransketolase activity >20%Pyruvate >1 mg/dL15–29%; more common in African Americans and Hispanics; often associated with poor hydrationRare, but occurs with RYGB, AGB, and BPD/DSSerum thiamin responds to dietary supplementation but is poor indicator of total body storesB6 (pyridoxine)PLP5–24 ng/mLRBC glutamic pyruvate OxaloaceticPLP <3 ng/mLUnknownRareConsider with unresolved anemia; diabetes could influence values transaminaseB12 (cobalamin)Serum B12200–1000 pg/mL↑Serum and urinary MMA↑Serum tHcySerum B12<200 pg/mL deficiency<400 pg/mL suboptimalsMMA >0.376 μmol/LµMMA >3.6 µmol/mmol CRTtHcy >13.2 μmol/L10–13%; may occur with older patients and those taking H2 blockers and PPIsCommon with RYGB in absence of supplementation, 12–33%When symptoms are present and B12 200–250 pg/mL, MMA and tHcy are useful; serum B12 may miss 25–30% of deficiency casesFolateRBC folate280–791 ng/mLUrinary FIGLU Normal serum and urinary MMA ↑Serum tHcyRBC folate<305 nmol/L deficiency,<227 nmol/L anemiaUncommonUncommonSerum folate reflects recent dietary intake rather than folate status; RBC folate is a more sensitive markerExcessive supplementation can mask B12 deficiency in CBC; neurologic symptoms will persistIronFerritinMales: 15–200 ng/mL Females: 12–150 ng/mL↓Serum iron↑TIBCFerritin <20 ng/mLSerum iron <50 μg/dLTIBC >450 μg/dL9–16% of adult women in general population are deficient20–49% of patients; common with RYGB for menstruating women (51%), and patients with super obesity (49–52%)Low Hgb and Hct are consistent with iron deficiency anemia in stage 3 or stage 4 anemia; ferritin is an acute phase reactant and will be elevated with illness and/or inflammation; oral contraceptives reduce blood loss for menstruating femalesVitamin APlasma retinol20–80 μg/dLRBPPlasma retinol <10 μg/dLUncommon; up to 7% in some studiesCommon (50%) with BPD/DS after 1 yr, up to 70% at 4 yr; may occur with RYGB/AGBOcular finding may suggest diagnosisVitamin D25(OH)D25–40 ng/mL↓Serum phosphorus↑Alkaline phosphatase↑Serum PTH↓Urinary calciumSerum 25(OH)D <20 ng/mL suggests deficiency 20–30 ng/mL suggests insufficiencyCommon; 60–70%Common with BPD/DS after 1 yr; may occur with RYGB; prevalence unknownWith deficiency, serum calcium may be low or normal; serum phosphorus may decrease, serum alkaline phosphatase increases; PTH elevatedVitamin EPlasma alpha tocopherol5–20 μg/mLPlasma lipids<5 μg/mLUncommonUncommonLow plasma alpha tocopherol to plasma lipids (0.8 mg/g total lipid) should be used with hyperlipidemiaVitamin KPT10–13 seconds↑DCP ↓Plasma phylloquinoneVariableUncommonCommon with BPD/DS after 1 yrPT is not a sensitive measure of vitamin K statusZincPlasma zinc60–130 μg/dL↓RBC zincPlasma zinc <70 μg/dLUncommon, but increased risk of low levels associated with obesityCommon with BPD/DS after 1 yr; may occur with RYGBMonitor albumin levels and interpret zinc accordingly, albumin is primary binding protein for zinc; no reliable method of determining zinc status is available; plasma zinc is method generally used; studies cited in this report did not adequately describe methods of zinc analysisProteinSerum albumin Serum total protein4–6 g/dL6–8 g/dL↓Serum prealbumin (transthyretin)Albumin <3.0 g/dLPrealbumin <20 mg/dLUncommonRare, but can occur with RYGB, AGB, and BPD/DS if protein intake is low in total intake or indispensable amino acidsHalf-life for prealbumin is 2–4 d and reflects changes in nutritional status sooner than albumin, a nonspecific protein carrier with a half-life of 22 dRYGB = Roux-en-Y gastric bypass; AGB = adjustable gastric banding; BPD/DS = biliopancreatic diversion/duodenal switch; PLP = pyridoxal-5'-phosphate; RBC = red blood cell; MMA = methylmalonic acid; tHcy = total homocysteine; CRT = creatinine; PPIs = protein pump inhibitors; FIGLU = formiminogluatmic acid; CBC = complete blood count; TIBC = total iron binding capacity; Hgb = hemoglobin; Hct = hematocrit; RPB = retinol binding protein; PTH = parathyroid hormone; 25(OH)D = 25-hydroxyvitamin D; PT = prothrombin time; DCP = des-gamma-carboxypromthrombin.In general, laboratory values should be reviewed annually or as indicated by clinical presentation. Laboratory normal values vary among laboratory settings and are method dependent. This chart provides a brief summary of monitoring tools. See the Appendix for additional detail and diagnostic tools.© Jeanne Blankenship, MS RD. Used with permission. Open table in a new tab Table 5: Suggested postoperative vitamin supplementationTable 5Suggested Postoperative Vitamin SupplementationSupplementAGBRYGBBPD/DSCommentMultivitamin-mineral supplement *A high-potency vitamin containing 100% of daily value for at least 2/3 of nutrients100% of daily value*200% of daily value*200% of daily value*Begin on day 1 after hospital discharge Begin with chewable or liquid Progress to whole tablet/capsule as tolerated Avoid time-released supplements Avoid enteric coating Choose a complete formula with at least 18 mg iron, 400 μg folic acid, and containing selenium and zinc in each serving Avoid children's formulas that are incomplete May improve gastrointestinal tolerance when taken close to food intake May separate dosage Do not mix multivitamin containing iron with calcium supplement, take at least 2 hr apart Individual brands should be reviewed for absorption rate and bioavailability Specialized bariatric formulations are availableAdditional cobalamin (B12) Available forms include sublingual tablets, liquid drops, mouth spray, or nasal gel/spray Intramuscular injection—1000 μg/mo—Begin 0–3 mo after surgery Oral tablet (crystalline form)—350–500 μg/d— Supplementation after AGB and BPD/DS may be requiredAdditional elemental calcium Choose a brand that contains calcium citrate and vitamin D3 Begin with chewable or liquid Progress to whole tablet/capsule as tolerated1500 mg/d1500– 2000 mg/d1800– 2400 mg/dMay begin on day 1 after hospital discharge or within 1 mo after surgery Split into 500–600 mg doses; be mindful of serving size on supplement label Space doses evenly throughout day Suggest a brand that contains magnesium, especially for BPD/DS Do not combine calcium with iron containing supplements: To maximize absorption To minimize gastrointestinal intolerance Wait ≥2 h after taking multivitamin or iron supplement Promote intake of dairy beverages and/or foods that are significant sources of dietary calcium in addition to recommended supplements, up to 3 servings daily Combined dietary and supplemental calcium intake >1700 mg/d may be required to prevent bone loss during rapid weight lossAdditional elemental iron (above that provided by mvi) Recommended for menstruating women and those at risk of anemia (total goal intake = 50-100 mg elemental iron/d)—Add a minimum of 18–27 mg/d elementalAdd a minimum of 18–27 mg/d elementalBegin on day 1 after hospital discharge Begin with chewable or liquid Progress to tablet as tolerated Dosage may need to be adjusted based on biochemical markers No enteric coating Do not mix iron and calcium supplements, take ≥2 h apart Avoid excessive intake of tea due to tannin interaction Encourage foods rich in heme iron Vitamin C may enhance absorption of non-heme iron sourcesFat-soluble vitamins With all procedures, higher maintenance doses may be required for those with a history of deficiency Water-soluble preparations of fat-soluble vitamins are available Retinol sources of vitamin A should be used to calculate dosage Most supplements contain a high percentage of beta carotene which does not contribute to vitamin A toxicity Intake of 2000 IU Vitamin D3 may be achieved with careful selection of multivitamin and calcium supplements No toxic effect known for vitamin K1, phytonadione (phyloquinone)——————10,000 IU of vitamin A2000 IU of vitamin D300 μg of vitamin KMay begin 2–4 weeks after surgery Vitamin K requirement varies with dietary sources and colonic production Caution with vitamin K supplementation for patients receiving coagulation therapy Vitamin E deficiency has been suggested but is not prevalent in published studiesOptional B complex B-50 dosage Liquid form is available1 serving/d1 serving/d1 serving/dMay begin on day 1 after hospital discharge Avoid time released tablets No known risk of toxicity May provide additional prophylaxis against B-vitamin deficiencies, including thiamin, especially for BPD/DS procedures as water-soluble vitamins are absorbed in the proximal jejunum Note >1000 mg of supplemental folic acid, provided in combination with multivitamins, could mask B12 deficiencyAbbreviations as in Table 4. Open table in a new tab BMI = body mass index. BMI = body mass index; PCP = primary care physician. RYGB = Roux-en-Y gastric bypass; AGB = adjustable gastric banding; BPD/DS = biliopancreatic diversion/duodenal switch; PLP = pyridoxal-5'-phosphate; RBC = red blood cell; MMA = methylmalonic acid; tHcy = total homocysteine; CRT = creatinine; PPIs = protein pump inhibitors; FIGLU = formiminogluatmic acid; CBC = complete blood count; TIBC = total iron binding capacity; Hgb = hemoglobin; Hct = hematocrit; RPB = retinol binding protein; PTH = parathyroid hormone; 25(OH)D = 25-hydroxyvitamin D; PT = prothrombin time; DCP = des-gamma-carboxypromthrombin. In general, laboratory values should be reviewed annually or as indicated by clinical presentation. Laboratory normal values vary among laboratory settings and are method dependent. This chart provides a brief summary of monitoring tools. See the Appendix for additional detail and diagnostic tools. © Jeanne Blankenship, MS RD. Used with permission. Abbreviations as in Table 4. These suggestions, included in Table 1, Table 2, Table 3, Table 4, Table 5, have been based on committee consensus and current research that has documented the pre- and postoperative likelihood of nutrition deficiency [1Cottam D.R. Atkinson J.A. Anderson A. Grace B. Fisher B. A case-controlled matched-pair cohort study of laparoscopic Roux-en-Y gastric bypass and Lap-Band® patients in a single U.S. center with three-year follow-up.Obes Surg. 2006; 16: 534-540Crossref PubMed Scopus (64) Google Scholar, 2Cummings D.E. Shannon M.H. Ghrelin and gastric bypass: is there a hormonal contribution to surgical weight loss?.J Clin Endocrinol Metab. 2003; 88: 2999-3002Crossref PubMed Scopus (132) Google Scholar, 3Position of the American Dietetic AssociationWeight Management.J Am Diet Assoc. 2002; 102: 1145-1155PubMed Google Scholar, 4Dietal M. Recommendations for reporting weight loss.Obes Surg. 2003; 13: 159-160Crossref PubMed Scopus (149) Google Scholar, 5Buchwald H. Avidor Y. Braunwald E. et al.Bariatric surgery, a systematic review and meta-analysis.JAMA. 2004; 292: 1724-1737Crossref PubMed Scopus (2737) Google Scholar, 6MacLean L.D. Rhode B.M. Samplais J. et al.Results of the surgical treatment of obesity.Am J Surg. 1993; 165: 155-159Abstract Full Text PDF PubMed Google Scholar, 7Kuczmarski R.J. Carrol M.D. Flegal K.M. et al.Varying body mass index cutoff points to describe overweight prevalence among U.S. adults: NHANES III (1988 to 1944).Obes Res. 1997; 5: 542-548Crossref PubMed Google Scholar, 8Neidman D.C. Trone G.A. Austin M.D. A new handheld device for measuring resting metabolic rate and oxygen consumption.J Am Diet Assoc. 2003; 103: 588Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar, 9Hsu L.K. Sullivan S.P. Benotti P.N. Eating disturbances and outcome of gastric bypass surgery: a pilot study.Int J Disord. 1997; 21: 385-390Crossref PubMed Scopus (101) Google Scholar, 10Saunders R. Grazing A. High risk behavior.Obes Surg. 2004; 14: 98-102Crossref PubMed Scopus (76) Google Scholar, 11Malone M. Alger-Mayer S. Binge status and quality of life after gastric bypass surgery: a one-year study.Obes Res. 2004; 12: 473-481Crossref PubMed Google Scholar, 12Marcus E. Bariatric surgery: the role of the RD in patient assessment and management.SCAN's Pulse, a newsletter of the Sports, Cardiovascular and Wellness Nutrition Practice Group of the American Dietetic Association. 2005; 24: 18-20Google Scholar, 13National Institutes of Health/National Heart Lung and Blood Institute, North American Association for the Study of Obesity in Adults. National Institutes of Health, Bethesda2000Google Scholar, 14Ray E.C. Nickels N.W. Sayeed S. et al.Predicting success after gastric bypass: the role of psychological and behavioral factors.Surgery. 2003; 134: 555-563Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 15Rosal M.C. Ebbeling C.B. Lofgren I. et al.Facilitating dietary change: the patient centered counseling model.J Am Diet Assoc. 2001; 101: 332-341Abstract Full Text Full Text PDF PubMed Google Scholar, 16Wing R.R. Hill J.D. Successful weight loss maintenance.Annu Rev Nutr. 2001; 21: 323Crossref PubMed Scopus (569) Google Scholar, 17Harrison's on lineDisorders of vitamin and mineral metabolism: identifying vitamin deficiencies.http://www.MerckMedicus.comGoogle Scholar, 18AGAAGA technical review of short bowel syndrome and intestinal transplantation.Gastroenterology. 2003; 124: 1111-1134Abstract Full Text Full Text PDF PubMed Google Scholar]. Deficiencies of single vitamins are less often encountered than those of multiple vitamins. Although protein–calorie undernutrition can result in concurrent vitamin deficiency, most deficiencies are associated with malabsorption and/or incomplete digestion related to negligible gastric acid and pepsin, alcoholism, medications, hemodialysis, total parenteral nutrition, food faddism, or inborn errors of metabolism. Bariatric surgery procedures specifically alter the absorption pathways and/or dietary intake. Symptoms of vitamin deficiency are commonly nonspecific, and physical examination might not be reliable for early diagnosis without laboratory confirmation. Most characteristic physical findings are seen late in the course of nutrient deficiency [[17]Harrison's on lineDisorders of vitamin and mineral metabolism: identifying vitamin deficiencies.http://www.MerckMedicus.comGoogle Scholar]. Laboratory markers are considered imperative for completing the initial nutrition assessment and follow-up for surgical weight loss patients. Established baseline values are important when trying to distinguish between postoperative complications, deficiencies related to surgery, noncompliance with recommended nutrient supplementation, or nutritional complications arising from pre-existing deficiencies. Additional laboratory measures might be required and are defined by the presence of the existing individual co-morbid conditions. They are not included in Table 4. Table 4 is a sample of laboratory measures that programs might consider using to comprehensively monitor patients' nutrition status. It is not a mandate or guideline for laboratory testing. Table 5 is an example of a supplementation regimen. As advances are made in the field of bariatrics and nutrition, updates regarding supplementation suggestions are expected. This information is intended for life-long daily supplementation for routine postoperative patients and is not intended to treat deficiencies. Information on treating deficiencies can be found in the Appendix “Identifying and Treating Micronutrient Deficiencies.” A patient's individual co-morbid conditions or changes in health status might require adjustments to this regimen. It is common knowledge that a comprehensive bariatric program includes nutritional supplementation guidance, routine monitoring of the patient's physical/mental well-being, laboratory values, and frequent counseling to reinforce nutrition education, behavior modification, and principles of responsible self-care. As the popularity of surgical interventions for morbid obesity continues to grow, concern is increasing regarding the long-term effects of nutritional deficiencies. Nutritional complications that remain undiagnosed and untreated can lead to adverse health consequences and loss of productivity. The benefits of weight loss surgery must be balanced against the risk of developing nutritional deficiencies to provide appropriate identification, treatment, and prevention. Vitamins and minerals are essential factors and co-factors in numerous biological processes that regulate body size. They include appetite, hunger, nutrient absorption, metabolic rate, fat and sugar metabolism, thyroid and adrenal function, energy storage, glucose homeostasis, neural activities, and others. Thus, micronutrient “repletion” (meaning the body has sufficient amounts of vitamins and minerals to perform these functions) is not only important for good health, but also for maximal weight loss success and long-term weight maintenance. Obtaining micronutrients from food is the most desirable way to ensure the body has sufficient amounts of vitamins and minerals. However, some experts have suggested that most individuals in our “fast-paced, eat-out” society fail to consume sufficient amounts of unprocessed foods that are high in vitamins and minerals, such as fruits and vegetables, fish and other protein sources, dairy products, whole grains, nuts and legumes. Poor dietary selection and habits, coupled with the reduced vitamin and mineral content of foods, can lead to micronutrient deficiencies among the general public that interfere with body weight control, increasing the risk of weight gain and obesity. Therefore, a daily vitamin and mineral supplement is likely to be of value in ensuring adequate intake of micronutrients for maximal functioning of those processes that help to regulate appropriate body weight. Taking daily micronutrient supplements and eating foods high in vitamins and minerals are important aspects of any successful weight loss program. For the morbidly obese, taking vitamin and mineral supplements is essential for appropriate micronutrient repletion both before and after bariatric surgery. Studies have found that 60–80% of morbidly obese preoperative candidates have defects in vitamin D [19Buffington C.K. Walker B. Cowan G.S. et al.Vitamin D deficiency in the morbidly obese.Obes Surg. 1993; 3: 421-424Crossref PubMed Scopus (96) Google Scholar, 20Ybarra J. Sanchez-Hernandez J. Vich I. et al.Unchanged hypovitaminosis D and secondary hyperparathyroidism in morbid obesity alter bariatric surgery.Obes Surg. 2005; 15: 330-335Crossref PubMed Google Scholar, 21Flancbaum L. Belsley S. Drake V. et al.Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity.J Gastrointest Surg. 2006; 10: 1033-1037Crossref PubMed Scopus (113) Google Scholar, 22Carlin A.M. Rao D.S. Meslemani A.M. et al.Prevalence of vitaminosis D depletion among morbidly obese patients seeking bypass surgery.Surg Obes Related Dis. 2006; 2: 98-103Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar]. Such defects would reduce dietary calcium absorption and increase a substance known as calcitriol, which, in turn, causes metabolic changes that favor fat accumulation [23El-Kadre L.J. Roca P.R. de Almeida Tinoco A.C. et al.Calcium metabolism in pre and postmenopausal morbidly obese women at baseline and after laparoscopic Roux-en-Y gastric bypass.Obes Surg. 2004; 14: 1062-1066Crossref PubMed Scopus (49) Google Scholar, 24Schrager S. Dietary calcium intake and obesity.J Am Board Fam Pract. 2005; 18: 205-210Crossref PubMed Google Scholar, 25Zemel M.B. Richards J. Mathis S. Milstead A. Gebhardt Silva E. Dairy augmentation of total and central fat loss in obese subjects.Int J Obes. 2005; 29: 391-397Crossref PubMed Scopus (174) Google Scholar]. Several of the B-complex vitamins, important for appropriate metabolism of carbohydrate and neural functions that regulate appetite, have been found to be deficient in some patients with morbid obesity [21Flancbaum L. Belsley S. Drake V. et al.Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity.J Gastrointest Surg. 2006; 10: 1033-1037Crossref PubMed Scopus (113) Google Scholar, 26Boylan L.M. Sugerman H.J. Driskell J.A. Vitamin E, vitamin B-6, vitamin B-12, and folate status of gastric bypass surgery patients.J Am Diet Assoc. 1988; 88: 579-585PubMed Google Scholar, 27Madan A.K. Orth W.S. Tichansky D.S. Ternovits C.A. Vitamin and trace mineral levels after laparoscopic gastric bypass.Obes Surg. 2006; 16: 603-606Crossref PubMed Scopus (100) Google Scholar]. Iron deficiencies, which would significantly hinder energy use, have been reported in nearly 50% of morbidly obese preoperative candidates [[21]Flancbaum L. Belsley S. Drake V. et al.Preoperative nutritional status of patients undergoing Roux-en-Y gastric b" @default.
• W2170189584 created "2016-06-24" @default.
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• W2170189584 date "2008-09-01" @default.
• W2170189584 modified "2023-10-16" @default.
• W2170189584 title "ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient" @default.
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