Nutrition Care for Patients Undergoing Bariatric Surgery

By Sangeeta Kashyap, MD

Close nutritional management of bariatric patients is a critical component of care because these patients have a long-term risk of both metabolic bone disease and kidney stones. Nutritional management needs to begin prior to the bariatric surgery and it must be ongoing following the procedure.

Often, patients having bariatric surgery are deficient in a variety of vitamins, including vitamin D, vitamin B12 and iron. Assessing these deficiencies prior to surgery is very important, as is assessing bone health.

There are a number of gastrointestinal complications that can occur following the procedure. It is necessary to vigilant about these complications and to manage adequate hydration and protein intake.

There are guidelines that have been published on the care of these patients. But the important message for endocrinologists is that the assessment occurs before surgery and is ramped up during surgery. And it must be continued annually after surgery for the life of the patient to prevent complications, such as bone disease and kidney stones.

Once patients get through that acute course following the surgery, and they are able to tolerate and eat soft foods, the goal is to make sure that they are complying with taking all their multiple vitamins and minerals. It is important that a physician assesses them every three to six months within the first two years of the procedure and annually thereafter.

Five years post procedure

Cleveland Clinic has looked at bariatric patients at five years post procedure and we have examined bone turnover markers to see how active these markers are in the body. We learned that even five years after having bariatric surgery, these bone turnover markers are very high, both in the sleeve gastrectomy and gastric bypass. This implies that we need to do a better job in terms of replacing calcium, vitamin D, magnesium and the minerals that are required to reduce bone turnover.

Some of this, we believe is related to inadequate calcium, vitamin D intake and some of it is related to weight loss effects from having the surgery. With weight loss, patients have an increase in bone turnover. Some of this might be adaptive in the body, but some of it could be pathological and could be leading to osteopenia and osteoporosis.

We need to ensure that our patients understand these potential complications from bariatric surgery. And we must do all we can to educate, monitor and follow up with patients to ensure that diet and bone health remain healthy following a bariatric surgery.

Cleveland Clinic endocrinologist Sangeeta Kashyap, MD, was a co-investigator on the STAMPEDE trial.