Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient: Micronutrients
1. Pre-WLS Nutrient Screening Recommendations
Thiamin
Vitamin B12 (cobalamin)
Folate (Folic Acid)
Iron
Vitamin D and Calcium
Fat-soluble vitamins (A, E, K)
Zinc
Copper
2. Post-WLS Nutrient Screening Recommendations
Thiamin
- Patients with risk factors for TD
- Females
- Blacks
- Patients not attending a nutritional clinic after surgery
- Patients with GI symptoms (intractable nausea and vomiting, jejunal dilation, mega-colon, or constipation)
- Patients with concomitant medical conditions such as cardiac failure (especially those receiving furosemide)
- Patients with SBBO.
Vitamin B12
Folate
Iron
Vitamin D and Calcium
Vitamins A, E, K
Zinc
Copper
3. Supplement Recommendations to Prevent Post-WLS Micronutrient Deficiency
Vitamin B1 (Thiamin)
- All post-WLS patients should take at least 12 mg thiamin daily
- and preferably a 50 mg dose of thiamin from a B-complex supplement or multivitamin once or twice daily
Vitamin B12 (Cobalamin)
- Orally by disintegrating tablet, sublingual, or liquid: 350–500 mg daily
- Nasal spray as directed by manufacturer
- Parenteral (IM or SQ): 1000 mg monthly.
Folate (Folic Acid)
Iron
Vitamin D and Calcium
- BPD/DS: 1800–2400 mg/d
- LAGB, SG, RYGB: 1200–1500 mg/d
- Calcium should be given in divided doses.
- Calcium carbonate should be taken with meals.
- Calcium citrate may be taken with or without meals.
Vitamins A, E, and K
- LAGB: Vitamin A 5000 IU/d and vitamin K 90–120 ug/d.
- RYGB and SG: Vitamin A 5000–10,000 IU/d and vitamin K 90–120 ug/d.
- LAGB, SG, RYGB, BPD/DS: Vitamin E 15 mg/d.
- DS: Vitamin A (10,000 IU/d) and vitamin K (300 mg/d).
Zinc
- BPD/DS: Multivitamin with minerals containing 200% of the RDA (16–22 mg/d)
- RYGB: Multivitamin with minerals containing 100–200% of the RDA (8–22 mg/d)
- SG/LAGB: Multivitamin with minerals containing 100% of the RDA (8–11 mg/d).
Copper
- BPD/DS or RYGB: 200% of the RDA (2 mg/d)
- SG or LAGB: 100% of the RDA (1 mg/d).
4. Repletion Recommendations for Post-WLS Micronutrient Deficiency
Thiamin
- Oral therapy: 100 mg 2–3 times daily until symptoms resolve.
- IV therapy: 200 mg 3 times daily to 500 mg once or twice daily for 3–5 d, followed by 250 mg/d for 3–5 d or until symptoms resolve, then consider treatment with 100 mg/d orally, usually indefinitely or until risk factors have been resolved.
- IM therapy: 250 mg once daily for 3–5 d or 100–250 mg monthly.
- Simultaneous administration of magnesium, potassium, and phosphorus should be given to patients at risk for refeeding syndrome.
Vitamin B12 (Cobalamin)
Folate (Folic Acid)
Iron
Vitamin D and Calcium
- Vitamin D3 at least 3000 IU/d and as high as 6000 IU/d, or 50,000 IU vitamin D2 1–3 times weekly.
- Vitamin D3 is recommended as a more potent treatment than vitamin D2 when comparing frequency and amount needed for repletion. However, both forms can be efficacious, depending on the dosing regimen.
- BPD/DS: 1800–2400 mg/d calcium
- LAGB, SG, RYGB: 1200–1500 mg/d calcium.
Vitamin A
Vitamin E
Vitamin K
Zinc
Copper
- Mild to moderate deficiency (including low hematologic indices): Treat with 3–8 mg/d oral copper gluconate or sulfate until indices return to normal
- Severe deficiency: 2–4 mg/d intravenous copper can be initiated for 6 d or until serum levels return to normal and neurologic symptoms resolve.
Recommendation Grading
Overview
Title
Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient: Micronutrients
Authoring Organization
American Society for Metabolic and Bariatric Surgery
Publication Month/Year
January 1, 2017
Last Updated Month/Year
August 2, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
The focus of this paper is to update the 2008 American Society for Metabolic and Bariatric Surgery Nutrition in Bariatric Surgery Guidelines with key micronutrient research in laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, biliopancreatic diversion, and biliopancreatic diversion/duodenal switch.
Target Patient Population
Patients with severe obesity
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Treatment
Diseases/Conditions (MeSH)
D009765 - Obesity, D050110 - Bariatric Surgery, D018977 - Micronutrients
Keywords
obesity, nutrition, bariatric surgery, micronutrient
Source Citation
J. Parrott et al. / Surgery for Obesity and Related Diseases ] (2017) 00–00