Long-term nutrition needs and management. Weight-regain and management. Sue Cummings, MS, RD, LDN

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1 Long-term nutrition needs and management. Weight-regain and management. Sue Cummings, MS, RD, LDN

2 Complications: Micronutrient Deficiency Vitamin D Vitamin B12 Iron Thiamin Pre-Op Rates Post-Op Rates Folate Zinc % 1. Stein et al 2. Parrot et al

3 Post Op Complications: Micronutrients Deficiencies Data suggest micronutrient deficiencies increase over time Number of patients monitored over time significantly declines

4 Monitoring Labs Lifelong Biochemical surveillance typically begins 2-3 months post-op Some deficiencies can manifest in days while others take years Use physical signs/symptoms to detect deficiencies Thiamin B12

5 Anemias Iron, Vitamin B12, Folate, Zinc, Copper

6 SIGNS AND SYMPTOMS Iron B12 Folic Acid Zinc (ZN) Fatigue, low productivity, spoon shaped nails / vertical ridges, glossitis Numbness / tingling fingers and toes, glossitis, fatigue, depression, dementia, gait ataxia Palpitations, fatigue, Neural Tube Defects, changes in skin pigmentation Skin lesions, poor wound healing, hair loss, taste changes Copper (Cu) Unsteady gait, tingling in hands / feet, poor wound healing, paralysis Stein J, et al.

7 Iron B12 Serum Markers Iron: <50 µg/dl TIBC: >450 µg/dl Ferritin: <20 µg/l ( H/H MCV TSAT stfr ZPP) Serum MMA >0.56 mmol/l Repletion (per day unless indicated) mg of elemental iron to 300 mg BID- TID Oral supplementation should be taken in divided doses separately from calcium supplements, acid-reducing medications, and foods high in phytates or polyphenols. If iron deficiency does not respond to oral therapy, intravenous iron infusion should be administered. 1,000-2,000 mcg~ OR 1000 mcg / wk IM Serum B12 (may miss 30%-50% of def) <400pg/mL suboptimal <200pg/mL deficiency Folate Zn Cu Homocysteine, H/H MCV Serum Folate <340 ng/ml RBC Folate, Homocysteine H/H MCV (Normal serum MMA) Plasma Zinc < 11 µmol/l RBC or WBC zinc Urinary zinc Serum Copper: 11 µmol/l Serum Ceruloplasmin 1 mg oral until serum levels wnl 60 mg BID until wnl ^ Mild Mod 3-8 mg until wnl Severe IV 2-4 mg x 6 days # * Cummings S, et al. # Mechanick, J. et al. ^ Bays H, et al. ~Stein J, et al. Parrot J, et al.

8 Bone Disease Vitamin D, Calcium, Magnesium (Vitamin K)

9 SIGNS AND SYMPTOMS Vitamin D Depression, muscle pain, involuntary muscle movements, osteoporosis Calcium Low bone density, osteoporosis, muscle contractions, spasms, pain Mg Muscle contractions, pain, spasms, osteoporosis Stein J, et al.

10 Serum Markers Repletion (per day unless indicated) Vitamin D 25 (OH)D <20ng/mL (def); 20-30ng/mL (ins) Alk Phos ipth DEXA 50k / wk x 8-12 weeks *^ 50k 1-3 x wk 2,000-6,000 IU / day Severe: 50k-150k / day ; calcitriol mcg /day ~ Calcium Ionized Ca <4.48 mg / dl Alk Phos ipth DEXA 1,200-2,000 mg~ (w/specific instruction) Bisphosphonates if T-score <2.5~ Mg Serum Mg <1.5 (1.8?) urinary Mg ND * Cummings S, et al. # Mechanick, J. et al. ^ Bays H, et al. ~Stein J, et al. Parrot, J et al.

11 Neuro Thiamin (Vitamin B1), B-vitamins, Essential Fatty Acids, Trace Minerals

12 SIGNS AND SYMPTOMS Thiamin Dry Beriberi: convulsions, muscle weakness, pain of lower/ upper extremities, brisk tendon reflexes Wet Beriberi: tachycardia or bradycardia, lactic acidosis, dyspnea Neuropsychiatric: confusion, ataxia, paralysis Wernicke encephalopathy: ophthalmoplegia, ataxia, confusion, hallucinations, psychosis * Cummings S, et al. ~Stein J, et al.

13 Serum Markers Thiamin Serum Thiamin <80 µg/l * TPP ETKA Severe: <10 µg/l~ urinary thiamin excretion RBC transketolase Lactic acid or pyruvate Repletion (per day unless indicated) Oral therapy: 100 mg orally two-to -three times daily until symptoms resolve IV therapy: 200 mg, three times daily to 500 mg once or twice daily for 3-5 days followed by 250 mg/day for 3-5 days or until resolutions of symptoms, then consider treatment with 100 mg/day orally, usually indefinitely or until risk factors have been resolved IM therapy: 250 mg once daily for 3-5 days or mg monthly * Cummings S, et al. # Mechanick, J. et al. ^ Bays H, et al. ~Stein J, et al., Parrot J, et al.

14 Fat soluble vitamins

15 SIGNS AND SYMPTOMS Vitamin A Loss of nocturnal vision itching dry hair xerophthalmia Decreased Immunity / poor wound healing Vitamin K Easy bruising Vitamin E Hyporeflexia/ weakness, gait ataxia Stein J, et al.

16 Serum Markers Repletion (per day unless indicated) Supplemental Toxicity Concern Vitamin A Plasma retinol <.70 micromoles/l (20 mcg/dl) Inadequacy micromoles/l Serum vitamin A lmol/l Without corneal changes: 10,000-25,000 IU (until clinical improvement) With corneal changes: 50, ,000 IU IM x 3 days followed by 50,000 IU IM x 2 weeks UL 10,000 (preformed NOT beta-carotene) / d Note: evaluate for iron and/or copper deficiencies - can impair resolution of vitamin A deficiency. Retinol binding protein Vitamin K Plasma vit K Acute malabsorption: parenteral dose of 10 mg Vitamin K Chronic malabsorption: either 1-2 mg/d orally or 1-2 mg/week parenterally. Vitamin E Plasma alpha tocopherol < 5 µg/ml None established IU 1,100 IU / day (synthetic form) * Cummings S, et al. # Mechanick, J. et al. ^ Bays H, et al. ~Stein J, et al. Parrot J, et al.

17 Nutrient Minimum daily level to prevent deficiencies (oral doses) Comments Iron mg Vitamin B mcg All procedures Folate mcg Childbearing F Thiamin mg New (All procedures) Calcium Vitamin D mg 3,000 IU (titrate to >30ng/mL serum D, 25(OH) Vitamin A 5,000-10,000 IU New Vitamins E / K 15 mg / mcg New Zinc / Copper 8-22 mg / 1-2 mg Zn:Cu important at high levels of zinc repletion Selenium high potency MVI New Magnesium Additional B-vitamins Multivitamin contains magnesium % DV Trace Minerals complete in minerals Molybdenum, Manganese, Chromium, etc. Based on Available Guidelines Recommendations based on procedure type and patient specific demographics

18 Routine Nutrient Supplementation* Supplement Dosage Multivitamin/multi-mineral 1-2 daily Vitamin B Complex should contain % RDA Zn and Cu Folate: mcg of folate/day; women childbearing age: 800-1,000 mcg; Thiamin 12 mg/day At least 50 mg thiamin Calcium Citrate/Carbonate X 2-3/day Ca: 1,200-2,400 mg/d: DIVIDED DOSES (from all sources) Vitamin D 3,000 IU daily (from all sources) Elemental iron not to be taken with calcium Vitamin B mg/d elemental mg/d menstruating females ug/d orally/sublingual, nasal or 1,000 mcg/mo intramuscularly *Patients with preoperative or post-operative biochemical deficiency states are treated beyond these recommendations

19 MBS Micronutrient Deficiencies: SLEEVE/BYPASS Data suggests nutrient deficiencies are increasing ¹ˉ⁴ Nutrition related deficiencies may be prevented with appropriate supplementation ⁵ˉ⁶ Adherence to micronutrient supplementation is low⁷ˉ⁸ 10 year data found 33% adherence; 8% never taking supplements⁹ 1. Gudzune KA, et al. 2. Gehrer S, et al. 3. Bal BS, et al. 4. Peterson LA, et al. 5. Pournaras D, et al 6. Saltzman E, et al 7. Nadkarni et al 8. Avani et al 9. Brolin, et al.

20 PRE- POST SURGERY LABORATORY MONITORING Iron Status Serum folate Ferritin TIBC Thiamin (B1) B12 cobalamin methylmalonic acid (optional) Folate Vitamin D, 25-OH Serum Calcium PTH Alkaline phosphatase Vitamin A Vitamin E* Vitamin K* Hemoglobin A1c Phosphorus Magnesium Zinc Copper* Selenium* PreSurgery 2 Months Post-Surgery Post Month 6 Post Yearly X BPD/DS BPD/DS X X X X x x RYGB; BPD/DS RYGB; BPD/DS x x RYGB; BPD/DS RYGB; BPD/DS * = with specific findings; check mark means check; x means not to check; Shaded areas indicate that it is not necessary unless indicated by physical assessment/specific findings; there is not data regarding copper or selenium post-sg Source adapted from Mechanick, et al, SOARD : ; Moize, et al; Parrott et al, SOARD 2017

21 Weight Regain 21

22 Defense against Starvation Our bodies seek a Stable Adipose Tissue Mass not unlike body temperature, blood volume Diet-induced weight loss is accompanied by physiological adaptations which encourage weight regain

23 Gut messengers involved in Weight Regulation Clinical Science (2013) 124, Priya Sumithran and Joseph Proietto

24 Key Hormone Changes Associated with Weight Loss and Regain Hormone Source Normal function Cholecystokinin (CCK) Duodenum Suppress appetite Ghrelin Gastric fundus Stimulate appetite, particularly for high-fat, high-sugar foods Glucagon-like peptide 1 (GLP-1) Ileum Suppress appetite and increase satiety Peptide YY (PYY) Distal small intestine Suppress appetite Amylin Pancreas slowing gastric emptying and promoting satiety Leptin Adipocytes Regulate energy balance Suppress appetite Sumithran P, Proietto J. Clin Sci (Lond). 2013;124:

25 Amylin Ghrelin CCK PYY Gut Hormone Changes Persistently Oppose Diet-induced Weight Loss Sumithran et al. NEJM 2011; 365:

Bariatric procedures, by restructuring the gut:

hormones, neural messaging and gut microbiota new

not known: decreased hunger, increased satiety,

27 Bariatric procedures, by restructuring the gut: Influence the body weight regulatory system gut hormones, neural messaging and gut microbiota new defended body weight (new set point) all mechanisms not known: decreased hunger, increased satiety, defense of lbm, energy expenditure (Hao X, et al. Obesity, Feb. 2016)

GI Endocrine Responses to RYGB Active GLP-1 (pg/ml) Acylated Ghrelin (pg/ml) 300 250 200 150 100 50 0-10 GLP-1 * 5 min mixed meal * * 0 20 40 60 80

, 2010 Ghrelin * 0 20 40 60 80 100 * Time after start of meal (min) * PYY (pg/ml) 300 250 200 150 100 50 * 0-10 * * 5 min mixed meal * PYY * * RYGB

28 GI Endocrine Responses to RYGB Active GLP-1 (pg/ml) Acylated Ghrelin (pg/ml) GLP-1 * 5 min mixed meal * * Time after start of meal (min) # RYGB Sham Lean 5 min mixed meal 300 RYGB Sham 250 Lean Shin et al., 2010 Ghrelin * * Time after start of meal (min) * PYY (pg/ml) * 0-10 * * 5 min mixed meal * PYY * * RYGB Sham Lean Time after start of meal (min) * Active Amylin (pg/ml) Amylin 5 min mixed meal * * Time after start of meal (min)

Obesity is a Heterogenetic Disease Despite the profound effects of bariatric surgery on energy balance and glucose homeostasis, outcomes in individual patients vary

29 Obesity is a Heterogenetic Disease Despite the profound effects of bariatric surgery on energy balance and glucose homeostasis, outcomes in individual patients vary widely. Most patients will not lose 100% of excess weight Therefore, it is important to manage expectations both in terms of amount of weight loss and weight regain

30 Weight Loss Variability Every bariatric procedure studied demonstrates similar wide variations in outcome among patients. RYGB SG

32 Inadequate Weight Loss Approximately 10-20% of patients fail to lose a significant amount of weight postoperatively. Inadequate Weight Loss: a failure to lose significant weight despite the major anatomic and physiological effects of surgery Inadequate weight loss is a biological event Not always predictable Requires careful assessment and varied approaches Aim of treatment is to enhance set point Optimization of life style/environment is essential May require conversion surgery Combination Therapies Addition of pharmacological therapies may be effective

33 Weight loss and Regain expectations 20-34% of the lost weight regained over a period of 10 years (Sjostrom, N Eng J Med 2007;Pajecki,Obes Surg, 2007) Swedish Obesity Subjects Diabetes Prevention Program Percent Total Weight Loss Time After Surgery (years) Lifestyle & Medications Gastric Banding Gastric Bypass

34 Physiological and Life Style factors Factors Related to Weight maintenance and Regain post WLS Anatomical Gastric Bypass G-G fistula Pouch Enlargement G-J Anastomosis Dilation Clinical Factors Physiological Behavioral Gastric Banding Band Migration Band Loosening

35 Life Style Influences: Amenable to Change Inadequate sleep Stress Inadequate physical activity Processed diets Irregular eating pattern Weight increasing medications Developmental Changes (pregnancy, aging, menopause)

36 Post-Operative Eating behaviors Increased stress and pace of life Chaotic eating patterns Skipped meals Unhealthier food choices

Meal Timing When combatting the effects of chronic disease, food timing has emerged as a new approach to the treatment of obesity and the metabolic syndrome.

37 Meal Timing When combatting the effects of chronic disease, food timing has emerged as a new approach to the treatment of obesity and the metabolic syndrome. Regular eating habits might facilitate weight balance Unplanned snacking as well as consuming the major part of the energy intake at the end of the day seem to be unfavorable. Proceedings of the Nutrition Society, Page 1 of 1 doi: /s Curr Obes Rep Mar;4(1):11-8. doi: /s y.

38 Disrupted eating patterns Proceedings of the Nutrition Society, Page 1 of 1 doi: /s

39 Post Op Complications DUMPING SYNDROME: There are two types of dumping described in the literature Early dumping which occurs minutes after eating and can last up to 60 minutes. (more common post-rygb) Symptoms: sweating, flushing, lightheadedness, tachycardia, palpitations, desire to lie down, upper abdominal fullness, nausea, diarrhea, cramping, and active audible bowels sounds. Late dumping which occurs 1-3 hours after eating. Mallory et al Obes Surg

40 Reactive hypoglycemia ( late dumping ) Occurs within a few hours after a meal, is caused by an overproduction of insulin Symptoms include sweating, shakiness, loss of concentration, hunger, and fainting or passing out. Reported to occur: 2-9 years after RYGB

41 Ukleja 2006 Post-op Triggers to Weight Gain: Reactive Hypoglycemia I I I I I GIP GLP-1 Rapid hypoglycemia from exaggerated insulin response Food moves to jejunum quickly; triggers hormone release (GLP-1 and GIP) which stimulates insulin response

42 Suspected Reactive Hypoglycemia OGTT Signs/Sx Food records/s BGM

43 Post-Operative Hypoglycemia Dietary Management 6 small meal; protein source at each Avoid fluids 30 minutes post-meal/snack Avoid high sugar/refined carbohydrate foods. Eat very slowly.

44 Suspected Reactive Hypoglycemia

45 Reactive Hypoglycemia: lack of diet response Pharmacological Treatments Drug Administration Mechanism of Action Side Effects Acarbose Somatostatin analogs- octreotide Diazoxide Oral Injection Oral Delays the breakdown of starch into sugar Delay gastric emptying Slow transit through the bowel Inhibit the release of gastrointestinal hormones, insulin secretion and postprandial vasodilation Slow release of insulin from pancreas Bloating Flatulence Diarrhea Gall stone formation Pain at injection site Steatorrhea Rare: chest pain Increase hair : back, legs, arms

Patients who present with severe postprandial symptoms of hypoglycemia unresponsive to diet manipulation or medication, need further endocrine

46 Patients who present with severe postprandial symptoms of hypoglycemia unresponsive to diet manipulation or medication, need further endocrine evaluation Tack J, et al Nature Reviews Gastroenterology & Hepatology (6) (2009) Consider the possibility of insulinoma or nesidioblastosis of the pancreas

47 Weight Regain Disruption of circadian clocks by genetic and/or environmental factors precipitate numerous common disorders, including Obesity. Gamble, K. L. et al. (2014) Circadian clock control of endocrine factors Nat. Rev. Endocrinol. doi: /nrendo

48 How Does meal timing influence weight Diet-induced thermogenesis (DIT) 50% lower in circadian evening than morning Theoretically can contribute to positive energy balance when eating is late Morris et al, Obesity, 2015

49 How Does meal timing influence weight:circadian Rhythm Multiple genes and hormones that are involved in energy regulation and nutrient metabolism display rhythmic oscillations Shift workers have higher rates of obesity (police, airline personnel, healthcare providers, etc) Ghrelin Cortisol Leptin INCREASED APPETITE

50 Ghrelin: Suppressed Longest by Protein Foster-Schubert et al. JCEM. 2008; 93(5): Lomenick et al. JCEM. 2009; 94(11):

51 Planning/Preparing OPTIMAL DISTRIBUTION of PROTEIN Enhance Satiety Addition of a protein food at each meal and mid morning, mid-afternoon and evening snacks B L D S S S

52 Weight Regain: Daily distress There is significant evidence suggesting potentially detrimental effects of stress on Increased binge eating Eating patterns (skipping meals) Increased preference and consumption of HIGHLY PALATABLE (high sugar/fat/salt) Stress as a Common Risk Factor for Obesity and Addiction Sinha, Rajita, Biological Psychiatry, Volume 73, Issue 9, Brunner EJ, et al Am J Epidemiol, 2008:165: Adam TC, Epel ES. Physiol Behav. 2008;91(4): Evans GW, et al Pediatrics.2012;129(1):e68-73

53 Stress Increased Cortisol Insulin resistance Hyperinsulinemia Leptin Resistance Decreased Metabolic Rate and Increased Food Intake Increased Hedonic Drive and Consumption of Palatable Foods Sinha R, Jastreboff AM. Biol Psychiatry. 2013; 73(9):

54 Weight Regain: Daily distress Dietitian can address: Eating patterns structure; planning, preparing Protein distribution Healthier Foods 1. Address Barriers to making Life Style changes 2. Provide patient with tools/techniques Teaching how to reduce/manage Stress

55 Weight Regain and Inactivity Epidemiologic, cross-sectional, and prospective correlation studies suggest an essential role for physical activity in weight-loss maintenance prospective trials shows a clear dose response relationship between physical activity and weight maintenance. Behavioral Reduced physical activity The addition of physical activity (60 90 min) to a dietary intervention substantially increases the odds of successful long-term weight-loss maintenance and might be essential for most overweight and individuals with obesity to maintain weight loss Mozaffarian, NEJM, 2011

56 Medications that Promote Weight Gain CNS drugs Endocrine agents Miscellaneous Atypical Antipsychotics eg. olanzipine Anti-epileptics eg.valproate Lithium Anti-depressants SSRIs eg. paroxetine Tricyclic agents eg. nortriptyline Others eg. venlafaxine,mirtazapine Glucocorticoids eg. prednisone Hormonal contraceptives eg. medroxyprogesterone Diabetes agents Insulin Sulfonylureas eg. glyburide Thiazolidenediones eg. pioglitazone, Beta blockers eg. metoprolol Antihistamines eg. diphenhydramine Sleep aids eg. zolpidem Leslie, et al. QJM. 2007;100:

57 Type of nutrients Eating Schedules Physical activity Sleep Health Stressors And Mental Health Drug and Medications

58 THANK YOU

59 References Beaulac, J et al. Critical review of bariatric surgery, medically supervised diets, and behavioral interventions for weight managements in adults. Perspectives in Public Health. June Hutter MM, Schirmer BD, Jones DB, et al. Frist report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Annals of Surgery, Sep;254(3): Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en Y gastric bypass for morbid obesity. Ann. Surg. 232(4); (2000) Stein J, Stier C, Raab H, et al. Review article: the nutritional and pharmacological Consequences of obesity surgery. Al Pharm Ther 2014;40: Parrot J, Frank L, Dilks R, et al. ASMBS Integrated Health Nutritional Guidelines for The Surgical Weight Loss Patient 2016 Update:Micronutrients. Surgery for Obesity and Related Diseases, Larjani S, Spivak I, Hao Guo M, et al. Preoperative predictors of adherence to multidisciplinary follow-up care postbariatric surgery. Surg Obes Relat Dis Feb;12(2): Matrana M, Davis W. Vitamin deficiency after gastric bypass surgery: a review. South Med J. 2009;102(10): Gletsu-Miller N, Wright B. Mineral malnutrition following bariatric surgery. Adv Nutr Sep.1;4(5): Brolin R, Leung M. Survey of vitamin and mineral supplementation after gastric bypass and biliopancreatic diversion for morbid obesity. Obes Surg. 1999;9: Gudzune KA, Huizinga MM, Chang HY, Asamoah V, Gadgil M, Clark JM. Screening and diagnosis of micronutrient deficiencies before and after bariatric surgery. Obesity surgery. 2013;23: EL 3, SS Gehrer S, Kern B, Peters T, Christoffel-Courtin C, Peterli R. Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux-Y-gastric bypass (LRYGB)-a prospective study. Obesity surgery. 2010;20: EL 2, PCS Bal BS, Finelli FC, Shope TR, Koch TR. Nutritional deficiencies after bariatric surgery. Nature reviews Endocrinology. 2012;8: EL 4, NE Review Peterson LA, Cheskin LJ, Furtado M, Papas K, Schweitzer MA, Magnuson TH, et al. Malnutrition in Bariatric Surgery Candidates: Multiple Micronutrient Deficiencies Prior to Surgery. Obesity surgery. 2016;26: EL 3, CSS Nadkarni A, Domeisen N, Hill D, et al. Patient adherence to vitamin therapy following bariatric surgery. Surg Obes Rel Dis. Accessed 2/3/17

60 References Avani C, Modi M, Zeller S. et al. Adherence to vitamin supplementation following adolescent bariatric surgery. Obesity. 2013;21: Dunstan MJ, Moena EJ, Ratnasignham K, et al. Variations in oral vitamin and mineral supplementation following bariatric gastric bypass surgery: a national survey. Obes Surg 2015;25: doi: /s Pournaras D, le Roux C. After bariatric surgery, what vitamins should be measured and what supplements should be given? Clin Endocrinol. 2009;71(3): Cummings S, Isom, K. WM DPG AND Pocket Guide to Bariatric Surgery Edition 2: Appendix D & E Bays H, Jones P, Jacobson T, et al. Lipids and bariatric procedures parts 1 & 2: Scientific statement from the National Lipid Association, ASMBS, OMA: Executive Summary. J Clin Lipid 2016;10:15-32 Saltzman E, Karl JP. Nutrient deficiencies after gastric bypass surgery. Annu Rev Nutr.2013;33: Hood, M. M., Corsica, J., Bradley, L., Wilson, R., Chirinos, D. A., & Vivo, A. (2016). Managing severe obesity: understanding and improving treatment adherence in bariatric surgery. Journal of Behavioral Medicine, 1-12 Olbers T, Beamish A, Gronowitz E, et al. Laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity (AMOS): a prospective, 5-year, Swedish nationwide study. Lancet Diabetes Endocrinol Published Online January 5, S (16)

61 Available Guidelines for Micronutrient Supplementation in the MBS patient 1. Aills L, Blankenship J, Buffington C, et al. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. SOARD. 4 (2008); S73-S Mechanick, Jeffrey I. et al. Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring, Md.)2009;17 Supppl 1:S Heber D, Greenway F, Kaplan L et al. Endocrine and nutritional management of the post-bariatric surgery patient: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2010;95(11): Mechanick, Jeffrey I. et al. Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient 2013 Update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring, Md.) (2013): S Parrot J, Frank L, Dilks R, et al. ASMBS Integrated Health Nutritional Guidelines for The Surgical Weight Loss Patient 2016 Update:Micronutrients. Surgery for Obesity and Related Diseases,

MUCH ADO ABOUT NUTRITION PREVENTION AND MANAGEMENT OF THE NUTRITIONAL CONSEQUENCES IN BARIATRIC SURGERY. Sue Cummings, MS, RD

MUCH ADO ABOUT NUTRITION PREVENTION AND MANAGEMENT OF THE NUTRITIONAL CONSEQUENCES IN BARIATRIC SURGERY Sue Cummings, MS, RD suescummings1@gmail.com Improving Surgical Outcomes Nutritional Complications