Nutrition and Dietary Management
What this domain tests
This domain covers the staged diet progression, protein and fluid targets, procedure-specific supplement regimens, and the nutrition syndromes - dumping, dehydration, thiamine deficiency - that appear on nearly every form.
Progression and targets
- Clear liquids day 0–1, full liquids 1–2 weeks, pureed about 2 weeks, soft about 2 weeks, regular diet by roughly 6 weeks.
- Protein 60–80 g/day, or about 1.2 g/kg ideal body weight; protein first at every meal.
- Fluids 48–64 oz/day, sipped; stop drinking 15–30 minutes before meals and resume 30 minutes after.
- No carbonation, no concentrated sweets, caffeine limited.
Supplements
- Bariatric-specific multivitamin with minerals twice daily.
- Calcium citrate 1,200–1,500 mg/day in divided doses; carbonate absorbs poorly without gastric acid.
- Vitamin D3 titrated to 25-OH vitamin D above 30 ng/mL.
- B12 350–500 mcg/day oral or 1,000 mcg monthly; iron 45–60 mg elemental with vitamin C.
- Thiamine at least 12 mg/day, higher when vomiting persists.
Worked example
A 45-year-old woman 8 weeks after RYGB presents with intractable vomiting, nystagmus, and ataxia. Reasoning: this is Wernicke encephalopathy from thiamine deficiency, not simple dehydration. Give IV thiamine before any glucose-containing fluid, then admit for thiamine and rehydration. Oral thiamine is inadequate in the acute setting, and glucose first can precipitate irreversible neurologic deficits.
Traps
- Missing thiamine deficiency in prolonged vomiting and giving glucose first.
- Prescribing calcium carbonate after RYGB, where gastric acid is minimal.
- Accepting "eating well" as proof of adequate protein without a 24-hour recall or documented supplement use.