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中华肥胖与代谢病电子杂志

中华肥胖与代谢病电子杂志 ›› 2023, Vol. 09 ›› Issue (03) : 165 -172. doi: 10.3877/cma.j.issn.2095-9605.2023.03.004

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减重手术后的营养管理与复胖：现状与思考
马俊蓉, 叶艳彬†()   
  1. 510630　广州，暨南大学第一附属医院临床营养科；暨南大学基础医学与公共卫生学院
    510630　广州，暨南大学第一附属医院临床营养科
  • 收稿日期:2023-06-10 出版日期:2023-08-30
  • 通信作者: 叶艳彬

Nutritional management and weight regain after bariatric surgery: current situation and thoughts

Junrong Ma, Yanbin Ye†()   

  1. Department of Clinical Nutrition, The First Affiliated Hospital of Jinan University, Guangzhou 510630, China; Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou 510630, China
    Department of Clinical Nutrition, The First Affiliated Hospital of Jinan University, Guangzhou 510630, China
  • Received:2023-06-10 Published:2023-08-30
  • Corresponding author: Yanbin Ye
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引用本文：

马俊蓉, 叶艳彬. 减重手术后的营养管理与复胖：现状与思考[J]. 中华肥胖与代谢病电子杂志, 2023, 09(03): 165-172.

Junrong Ma, Yanbin Ye. Nutritional management and weight regain after bariatric surgery: current situation and thoughts[J]. Chinese Journal of Obesity and Metabolic Diseases(Electronic Edition), 2023, 09(03): 165-172.

肥胖已成为全球性的公共卫生问题，减重手术目前是治疗肥胖最长期有效的方法。患者的术后营养管理也非常重要，术后蛋白质营养不良是最常见的宏量营养素缺乏症，且术前微量营养素缺乏症也会在术后持续存在甚至加剧。与其他减重手术相比，Roux-en-Y胃旁路术（RYGB）术后微量营养素缺乏最严重。复胖是术后面临的一项长期挑战，患者术后不遵循饮食建议和饮食控制、放牧行为是重要因素。本文对减重手术术后营养缺乏现状、复胖现状及危险因素进行了综述，提供了术后营养管理建议，以及长期随访策略。未来，需要更多深入研究临床实践以达成术后营养管理及预防复胖的共识，提高减重手术的长期疗效，改善患者生活质量。

关键词: 肥胖, 减重手术, 营养缺乏, 营养管理, 复胖, 术后管理

Obesity has become a global public health problem, and bariatric surgery is currently the most enduring treatment for obesity. Postoperative nutritional management is crucial, with postoperative protein malnutrition being the most common micronutrient deficiency, and preoperative micronutrient deficiencies persisting and potentially worsening postoperatively. Among various bariatric surgeries, Roux-en-Y gastric bypass (RYGB) is associated with the most severe postoperative micronutrient deficiencies. Long-term weight regain presents a significant challenge postoperatively, with non-adherence to dietary recommendations and behavior contributing as important factors. This article reviews the current status of postoperative nutritional deficiencies, the state of weight regain, and associated risk factors, offering postoperative nutritional management recommendations, as well as long-term follow-up strategies. Future research is needed to establish consensus in clinical practice to improve postoperative nutritional management and prevent weight regain, ultimately enhancing the long-term effectiveness of weight loss surgery and the quality of life for patients.

Key words: Obesity, Bariatric Surgery, Nutritional Deficiency, Nutritional Management, Weight Regain, Postoperative Management
表1 不同手术方式的营养缺乏状况
营养素 RYGB SG LAGB BPD-DS
宏量营养素        
蛋白质 严重缺乏 缺乏 缺乏 严重缺乏
微量营养素        
铁 明显缺乏 缺乏 明显缺乏 缺乏
钙 明显缺乏 普遍缺乏 普遍缺乏 明显缺乏
叶酸 缺乏 待研究 缺乏 缺乏
维生素D 明显缺乏 普遍缺乏 普遍缺乏 明显缺乏
维生素B12 明显缺乏 缺乏 明显缺乏 缺乏
脂溶性维生素（A、K、E） 缺乏 缺乏 缺乏 缺乏
其他B族维生素（如B1、B2、B6） 常见于RYGB术后患者，其余手术方式此类营养素缺乏有待确定
其他矿物质（镁、锌、铜、硒） 矿物质缺乏症在BPD和RYGB术后患者中更常见，BPD-DS术后硒缺乏明显
表2 减重手术术后1~3月饮食建议
术后阶段 饮食目标和建议
术后24 h 少量低糖清流食
术后第1周 清流饮食，逐渐增加饮水量，最终保证每天饮水量≥2 000 mL
术后第2周 无渣全流质饮食，不含植物纤维成分
术后第3~4周 半流质饮食，主要以细软、清淡易消化的食物为主，彻底咀嚼
术后第1~2个月 以软食为主，即容易软烂、易消化的食物
术后第3个月起 低脂普食，逐渐增加高蛋白食物，同时谨慎摄入红肉、鸡肉和火鸡等食物，需处理成易消化的细块
表3 术后营养素补充建议及膳食来源
营养素 建议摄入量 膳食来源
钙 减重术后摄入1 200~1 500 mg/d；
BPD-DS术后建议摄取1 800~2 400 mg/d		 奶制品、豆制品
铁 复合维生素–矿物质方案补充18~60 mg/d的总铁量；
若吸收不足口服维生素B12；
口服铁不耐受或难治性铁缺乏患者建议静脉输注铁剂		 内脏、牛肉、羊肉、菠菜、油麦菜等蔬菜，香蕉、橙子等水果
B族维生素 维生素B12口服补充350~1 000 μg/d，育龄妇女等特殊人群的剂量应为8 00~1 000 μg/d；
维生素B复合物制剂或复合维生素–多矿物质补充剂12 mg，50~100 mg/d最佳；
每天口服叶酸5 mg，持续至少4个月治疗叶酸缺乏症		 海鲜（如蛤蜊、虾、沙丁鱼）、肉类（如牛肝）及蛋类
脂溶性维生素 既往有维生素A、E、K缺乏病史的患者，考虑在常规剂量外适当增加；
每天补充2 000~4 000 IU维生素D3以维持术后血清25-OHD水平		 奶制品、豆制品
[1]
Gasmi A, Bjørklund G, Mujawdiya PK, et al. Micronutrients deficiences in patients after bariatric surgery [J]. Eur J Nutr, 2022, 61(1): 55-67.
[2]
Chong B, Jayabaskaran J, Kong G, et al. Trends and predictions of malnutrition and obesity in 204 countries and territories: an analysis of the Global Burden of Disease Study 2019 [J]. EClinicalMedicine, 2023, 57: 101850.
[3]
Pan X-F, Wang L, Pan A. Epidemiology and determinants of obesity in China [J]. The lancet Diabetes & endocrinology, 2021, 9(6): 373-392.
[4]
Deledda A, Pintus S, Loviselli A, et al. Nutritional Management in Bariatric Surgery Patients [J]. Int J Environ Res Public Health, 2021, 18(22): 12049.
[5]
El Ansari W, Elhag W. Weight Regain and Insufficient Weight Loss After Bariatric Surgery: Definitions, Prevalence, Mechanisms, Predictors, Prevention and Management Strategies, and Knowledge Gaps-a Scoping Review [J]. Obes Surg, 2021, 31(4): 1755-1766.
[6]
Zarshenas N, Tapsell LC, Neale EP, et al. The Relationship Between Bariatric Surgery and Diet Quality: a Systematic Review [J]. Obes Surg, 2020, 30(5): 1768-1792.
[7]
Gasmi A, Bjørklund G, Mujawdiya PK, et al. Micronutrients deficiences in patients after bariatric surgery [J]. European journal of nutrition, 2022, 61(1): 55-67.
[8]
Bustamante-Lopez L, Sulbaran M, Changoor NR, et al. Impact of bariatric surgery on early-onset colorectal cancer risk: a systematic review and meta-analysis [J]. Updates Surg, 2023, 75(5): 1051-1057.
[9]
Gu L, Fu R, Chen P, et al. In terms of nutrition, the most suitable method for bariatric surgery: laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass? A systematic review and meta-analysis [J]. Obes Surg, 2020, 30(5): 2003-2014.
[10]
Enani G, Bilgic E, Lebedeva E, et al. The incidence of iron deficiency anemia post-Roux-en-Y gastric bypass and sleeve gastrectomy: a systematic review [J]. Surg Endosc, 2020, 34(7): 3002-3010.
[11]
Al Mansoori A, Shakoor H, Ali HI, et al. The Effects of Bariatric Surgery on Vitamin B Status and Mental Health [J]. Nutrients, 2021, 13(4): 124-132.
[12]
Dogan K, Homan J, Aarts EO, et al. Long-term nutritional status in patients following Roux-en-Y gastric bypass surgery [J]. Clin Nutr, 2018, 37(2): 612-617.
[13]
Dalcanale L, Oliveira CP, Faintuch J, et al. Long-term nutritional outcome after gastric bypass [J]. Obes Surg, 2010, 20(2): 181-187.
[14]
Kwon Y, Ha J, Lee YH, et al. Comparative risk of anemia and related micronutrient deficiencies after Roux-en-Y gastric bypass and sleeve gastrectomy in patients with obesity: An updated meta-analysis of randomized controlled trials [J]. Obes Rev, 2022, 23(4): e13419.
[15]
Farsani TM, Sikaroudi MK, Janmohammadi P, et al. Inadequate Protein Intake Before and After Different Types of Bariatric Surgery: Systematic Review [J]. Annals of Bariatric Surgery, 2021, 10(1): 9-14.
[16]
Kehagias I, Zygomalas A, Karavias D, et al. Sleeve gastrectomy: have we finally found the holy grail of bariatric surgery? A review of the literature [J]. Eur Rev Med Pharmacol Sci, 2016, 20(23): 4930-4942.
[17]
Wang Y, Duan L, Han X, et al. Changes in Nutritional Outcomes After Sleeve Gastrectomy: a Systematic Review and Meta-analysis [J]. Obes Surg, 2022, 32(1): 103-114.
[18]
Gillon S, Jeanes YM, Andersen JR, et al. Micronutrient Status in Morbidly Obese Patients Prior to Laparoscopic Sleeve Gastrectomy and Micronutrient Changes 5 years Post-surgery [J]. Obes Surg, 2017, 27(3): 606-612.
[19]
Al-Mutawa A, Al-Sabah S, Anderson AK, et al. Evaluation of Nutritional Status Post Laparoscopic Sleeve Gastrectomy-5-Year Outcomes [J]. Obes Surg, 2018, 28(6): 1473-1483.
[20]
Jastrzębska-Mierzyńska M, Ostrowska L, Witczak-Sawczuk K, et al. Assessment of the Clinical Condition and Way of Patients' Nutrition before and after Laparoscopic Sleeve Gastrectomy [J]. Nutrients, 2023, 15(3): 514.
[21]
Sherf Dagan S, Tovim TB, Keidar A, et al. Inadequate protein intake after laparoscopic sleeve gastrectomy surgery is associated with a greater fat free mass loss [J]. Surg Obes Relat Dis, 2017, 13(1): 101-109.
[22]
Furbetta N, Cervelli R, Furbetta F. Laparoscopic adjustable gastric banding, the past, the present and the future [J]. Ann Transl Med, 2020, 8(Suppl 1): S4.
[23]
Conner J, Nottingham JM. Biliopancreatic diversion with duodenal switch [M]. 2020.
[24]
Lange J, Königsrainer A. Malnutrition as a Complication of Bariatric Surgery—A Clear and Present Danger? [J]. Visceral medicine, 2019, 35(5): 305-311.
[25]
孙铭遥, 陈伟. 《中国超重/肥胖医学营养治疗指南(2021)》解读 [J]. 协和医学杂志, 2022, 13(2): 255-262.
[26]
King WC, Hinerman AS, Belle SH, et al. Comparison of the Performance of Common Measures of Weight Regain After Bariatric Surgery for Association With Clinical Outcomes [J]. JAMA, 2018, 320(15): 1560-1569.
[27]
Athanasiadis DI, Martin A, Kapsampelis P, et al. Factors associated with weight regain post-bariatric surgery: a systematic review [J]. Surg Endosc, 2021, 35(8): 4069-4084.
[28]
Sjöström CD, Lissner L, Wedel H, et al. Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study [J]. Obes Res, 1999, 7(5): 477-484.
[29]
Parmar CD, Efeotor O, Ali A, et al. Primary Banded Sleeve Gastrectomy: a Systematic Review [J]. Obes Surg, 2019, 29(2): 698-704.
[30]
El Ansari W, Elhag W. Weight regain and insufficient weight loss after bariatric surgery: definitions, prevalence, mechanisms, predictors, prevention and management strategies, and knowledge gaps—a scoping review [J]. Obesity surgery, 2021, 31(2): 1755-1766.
[31]
Kushner RF, Sorensen KW. Prevention of Weight Regain Following Bariatric Surgery [J]. Curr Obes Rep, 2015, 4(2): 198-206.
[32]
Bohdjalian A, Langer F B, Shakeri-Leidenmühler S, et al. Sleeve gastrectomy as sole and definitive bariatric procedure: 5-year results for weight loss and ghrelin [J]. Obes Surg, 2010, 20(5): 535-540.
[33]
Karmali S, Brar B, Shi X, et al. Weight recidivism post-bariatric surgery: a systematic review [J]. Obes Surg, 2013, 23(11): 1922-1933.
[34]
闫文貌, 白日星. 减重代谢术后体重反弹的原因和防治措施 [J]. 外科理论与实践, 2020, 25(05): 386.
[35]
Pizato N, Botelho PB, Gonçalves VSS, et al. Effect of Grazing Behavior on Weight Regain Post-Bariatric Surgery: A Systematic Review [J]. Nutrients, 2017, 9(12): 1322.
[36]
中国医师协会外科医师分会肥胖和糖尿病外科医师委员会（CSMBS）. 精准肥胖代谢外科手术中国专家共识（2022版） [J]. 中华胃肠外科杂志, 2022, 25(10): 841-851.
[37]
Kulick D, Hark L, Deen D. The bariatric surgery patient: a growing role for registered dietitians [J]. J Am Diet Assoc, 2010, 110(4): 593-599.
[38]
Jastrzębska-Mierzyńska M, Ostrowska L, Wasiluk D, et al. Dietetic recommendations after bariatric procedures in the light of the new guidelines regarding metabolic and bariatric surgery [J]. Rocz Panstw Zakl Hig, 2015, 66(1): 13-19.
[39]
Moizé VL, Pi-Sunyer X, Mochari H, et al. Nutritional pyramid for post-gastric bypass patients [J]. Obes Surg, 2010, 20(8): 1133-1141.
[40]
Tabesh MR, Maleklou F, Ejtehadi F, et al. Nutrition, Physical Activity, and Prescription of Supplements in Pre- and Post-bariatric Surgery Patients: a Practical Guideline [J]. Obes Surg, 2019, 29(10): 3385-3400.
[41]
Guillet C, Masgrau A, Mishellany-Dutour A, et al. Bariatric surgery affects obesity-related protein requirements [J]. Clin Nutr ESPEN, 2020, 40(3): 392-400.
[42]
Sherf Dagan S, Goldenshluger A, Globus I, et al. Nutritional Recommendations for Adult Bariatric Surgery Patients: Clinical Practice [J]. Adv Nutr, 2017, 8(2): 382-394.
[43]
Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures–2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists [J]. Surg Obes Relat Dis, 2020, 16(25): 175-247.
[44]
Aguas-Ayesa M, Yárnoz-Esquíroz P, Olazarán L, et al. Precision nutrition in the context of bariatric surgery [J]. Rev Endocr Metab Disord, 2023, 24(5): 979-991.
[45]
Pathak K, Zhao Y, Calton E, et al. Leucine supplementation during caloric restriction in adults at risk of metabolic syndrome: An 8 week double blind randomized controlled trial [J]. Rev Endocr Metab Disord, 2023, 24(3): 645-651..
[46]
Parrott J, Frank L, Rabena R, et al. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients [J]. Surg Obes Relat Dis, 2017, 13(5): 727-741.
[47]
Chakhtoura M, Rahme M, Fuleihan GE-H. Vitamin D metabolism in bariatric surgery [J]. Endocrinology and Metabolism Clinics, 2017, 46(4): 947-982.
[48]
O'Kane M, Parretti HM, Pinkney J, et al. British Obesity and Metabolic Surgery Society Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery-2020 update [J]. Obes Rev, 2020, 21(11): e13087.
[49]
Topart P, Becouarn G, Sallé A, et al. Biliopancreatic diversion requires multiple vitamin and micronutrient adjustments within 2 years of surgery [J]. Surg Obes Relat Dis, 2014, 10(5): 936-941.
[50]
Coupaye M, Rivière P, Breuil MC, et al. Comparison of nutritional status during the first year after sleeve gastrectomy and Roux-en-Y gastric bypass [J]. Obes Surg, 2014, 24(2): 276-283.
[51]
James H, Lorentz P, Collazo-Clavell ML. Patient-Reported Adherence to Empiric Vitamin/Mineral Supplementation and Related Nutrient Deficiencies After Roux-en-Y Gastric Bypass [J]. Obes Surg, 2016, 26(11): 2661-2666.
[52]
Sethi M, Chau E, Youn A, et al. Long-term outcomes after biliopancreatic diversion with and without duodenal switch: 2-, 5-, and 10-year data [J]. Surg Obes Relat Dis, 2016, 12(9): 1697-1705.
[53]
Argyrakopoulou G, Konstantinidou SK, Dalamaga M, et al. Nutritional Deficiencies Before and After Bariatric Surgery: Prevention and Treatment [J]. Curr Nutr Rep, 2022, 11(2): 95-101.
[54]
中华医学会肠外肠内营养学分会营养与代谢协作组, 北京协和医院减重多学科协作组. 减重手术的营养与多学科管理专家共识 [J]. 中华外科杂志, 2018, (2): 81-90.
[55]
Bjørklund G, Semenova Y, Pivina L, et al. Follow-up after bariatric surgery: A review [J]. Nutrition, 2020, 78: 110831.
[56]
O'Kane M, Parretti HM, Hughes CA, et al. Guidelines for the follow-up of patients undergoing bariatric surgery [J]. Clin Obes, 2016, 6(3): 210-224.
[57]
Kanerva N, Larsson I, Peltonen M, et al. Changes in total energy intake and macronutrient composition after bariatric surgery predict long-term weight outcome: findings from the Swedish Obese Subjects (SOS) study [J]. Am J Clin Nutr, 2017, 106(1): 136-145.
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[15] 冯婷, 叶俊钊. 粪菌移植治疗肥胖及代谢相关脂肪性肝病的临床研究进展[J]. 中华肥胖与代谢病电子杂志, 2024, 10(02): 138-144.
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