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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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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
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