**6. Guidelines for nutritional management post bariatric surgery**

Recently, updated guidelines for post-operative nutritional and metabolic support of patients post bariatric surgery were published by the American Association of Clinical Endocrinologists in collaboration with multiple societies [10].

	- For LAGB, it should monthly for the first year and then annually
	- For LSG, it is recommended at 1, 3, 6, 12 months and then annually
	- For RYGB, the recommended follow up is at 1, 3, 6, 12 months and biannually or annually thereafter
	- For BPD/DS and other malabsorptive procedure, the recommended follow up is at 1, 3, 6 months and biannual thereafter.
	- Complete metabolic panel, complete blood count with each visit
	- Iron studies at baseline and after BS as needed
	- B12 annually then every 3–6 months for all type of BS (measurement of methylmalonic acid and homocysteine level are optional)
	- Folic acid level (measurement of red blood cell folic acid level is optional), 25-vitamin D and intact parathyroid hormone (PTH) post RYGB and BPD/DS
	- Vitamin A (initially and every 6–12 months thereafter) for BPD/DS and it is optional for RYGB
	- Copper/ceruloplasmin, zinc, selenium evaluation after malabsorptive bariatric surgical procedures (RYGB and BPD/DS) at least annually, or with symptoms of deficiency
	- Thiamine evaluation in symptomatic patients
	- Two adult multivitamins plus minerals (each containing iron, folic acid, thiamine, zinc, copper; chewable form initially then tablets).
	- Vitamin B12 (Cobalamin): 350–1000 μg dose can be administrated orally (disintegrating tablet, sublingual, or liquid), nasal spray or parenteral (1000 μg monthly intramuscular or subcutaneous).
	- Iron: 18–60 mg of elemental iron daily included in the multivitamins and additional supplements can be added if required.
	- Vitamin D: at least 2000–3000 international units of vitamin D (titrated to therapeutic 25-hydroxyvitamin D levels >30 ng/mL)
	- Elemental calcium: appropriate dose of daily calcium varies by bariatric procedure. About 200–1500 mg daily for LAGB, LSG and RYGB, and 1800–2400 mg daily for or BPD/DS. Calcium citrate is preferred than calcium carbonate because it is better absorbed in the absence of gastric acid.

Commercial products that are used for micronutrient supplementation after BS need to be discussed with a healthcare professional familiar with dietary supplements, since many products are adulterated and/or mislabeled [10].
