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Nutritional Deficiencies in Obesity and After Bariatric Surgery. Stavra A Xanthakos , MD, MS Pediatric Clinics of North America October 2009 56(5): 1105-1121. Background. Research has shown micronutrient deficiencies common in obese individuals Suspected mechanisms : - PowerPoint PPT Presentation
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Nutritional Deficiencies in Obesity and After Bariatric Surgery
Stavra A Xanthakos, MD, MSPediatric Clinics of North America
October 200956(5): 1105-1121
Background
Research has shown micronutrient deficiencies common in obese individuals Suspected mechanisms :
Nutrient dense food sources displaced by high-calorie nutrient poor foods and beverages
These deficiencies are exacerbated with bariatric surgery
Critical to establish baseline nutritional status prior to bariatric surgery
Purpose
Present latest information regarding nutritional deficiencies in obese individuals
Discuss common post-bariatric surgery nutritional deficiencies
Review screening and supplementation to address deficiencies
Bariatric SurgeriesMalabsorptive and Restrictive
Carry the greatest risk of malnutrition Roux-en-Y gastric bypass (RYGB) – most common Biliopancreatic Diversion with duodenal switch (BPD-DS) Biliopancreatic Diversion (BPD) –rarely performed
The risk increases as more of the small intestine is bypassed Nutrients absorbed in the Proximal Small Intestine:
Vitamin D Calcium Cooper Iron
Bariatric SurgeriesPurely Restrictive
Deficiencies primarily due to limited intake Vertical Banded Gastroplasty (VBG) Adjustable Gastric Band (AGB) Vertical Sleeve Gastrectomy (VSG)
Mechanical digestion and acid production are impaired with gastric resection or bypass The result is a decline in the absorption/digestion of:
Iron, B12, Protein-bound nutrients Production of intrinsic factor also is negatively impacted
Post Bariatric Surgery
Very low caloric intake typical for 6 months after surgery Results in reduced intake of ALL macronutrients
Particularly protein Studies have shown in some cases to be as low at 0.5 g/kg
Most common symptoms of micronutrient deficiency: Anemia – up to 75% of all patients Neurological Dysfunction – 5-9%
Micronutrient Deficiencies
Prevention Research is complicated due to: Currently no standard for supplementation post
surgery Variable adherence to supplementation regime
makes determining efficacy difficult
Supplementation
General supplement recommendation 1 daily multivitamin w/folic acid – AGB & VSG 1-2 daily multivitamin w/folic acid – RYGB 2 daily multivitamin w/folic acid – BPD-DS
Supplements should be not be Enteric-coated or time-released
Liquid, Suspension, or Chewable supplements are recommended Liquid and chewable advisable for the 1st month post surgery
Iron
Most common deficiency post-surgery : 12-47% Baseline Deficiency: 44% Primary symptom: Microcytic Anemia Biomarker: Serum, Ferritin, Total Iron Binding Capacity,
CBC Supplementation: 65 mg elemental iron for
menstruating women (RYGB & BDP-DS)
Vitamin D and Calcium
Baseline Vitamin D Deficiency: 25-80% Post-surgery: serum calcium typically normal while parathyroid
hormone frequently elevated Primary symptom: Decreased bone mineral density,
secondary to hyperparathyroidism Biomarker: Serum 25-OH-D, calcium, phosphorus, PTH Supplementation:
Calcium citrate w/Vit D3: 1200-1500 mg/day –AGB 1800 mg/day-RYGB, BDP-DS
Vit D3: 1000 IU/day-RYGB 2000 IU/day BDP-DS
Fat Soluble Vitamins
Deficiency more common in BPD-DS due to fat malabsorption Baseline deficiencies:
Retinal and beta-carotene - 12.5 % Vitamin E - 23%
Biomarker: Vitamin A: plasma retinal Vitamin E: plasma alpha-tocopherol Vitamin K: prothrombin time
Supplementation: for BPD-DS – 10,000 IU vit A and 300 μg vit K
Vitamin B12
Most common following RYGB – 33% Baseline deficiency: 18% Primary symptom: anemia, neurological
dysfunction, visual loss Biomarker: Serum vitamin B12
Supplementation: Crystalline 500μm/day - sufficient for 80-95% of post-
RYGB patients 1000μm/day intramuscularly if oral not effective
Vitamin B1
Asymptomatic deficiency post-surgery:18% Baseline Deficiency: 29% Primary symptom: Opthalmoplegia, nystagmus,
ataxia, encephalopathy, rapid visual loss (Wernicke encephalopathy)
Biomarker: Serum thiamine
Folate
Folate deficiency rare pre or post surgery Regular supplementation is sufficient Deficiency may indicate noncompliance with
supplementation Primary symptom: Anemia Biomarker: Red blood cell folate, plasma
homocysteine
Vitamin C
Post-surgery deficiency (RYGB): 34.5% Baseline deficiency: 36%
Deficiency correlated with elevated BMI No adverse effects of deficiency noted to date Some studies have shown vitamin C to lower markers of
inflammation Standard supplementation is sufficient to address deficiency
Zinc, Selenium, Cooper
Post surgery zinc deficiency: 36-51% Most cases asymptomatic Non-compliant supplementation can result in: Acrodermatitis
enteropathic-like rash Base-line zinc deficiency: 28% Selenium deficiency can result in Cardiomyopathy Copper deficiency
Screen for if unexplained anemia persists and with prolonged zinc supplementation
Recommendations for Screening
Baseline, 6 months post surgery and then annually: Vitamin B1 and B12
Folate Iron Vitamin D Protein
Screen if symptoms present: B6, Copper, Zinc Those undergoing BPD or BPD-DS should also be screened
annually for: Vitamin A, E, K
Recommended