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Nutritional Deficiencies in Obesity and After Bariatric Surgery

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 :

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Nutritional Deficiencies in Obesity and After Bariatric Surgery

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  1. Nutritional Deficiencies in Obesity and After Bariatric Surgery Stavra A Xanthakos, MD, MS Pediatric Clinics of North America October 2009 56(5): 1105-1121

  2. 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

  3. Purpose • Present latest information regarding nutritional deficiencies in obese individuals • Discuss common post-bariatric surgery nutritional deficiencies • Review screening and supplementation to address deficiencies

  4. 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

  5. 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

  6. 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%

  7. Micronutrient Deficiencies • Prevention Research is complicated due to: • Currently no standard for supplementation post surgery • Variable adherence to supplementation regime makes determining efficacy difficult

  8. 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

  9. 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)

  10. 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

  11. 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 μgvit K

  12. 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

  13. Vitamin B1 • Asymptomatic deficiency post-surgery:18% • Baseline Deficiency: 29% • Primary symptom: Opthalmoplegia, nystagmus, ataxia, encephalopathy, rapid visual loss (Wernicke encephalopathy) • Biomarker: Serum thiamine

  14. 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

  15. 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

  16. 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

  17. 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

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