Early Thoughts on Micronutrient Management

Jacqueline Jacques, ND

As a primary procedure, sleeve gastrectomy is still new   Sleeve is not included in the current ASMBS nutrition guidance   We have very little published data – and what we have is early, small number of patients
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So how do we start…

The place it all begins

selenium and others. thiamine.   .   Identified deficiencies include vitamin D. zinc.   Regardless of what procedure is done.Pre-operative deficiencies are more commonly being identified in research. the starting point is the same.

191 adults ◦  Kimmons JE. D. MedGenMed. 2006 Dec 19. Blanck HM.   Evaluated data from NHANES III (Third National Health and Nutrition Examination Survey: 1988–1994) Higher BMI was associated with deficiency of vitamins A. E. Tohill BC.  Associations between body mass index (BMI) and the prevalence of low micronutrient levels among US adults. folate and carotenoids.8(4):59   . selenium. et al. ◦  This data included 16. C.

  Demonstrated “a pattern of low micronutrient levels among overweight and obese adults compared with normalweight adults.   .” Odds of being low in multiple nutrients were the highest among overweight and obese premenopausal women.

Jouet P. Clerici C. 19(1):56-65. Study examined pre and postoperative nutritional status in AGB and RNY patients (21 AGB and 49 GBP)   Preoperatively.  Nutritional consequences of adjustable gastric banding and gastric bypass: a 1-year prospective study. Msika S. 2009 Jan.   ◦  Coupaye M. Ledoux S. Larger E. numerous deficiencies were found. Puchaux K. Obes Surg. . Bogard C.

average BMI = 43                 Hbg .2.3. 5%   Vit C .21 AGB Patients. 23%   .5.19% Transferrin .8. 14% B1 . 5%   B12 . 43%   Vit A .1. 47% Ferritin .1. 15% PT . 10% Iron .1. 10% MCV . 10% Vit D . 5% Incr PTH .2.1.10.9. 5%   Folate . 38%   B6 .4.3.2.

average BMI = 49               Hbg .6. 14%   .28. 4% MCV . 47%   Vit A .14. 14%   Folate . 16%   B1 . 12% Vit D . 29% Transferrin .7. 25%   B6 .1.3.2.5. 57% Ferritin .49 RNY Patients.2.23.7.12.4. 2% PT . 6% Incr PTH . 4%   B12 . 10%   Vit C .8. 8% Iron .

calcium. folate. B(6). et al. vitamin B(12).19(1):66-73. B(3). A. Epub 2008 May 20. 2009 Jan.  Evidence for the Necessity to Systematically Assess Micronutrient Status Prior to Bariatric Surgery. phosphate. and E. ◦  Ernst B. vitamin B(1). hemoglobin. Obes Surg. iPTH.       Study of 232 morbidly obese patients preparing for bariatric surgery Assessed: Serum albumin. selenium. ferritin. magnesium. In a sub-sample of 89 subjects assessed copper. . 25-OH vitamin D (3). zinc.

9% ◦  Zinc 24.4% ◦  B12 18.0% ◦  Magnesium 4.6% ◦  Folate 3. .4%   accompanied by a secondary hyperparathyroidism in 36.9% ◦  Hemoglobin 6.6% cases.5% ◦  Phosphate 8.  Deficiencies found: ◦  Albumin 12.1% ◦  Severe Vitamin D deficiency 25.7% ◦  Ferritin 6.

007) and of anemia (p < 0. ◦  48.2% ◦  No copper. in women only) significantly increased with BMI. ◦  Selenium 32.2% ◦  Vitamin E 2. .6% ◦  B3 5.7% had at least one of the most prevalent deficiencies. or vitamin A deficiency was found.003.6% ◦  B6 2. vitamin B1.  Sub-sample deficiencies: ◦  Prevalence of albumin deficiency (p < 0. (B12. zinc and D).

Preoperative deficiencies are common   They tend to be worse at higher BMIs   They set the nutritional stage regardless of procedure chosen   .

I’m warning you it’s not much .

had their labs followed for one year.   .  Hakaem HA. ◦  Obes Surg. Eldali AM. Salem AM. Impact of Laparoscopic Sleeve Gastrectomy on Iron Indices: 1 Year Follow-Up. 151 patients who underwent the vertical sleeve gastrectomy procedure in Saudia Arabia. Bamehriz FY. 2009 Jul 15. O’Regan PJ.

2% postoperatively.1% pre-operatively to 26.9% of patients.   Folate deficiency developed in 9.   These findings suggest that VSG patients are at nutritional risk based on their procedure and should be monitored for deficiency after surgery.8% of patients   Iron deficiency developed in 4.   .The incidence of B12 deficiency increased from 8.

Jorgensen J. Prevalence of nutrient deficiencies in bariatric patients. Zarshenas N. 2009 Nov-Dec. vitamin D.25(11-12):1150-6. folate.  Toh SY. homocysteine.   Compared 1 year data to pre-op data   Vitamin D deficiency was found in 57% pre-op   ◦  Nutrition. Researchers looked at serum ferritin. vitamin B12. 43%(VSG) . and hbg in 149 patients who had RNY (n=138) or sleeve (n=11). RBC folate. ◦  At one yr: 30%(RNY).

  At one year for RNY (n=57): ◦  17% ◦  29% ◦  15% ◦  11% ◦  12% anemic elevated homocysteine low ferritin low B12 low RBC folate   At one year in VSG (n=11) ◦  15% low hgb ◦  25% elevated homocysteine .

  .   Patients were instructed to take a multivitamin with 150% of then RDA three times daily (exact contents unknown).21(2):207-11 Researchers studied 60 VSG patients for one year. Janssen IM. 2011 Feb. Berends FJ.  Aarts EO. The gastric sleeve: losing weight as fast as micronutrients? ◦  Obes Surg.

At the end of one year:   26% of patients had anemia   43% had iron deficiency   15% had folic acid deficiency   9% had B12 deficiency   15% had low albumin   4% had low vitamin A   39% had low vitamin D They also found excesses of:   Vitamin A (48%)   B1 (31%)   B6 (30%) .

  Recommended making adjustments to protocol based on labs   .Authors expressed concern about both prevention and about development of potential nutritional toxicity.

◦  Obes Surg. Wernicke’s Syndrome after Sleeve Gastrectomy. vomiting. Case report of 38-y/o female who underwent uncomplicated sleeve gastrectomy for morbid obesity   Patient presented to ER at 1wk post-op with nausea. 2007 May. dehydration.  Makarewicz W.17(5):704-6. et al.   .

et al.   ◦  Given electrolytes and parenteral nutrition ◦  Scope showed edema. Case report of 38-y/o female who underwent uncomplicated sleeve gastrectomy for morbid obesity   Patient presented to ER at 1wk post-op with nausea. 2007 May. PPI given and dietary counseling .17(5):704-6.  Makarewicz W. vomiting. dehydration. ◦  Obes Surg. Wernicke’s Syndrome after Sleeve Gastrectomy.

diplopia w/ impaired eye movement.5 days later pt presented again w/same sx   Given electrolytes and IV replacement   Following IV patient developed changes in consciousness. hypokinesis. and “loss of logical verbal contact.”     Clinician chose to convert pt to minigastric bypass to correct emptying ◦  Normal MRI ◦  Scope showed functional stenosis and retained gastric contents .

nystagmus. foot drop. periodic LOC. no logical verbal contact.   Clinicians now diagnose WE and institute immediate IV thiamine repletion.   .Post-operatively neuro sx worsened dramatically with convergent squint.   Symptoms completely resolved over several months.

Should we really expect less deficiency? .

  Gehrer S. Christoffel-Courtin C.20(4):447-53. 2010 Apr. Kern B. Peterli R. Peters T. ◦  Obes Surg. 3. 30 and 36 months   . 6. Epub 2010 Jan 26 3-yr study comparing 86 RNY pts to 50 VSG pts   Preop. 24. Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux-Y-gastric bypass (LRYGB)-a prospective study. 12.

1000mg calcium. 500mg C. 30g fat. 100mg calcium. 80g CHO. 10mg B6. 15mg B2. 100mcg B12. 100mg magnesium. 10mg zinc.   Deficiencies were treated as they arose   . 50mg niacin. 2mcg Vit D (80 IU)   Supplements: 15mg B1. 23mg B5. 400mcg folate.Post-op diet: 820 cal. 50g protein. 150mcg biotin.

Iron . 57% of patients had deficiencies: ◦  23% D ◦  14% Zn ◦  6% Albumin ◦  3% B12. Folate.  Prior to surgery.

  VSG   ◦  34% Zinc ◦  32% D ◦  14% Incr PTH ◦  22% Folate ◦  18% Iron ◦  18% B12 ◦  4% Albumin RNY ◦  37% Zinc ◦  52% D ◦  33% Incr PTH ◦  12% Folate ◦  28% Iron ◦  58% B12 ◦  8% Albumin In 7.7% of all patients. the same deficiency was present preoperatively .

Bowling Green State University   . and Biliopancreatic Diversion with Duodenal Switch Followed 119 patients for 6-18 months postop (58 RNY. Roux-en-y Gastric Bypass. 46 VSG. 15 BPD-DS) ◦  Unpublished master’s thesis.  Miller. (2009)Comparison of Nutritional Deficiencies and Complications following Vertical Sleeve Gastrectomy. K.

VSG patients were told to reduce this to 2/day after 3 months. 400 IU D. and 1000mg calcium as citrate   Deficiencies were treated as they arose   Only 37% of patients completed 18 month follow-up   .All patients were instructed to take Optisource® Resource vitamins 4/day.000 IU A.   RNY and BPD patients were given an additional 10.

1 11.1 .3 42.5 83.3 62.9 9.1 3.4 0 2.8 3.5 0 37.4 0 20 RNY 2.9 20.Nutrient Calcium Phosphorus Potassium B12 Folate Vit D Albumin Thiamin Vitamin A VSG 0 0 17.1 BPD-DS 14.3 25 37.3 4 25.4 30 14.5 0 57.

and more anemia   Patients who had more RD visits lost more weight and had better vitamin status   Compliance was a problem across the board and impacted the accuracy of for E.   . K and Zinc so much that they could not be properly evaluated.Low vitamin compliance was associated with more deficiency of iron and D.

Goday A. 2010 Aug.   Pre-operative data was compared to 1 year post-operative data.  Nogués X. Epub 2010 Jul 8 . et al. Bone mass loss after sleeve gastrectomy: a prospective comparative study with gastric bypass.88(2):103-9. [Article in Spanish] A small study from Spain compared both blood chemistries and bone density findings in SG patients (n = 8) to gastric bypass patients (n = 7).   ◦  Cir Esp.

7 ◦  0. though it was generally somewhat less in the SG group.   Sleeve patients lost:   ◦  4.2%±6.4 ◦  8. .2 ◦  7.1%±3.3 ◦  3.6%±4.Both groups were found to have similar losses of bone at all areas measured.3%±5.3 in in in in in the the the the the lumbar spine femoral neck total hip measurement proximal radius distal radius.2%±9.

  In blood chemistries: ◦  Vitamin D levels increased ◦  N-telopeptide increased ◦  Bone alkaline phosphatase. .

What you don’t know. you don’t know. but it still might hurt you .

pepsinogen and renin are removed in sleeve ◦  This may cause problems with protein intolerance ◦  This has been discussed in one paper:   O. Brunaud. Quilliot. Volume 35. N. M.  Protein: ◦  Many of the cells that make gastric acid. D. Medical follow up after bariatric surgery: nutritional and drug issues General recommendations for the prevention and treatment of nutritional deficiencies  
 Diabetes & Metabolism. Issue 6. Part 2. Pages 544-557
 . Sirveaux.A. Ziegler. Reibel. L. December 2009.

  Copper:   Thiamine ◦  A portion of copper is absorbed in the stomach ◦  Despite current low reports in literature. vomiting is reported as a frequent issue .

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rapid movement of food through the duodenum   ◦  Folate ◦  Iron/protein .Pre-operative deficiency (D. due to intolerance   Loss of gastric acid   Loss if IF   Other possible issues: PPIs. for example)   People eat less food   Different food –by instruction.

What do you do today? .

we have to make some educated guesses   I err on the conservative side   .The big question right now is: “Do we treat it like a band or a bypass?”   The real answer is that this we don’t have data to support either path.   So right now.

  4. and may have intolerances New anatomy creates some risks Early literature is starting to show some patterns.  5.1.  2.  People start out deficient After patients eat less . and they don’t look too different from RNY (perhaps with the exception of iron) – SO FAR… .a lot less After patients eat differently differently.  3.

      So the risk is likely to be closer to a gastric bypass than a band We should probably treat as such until we have research that gives us real data A conservative approach is also more prudent since the procedure is still relatively new as a primary weight loss surgery .

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French writer and playwright .Sebastien Roch Nicolas Chamfort. 1741-1794.