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

S Research has shown micronutrient deficiencies common

in obese individuals
S Suspected mechanisms : S Nutrient dense food sources displaced by high-calorie nutrient poor foods and beverages

S These deficiencies are exacerbated with bariatric surgery S Critical to establish baseline nutritional status prior to

bariatric surgery

Purpose

S Present latest information regarding nutritional

deficiencies in obese individuals

S Discuss common post-bariatric surgery nutritional

deficiencies
S Review screening and supplementation to address

deficiencies

Bariatric Surgeries
Malabsorptive and Restrictive

S Carry the greatest risk of malnutrition

S S S

Roux-en-Y gastric bypass (RYGB) most common Biliopancreatic Diversion with duodenal switch (BPD-DS) Biliopancreatic Diversion (BPD) rarely performed

S The risk increases as more of the small intestine is bypassed S Nutrients absorbed in the Proximal Small Intestine:
S S S S

Vitamin D Calcium Cooper Iron

Bariatric Surgeries
Purely Restrictive

S Deficiencies primarily due to limited intake

S

Vertical Banded Gastroplasty (VBG) S Adjustable Gastric Band (AGB) S Vertical Sleeve Gastrectomy (VSG)
S Mechanical digestion and acid production are impaired with

gastric resection or bypass S The result is a decline in the absorption/digestion of:

S

Iron, B12, Protein-bound nutrients

S Production of intrinsic factor also is negatively impacted

Post Bariatric Surgery

S Very low caloric intake typical for 6 months after surgery

S Results in reduced intake of ALL macronutrients

S Particularly protein S Studies have shown in some cases to be as low at 0.5 g/kg

S Most common symptoms of micronutrient deficiency:

S Anemia up to 75% of all patients S Neurological Dysfunction 5-9%

Micronutrient Deficiencies

S Prevention Research is complicated due to:

S Currently no standard for supplementation post surgery
S Variable adherence to supplementation regime makes

determining efficacy difficult

Supplementation

S General supplement recommendation

S 1 daily multivitamin w/folic acid AGB & VSG
S 1-2 daily multivitamin w/folic acid RYGB S 2 daily multivitamin w/folic acid BPD-DS

S Supplements should be not be Enteric-coated or time-released S Liquid, Suspension, or Chewable supplements are

recommended
S Liquid and chewable advisable for the 1st month post surgery

Iron

S Most common deficiency post-surgery : 12-47%

S Baseline Deficiency: 44%

S Primary symptom: Microcytic Anemia S Biomarker: Serum, Ferritin, Total Iron Binding Capacity, CBC S Supplementation: 65 mg elemental iron for menstruating

women (RYGB & BDP-DS)

Vitamin D and Calcium

S Baseline Vitamin D Deficiency: 25-80% S Post-surgery: serum calcium typically normal while parathyroid

hormone frequently elevated

S Primary symptom: Decreased bone mineral density, secondary to

hyperparathyroidism
S Biomarker: Serum 25-OH-D, calcium, phosphorus, PTH

S Supplementation: S Calcium citrate w/Vit D3: 1200-1500 mg/day AGB 1800 mg/day-

RYGB, BDP-DS S Vit D3: 1000 IU/day-RYGB 2000 IU/day BDP-DS

Fat Soluble Vitamins

S Deficiency more common in BPD-DS due to fat malabsorption S Baseline deficiencies: S Retinal and beta-carotene - 12.5 % S Vitamin E - 23% S Biomarker: S Vitamin A: plasma retinal S Vitamin E: plasma alpha-tocopherol S Vitamin K: prothrombin time S Supplementation: for BPD-DS 10,000 IU vit A and 300 g vit K

Vitamin B12
S Most common following RYGB 33%
S Baseline deficiency: 18% S Primary symptom: anemia, neurological dysfunction,

visual loss
S Biomarker: Serum vitamin B12 S Supplementation:
S
S

Crystalline 500m/day - sufficient for 80-95% of post-RYGB patients

1000m/day intramuscularly if oral not effective

Vitamin B1

S Asymptomatic deficiency post-surgery:18%

S Baseline Deficiency: 29%

S Primary symptom: Opthalmoplegia, nystagmus, ataxia,

encephalopathy, rapid visual loss (Wernicke encephalopathy)

S Biomarker: Serum thiamine

Folate

S Folate deficiency rare pre or post surgery

S Regular supplementation is sufficient
S Deficiency may indicate noncompliance with

supplementation
S Primary symptom: Anemia S Biomarker: Red blood cell folate, plasma homocysteine

Vitamin C

S Post-surgery deficiency (RYGB): 34.5%

S Baseline deficiency: 36% S Deficiency correlated with elevated BMI

S No adverse effects of deficiency noted to date S Some studies have shown vitamin C to lower markers of

inflammation
S Standard supplementation is sufficient to address deficiency

Zinc, Selenium, Cooper

S Post surgery zinc deficiency: 36-51% S Most cases asymptomatic S Non-compliant supplementation can result in: Acrodermatitis

enteropathic-like rash
S Base-line zinc deficiency: 28% S Selenium deficiency can result in Cardiomyopathy S Copper deficiency S Screen for if unexplained anemia persists and with prolonged

zinc supplementation

Recommendations for Screening

S Baseline, 6 months post surgery and then annually: S Vitamin B1 and B12 S Folate S Iron S Vitamin D S Protein

S Screen if symptoms present: B6, Copper, Zinc

S Those undergoing BPD or BPD-DS should also be screened

annually for: Vitamin A, E, K