micro nutrition & sleeve 2011

8/4/2019 Micro Nutrition & Sleeve 2011

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Early Thoughts on

Micronutrient Management

Jacqueline Jacques, ND


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As a primary procedure, sleeve gastrectomyis still new

Sleeve is not included in the current ASMBSnutrition guidance

We have very little published data and whatwe have is early, small number of patients


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So how do we start


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The place it all begins


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Pre-operative deficiencies are morecommonly being identified in research.

Identified deficiencies include vitamin D,thiamine, zinc, selenium and others.

Regardless of what procedure is done, thestarting point is the same.


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Associations between body mass index(BMI) and the prevalence of lowmicronutrient levels among US adults. Kimmons JE, Blanck HM, Tohill BC, et al. MedGenMed.

2006 Dec 19;8(4):59 Evaluated data from NHANES III (Third

National Health and Nutrition ExaminationSurvey: 19881994) This data included 16,191 adults

Higher BMI was associated with deficiencyof vitamins A, E, C, D, selenium, folate andcarotenoids.


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Demonstrated a pattern of lowmicronutrient levels among overweightand obese adults compared with normal-

weight adults.

Odds of being low in multiple nutrientswere the highest among overweight andobese premenopausal women.


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Nutritional consequences of adjustablegastric banding and gastric bypass: a1-year prospective study. Coupaye M, Puchaux K, Bogard C, Msika S, Jouet P,

Clerici C, Larger E, Ledoux S. Obes Surg. 2009 Jan;19(1):56-65.

Study examined pre and postoperativenutritional status in AGB and RNYpatients (21 AGB and 49 GBP)

Preoperatively, numerous deficiencieswere found.


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Hbg - 2, 10% MCV - 2, 10% Iron - 4,19% Transferrin - 10,

47%

Ferritin - 3, 15% PT - 1, 5% Incr PTH - 2, 10% Vit D - 3, 14%

B1 - 8, 38% B6 - 1, 5% Folate - 1, 5% B12 - 1, 5% Vit C - 9, 43% Vit A - 5, 23%

21 AGB Patients, average BMI = 43


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Hbg - 2, 4% MCV - 4, 8% Iron - 14, 29% Transferrin - 28,

57%

Ferritin - 1, 2% PT - 3, 6% Incr PTH - 6, 12%

Vit D - 8, 16% B1 - 12, 25% B6 - 7, 14% Folate - 2, 4% B12 - 5, 10% Vit C - 23,

47% Vit A - 7, 14%

49 RNY Patients, average BMI = 49


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Evidence for the Necessity to SystematicallyAssess Micronutrient Status Prior to BariatricSurgery. Ernst B, et al. Obes Surg. 2009 Jan;19(1):66-73. Epub 2008

May 20. Study of 232 morbidly obese patients

preparing for bariatric surgery Assessed: Serum albumin, calcium,

phosphate, magnesium, ferritin, hemoglobin,zinc, folate, vitamin B(12), 25-OH vitamin D

(3), iPTH. In a sub-sample of 89 subjects assessed

copper, selenium, vitamin B(1), B(3), B(6), A,and E.


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Deficiencies found: Albumin 12.5% Phosphate 8.0% Magnesium 4.7% Ferritin 6.9% Hemoglobin 6.9% Zinc 24.6% Folate 3.4% B12 18.1% Severe Vitamin D deficiency 25.4%

accompanied by a secondaryhyperparathyroidism in 36.6% cases.


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Prevalence of albumin deficiency (p < 0.007) andof anemia (p < 0.003; in women only)significantly increased with BMI.

48.7% had at least one of the most prevalentdeficiencies, (B12, zinc and D).

Sub-sample deficiencies: Selenium 32.6% B3 5.6% B6 2.2% Vitamin E 2.2% No copper, vitamin B1, or vitamin A deficiency

was found.


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

procedure chosen


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Im warning you its not much


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Hakaem HA, ORegan PJ, Salem AM,Bamehriz FY, Eldali AM. Impact ofLaparoscopic Sleeve Gastrectomy on IronIndices: 1 Year Follow-Up. Obes Surg. 2009 Jul 15.

151 patients who underwent the verticalsleeve gastrectomy procedure in Saudia

Arabia, had their labs followed for one year.


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The incidence of B12 deficiency increasedfrom 8.1% pre-operatively to 26.2% post-operatively.

Folate deficiency developed in 9.8% ofpatients

Iron deficiency developed in 4.9% ofpatients.

These findings suggest that VSG patientsare at nutritional risk based on their

procedure and should be monitored fordeficiency after surgery.


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Toh SY, Zarshenas N, Jorgensen J.Prevalence of nutrient deficiencies inbariatric patients. Nutrition. 2009 Nov-Dec;25(11-12):1150-6.

Researchers looked at serum ferritin,vitamin D, vitamin B12, homocysteine,folate, RBC folate, and hbg in 149patients who had RNY (n=138) or sleeve(n=11).

Compared 1 year data to pre-op data Vitamin D deficiency was found in 57%

pre-op At one yr: 30%(RNY), 43%(VSG)


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At one year for RNY (n=57): 17% anemic 29% elevated homocysteine 15% low ferritin

11% low B12 12% low RBC folate

At one year in VSG (n=11) 15% low hgb 25% elevated homocysteine


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Aarts EO, Janssen IM, Berends FJ. The gastricsleeve: losing weight as fast asmicronutrients?

Obes Surg. 2011 Feb;21(2):207-11 Researchers studied 60 VSG patients for one

year.

Patients were instructed to take amultivitamin with 150% of then RDA threetimes daily (exact contents unknown).


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At the end of one year:

26% of patients hadanemia

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 foundexcesses of:

Vitamin A (48%) B1 (31%) B6 (30%)


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Authors expressed concern about bothprevention and about development ofpotential nutritional toxicity.

Recommended making adjustments toprotocol based on labs


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Makarewicz W, et al. Wernickes Syndromeafter Sleeve Gastrectomy. Obes Surg. 2007 May;17(5):704-6.

Case report of 38-y/o female whounderwent uncomplicated sleevegastrectomy for morbid obesity

Patient presented to ER at 1wk post-opwith nausea, vomiting, dehydration.


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Makarewicz W, et al. Wernickes Syndromeafter Sleeve Gastrectomy. Obes Surg. 2007 May;17(5):704-6.

Case report of 38-y/o female whounderwent uncomplicated sleevegastrectomy for morbid obesity

Patient presented to ER at 1wk post-opwith nausea, vomiting, dehydration. Given electrolytes and parenteral nutrition Scope showed edema, PPI given and dietary

counseling


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5 days later pt presented again w/same sx Given electrolytes and IV replacement Following IV patient developed changes in

consciousness, hypokinesis, diplopia w/impaired eye movement, and loss oflogical verbal contact. Normal MRI Scope showed functional stenosis and retained

gastric contents

Clinician chose to convert pt to mini-gastric bypass to correct emptying


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Post-operatively neuro sx worseneddramatically with convergent squint,periodic LOC, no logical verbal contact,

foot drop, nystagmus. Clinicians now diagnose WE and institute

immediate IV thiamine repletion.

Symptoms completely resolved overseveral months.


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Should we really expect lessdeficiency?


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Gehrer S, Kern B, Peters T, Christoffel-CourtinC, Peterli R.Fewer nutrient deficiencies afterlaparoscopic sleeve gastrectomy (LSG) thanafter laparoscopic Roux-Y-gastric bypass(LRYGB)-a prospective study. Obes Surg. 2010 Apr;20(4):447-53. Epub 2010 Jan

26

3-yr study comparing 86 RNY pts to 50 VSGpts

Preop, 3, 6, 12, 24, 30 and 36 months


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Post-op diet: 820 cal, 50g protein, 80g CHO,30g fat, 1000mg calcium, 2mcg Vit D (80 IU)

Supplements: 15mg B1, 15mg B2, 10mg B6,100mcg B12, 50mg niacin, 23mg B5, 150mcgbiotin, 500mg C, 400mcg folate, 100mgcalcium, 100mg magnesium, 10mg zinc.

Deficiencies were treated as they arose


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Prior to surgery, 57% of patients haddeficiencies: 23% D 14% Zn 6% Albumin 3% B12, Folate, Iron


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In 7.7% of all patients, the same deficiency waspresent preoperatively

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


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Miller, K. (2009)Comparison of NutritionalDeficiencies and Complications followingVertical Sleeve Gastrectomy, Roux-en-y

Gastric Bypass, and Biliopancreatic Diversionwith Duodenal Switch Unpublished masters thesis, Bowling Green State

University

Followed 119 patients for 6-18 months post-op (58 RNY, 46 VSG, 15 BPD-DS)


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All patients were instructed to takeOptisource Resource vitamins 4/day. VSGpatients were told to reduce this to 2/day

after 3 months. RNY and BPD patients were given an

additional 10,000 IU A, 400 IU D, and1000mg calcium as citrate

Deficiencies were treated as they arose

Only 37% of patients completed 18 monthfollow-up


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Nutrient VSG RNY BPD-DSCalcium 0 2.8 14.3

Phosphorus 0 3.1 25

Potassium 17.1 11.4 37.5B12 3.3 0 0

Folate 4 2.9 37.5

Vit D 25.9 9.4 83.3

Albumin 20.4 30 62.5Thiamin 0 14.3 0

Vitamin A 20 42.1 57.1


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Low vitamin compliance was associated withmore deficiency of iron and D, and moreanemia

Patients who had more RD visits lost moreweight 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 properlyevaluated.


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Nogus X, Goday A, et al. Bone mass lossafter sleeve gastrectomy: a prospectivecomparative study with gastric bypass.[Article in Spanish] Cir Esp. 2010 Aug;88(2):103-9. Epub 2010 Jul 8

A small study from Spain compared bothblood chemistries and bone density findingsin SG patients (n = 8) to gastric bypasspatients (n = 7).

Pre-operative data was compared to 1 yearpost-operative data.


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Both groups were found to have similarlosses of bone at all areas measured, thoughit was generally somewhat less in the SG

group. Sleeve patients lost:

4.6%4.4 in the lumbar spine 8.3%5.2 in the femoral neck 7.1%3.7 in the total hip measurement 0.2%9.3 in the proximal radius 3.2%6.3 in the distal radius.


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


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What you dont know, youdont know, but it still mighthurt you


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Protein: Many of the cells that make gastric acid,

pepsinogen and renin are removed in sleeve This may cause problems with protein intolerance This has been discussed in one paper:

O. Ziegler, M.A. Sirveaux, L. Brunaud, N. Reibel, D.Quilliot. Medical follow up after bariatric surgery:nutritional and drug issues General recommendationsfor the prevention and treatment of nutritionaldeficienciesDiabetes & Metabolism, Volume 35, Issue 6, Part 2,December 2009, Pages 544-557


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Copper: A portion of copper is absorbed in the stomach

Thiamine

Despite current low reports in literature, vomiting isreported as a frequent issue


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Pre-operative deficiency (D, for example) People eat less food Different food by instruction, due to

intolerance Folate Iron/protein

Loss of gastric acid

Loss if IF Other possible issues: PPIs, rapid movement

of food through the duodenum


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What do you do today?


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The big question right now is: Do we treat itlike a band or a bypass?

The real answer is that this we dont havedata to support either path.

So right now, we have to make someeducated guesses I err on the conservative side


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1. People start out deficient2. After patients eat less - a lot less3. After patients eat differently differently, and

may have intolerances

4. New anatomy creates some risks5. Early literature is starting to show some

patterns, and they dont look too differentfrom RNY (perhaps with the exception ofiron) SO FAR


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So the risk is likely to be closer to a gastricbypass than a band

We should probably treat as such until wehave research that gives us real data

A conservative approach is also moreprudent since the procedure is still relativelynew as a primary weight loss surgery


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

micro nutrition & sleeve 2011

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