Nutrition Deficiencies in Bariatric Surgery

Bruce M. Wolfe MDProfessor of Surgery

Oregon Health & Science University

Potential Conflict of Interest

• Allergan• Covidian• EnteroMedics• Ethicon Endosurgery

Deficiency due to:•Decreased intake•Vomiting•Malabsorption

Protein-Calorie Malnutrition

• Uncommon/rare after LAGB, RYGBP• Prevented by 40-80g protein/day• May occur:– Dysfunctional eating habits/anorexia– Protracted vomiting– Malabsorptive procedure

Shikora: Nutr Clin Prac 2007;22:35

Nutritional Deficiency

• LAGB: – Vomiting

• RYGBP: – Iron– Calcium– Vitamin B12

• Malabsorption:– Protein– Fat-soluble vitamins– Minerals (Na, K, Mg, Zn)

Dehydration

• Poor intake, difficulty catching up

• Decreased sodium intake from food

• Symptoms increased by medications

Thiamine

• May be deficient pre-op

• Vomiting is the usual cause

• Encephalopathy, neuropathy

• Replace, then glucose

Iron

• Absorbed in duodenum and jejunum in acid medium

• Measure serum Fe, TIBC

• Deficiency may precede anemia, heart failure

Vitamin B12

• RYGBP deficiency 26-70%

• Macrocytic anemia, thrombocytopenia

• Neurologic derangements

• Oral or sublingual supplement

Hollick MF; N Engl J Med 2007, 357;3:269

Hollick MF; N Engl J Med 2007, 357;3:269

Vitamin D, Calcium and Bone

• Calcium absorption• PTH inversely related• Bone Calcium• Supplement use leads to decreased fractures

Hollick MF; N Engl J Med 2007, 357;3:272

Non-skeletal Actions of Vitamin D

• Cancer• Autoimmune disease• Diabetes• CV disease• Schizophrenia, depression• Pulmonary function, asthma

Vitamin D – Cancer

• <20 ng/ml increases by 30-50% the risk for:– Colon– Prostate– Breast

Vitamin D

• CV disease: – HTN– CHF

• Autoimmune disease: – TIDM– MS

• Muscle function, athletic performance• Others

Vitamin D

• IOM recommendations: – 200 IU/d <50y– 400 IU/d >50y– Inadequate sun: 800-1000 IU/d

• Replacement:– 50,000 IU weekly x 8 weeks, then q 2-4 weeksOr– 1000 IU D₃/d or 3000 IU D₂/d

Bariatric Surgery Recommendations

• Pre-operative routine:– Iron– Vitamin D levels– Others as clinically indicated– Pre-operative supplementation– Treatment deficiency