Bypassing more than the Stomach: Micronutrient ... › ... › 08 ›...

BypassingmorethantheStomach:MicronutrientDeficienciesafter

BariatricSurgeryJayshilPatel,MD

AssociateProfessorofMedicinePulmonary&CriticalCareMedicine

MedicalCollegeofWisconsin

YouareaskedtoseeMr.Jonestoevaluateforpoorappetite…

Mr.Jonesisa50-yearoldmanwithahistoryofdiabetesandgastricbypassformorbidobesity.Heisadmittedtothehospitalafterhavingmultiplefalls,particularlyatnight.

Hehasapoorappetiteandisonlyabletoeatsmallmealsbeforefeeling“full.”Hefeelshe“loseshisbalance”aftergettingupandwalkingafewsteps.

CouldmicronutrientdeficienciesberesponsibleforMr.Jones’symptoms?

Whatdoeshishistoryofgastricbypasshavetodowithmicronutrientdeficiency?

(1) Review the epidemiology of obesity and indications for bariatric surgery.

(2) Classify common bariatric surgical procedures leading to micronutrient deficiencies.

(3) Describe the pathophysiology of micronutrient deficiencies after bariatric surgery.

(4) Characterize common micronutrient deficiencies after bariatric surgery.

(5) Discuss strategies to evaluate for and manage micronutrient deficiencies

Objectives for Discussion

Patel JJ, Rosenthal MD, Miller KR et al. Curr Gastroenterol Rep. 2016 Sep;18(9):45.

A Brief History of Obesity

How is obesity classified?

Body mass index (kg/m2) Interpretation

<18.49 Underweight18.5-24.9 Normal weight25-29.9 Overweight*

30-34.9 Class I obesity35-39.9 Class II obesity>40 Class III obesity>50 Class IV obesity

Hurt RT, Frazier TH, McClave SA, Kaplan LM. JPEN 2011;35:4S-13S

Quetelet Index

*Defines obese for Asian population using WHO and NIH scale.

http://www.cdc.gov/obesity/data/adult.html

Where are the obese?

Obesity and Race

http://www.cdc.gov/obesity/data/adult.html

Sturm P. Public Health. 2007 Jul;121(7):492-6.

A Growing Problem

Airway management

Special equipment

Vascular access

Challenges Posed by the Obese ICU Patient

Leonard KL, Davies SW, Waibel BH. Surg Clin N AM. 2015;95:379-390

Pulmonary Mechanics

Cardiovascular

Pharmacology Limited diagnostics and therapies

Challenges Consequences

Nutrition Support

More immobility

Adams KF, Schatkin A, Harris T et al. N Engl J Med 2006; 355:763-778

Why is Obesity a Problem?

CNS-endocrine• Alteration in

satiety signals

Genetic Factors• Monogenic obesity• Polygenic obesity

ObesogenicEnvironment• Energy-dense

foods• Reduced

physical activity

Expend Energy

Food intake

Patel JJ, Rosenthal MD, Miller KR et al. Curr Gastroenterol Rep. 2016 Sep;18(9):45.

Not Simply “eating too much”

Why do Ambulatory Treatments Fail?

• Primary care MD’s • Have limited clinical time• Decreased incentive • Negative perception of obese patients• Poor training in lifestyle counseling• Use one liners: “eat less, exercise more”

• Obese patients• Don’t perceive weight as unhealthy: “it’s cosmetic”• Want a quick fix for a chronic problem

Indications for Bariatric Surgery

q BMI>40kg/m2 withoutco-morbidconditions

q BMI35-40kg/m2 withONEof:ü HTNü Type2DMü Nonalcoholicfattyliverü Obstructivesleepapneaü Obesity-hypoventilationü Asthmaü Impairedqualityoflife

Burguera B, Agusti A, Arner P et al. J Endocrinol Invest.2007;10:844-52

Mechanism of Weight Loss

RESTRICTIVE MALABSORPTIVE

The stomach’s reservoir capacity isreduced, thus restricting caloric intake(surgically-induced early satiety).

The small bowel is shortened, thusreducing nutrient absorption(surgically-induced malabsorption)

DeMaria EJ. N Engl J Med 2007;356:2176-83

MALABSORPTIVE: jejunoileal bypass

DeMaria EJ. N Engl J Med 2007;356:2176-83

RESTRICTIVE: Sleeve Gastrectomy

Saltzman E, Karl JP. Annu Rev Nutr 2013;33:183-203

MIXED: Roux-en-Y

Saltzman E, Karl JP. Annu Rev Nutr 2013;33:183-203

MIXED: biliopancreatic diversion with duodenal switch

Bariatric Surgery Worldwide

Buchwald H, Oien DA. Obes Surg.2013;23:427–436

Bariatric Surgery in USA

https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers

Nguyen NT, Mosoomi H, Magno CP et al. J Am Coll Surg. 2011;213(2):261.

Open versus Laparoscopic

Bariatric Surgery Outcomes

Carlsson L, Peltonen M, Ahlin S et al. N Engl J Med 2012; 367:695-704

Schauer PR, Bhatt DL, Kirwan JP et al. N Engl J Med 2014;370:2002-13.

Bariatric Surgery Outcomes

Bariatric Surgery Outcomes

Schauer PR, Bhatt DL, Kirwan JP et al. N Engl J Med 2014;370:2002-13.

Schauer PR, Bhatt DL, Kirwan JP et al. N Engl J Med 2014;370:2002-13.

Bariatric Surgery Outcomes

Buchwald H, Avidor Y, Braunwald E et al. JAMA. 2004;292(14):1724-1737.

Bariatric Surgery Outcomes

MEDICALCONDITION %RESOLVED

Type2Diabetes 77

Hypertension 62

Hyperlipidemia 62

Obstructivesleepapnea 84

Complications of Bariatric Surgery

30DAYS

UlcersLeaks/StenosisObstructionBleedingPulmonaryDVT/PE

UlcersLeaks/Stenosis

VomitingBleedingDumping

NUTRITIONAL

DIETSTAGE BEGIN FLUIDS/FOOD

StageI POD 1-2 Clearliquids

StageIIPOD3(dischargediet)

No sugarliquidsProteinrichliquidsChewableMVIChewableCa-vitaminD

Stage III POD 10-14 Increaseclear liquidsSoftproteinsources

StageIII 4weekspost-op Advancedietastolerated

StageIII 5weekspost-op

Continue proteinwithfruitSaladastolerated

StageIV Ashungerincreases

Healthy solidfoodVitaminandmineralsupplementation

Mechanik JI, Kushner RF, Sugerman HJ et al. Surg for Obes Rel Dis 2008;4:S109-S184

Post-Bariatric Surgery Malnutrition

Macronutrients Micronutrients

Protein-caloriedeficiency

Vitaminsandtraceminerals

q Traceminerals<0.01%bodyweight• Require1-100mg/dayinadults

q Vitaminsareorganiccompoundsessentialfornormalmetabolism

Vitaminsandtraceminerals

Fatsolublevitamins(A,D,E,K)

Watersolublevitamins(B1,B9,B12)

Traceminerals(Fe,Zn,Cu)

SUPPLEMENT DOSAGEVitaminAVitaminEVitaminKThiaminFolic acidBiotinSeleniumZincCopper

500 mcg10mg90-120mcg1.2mg400mcg30mg55mg8-11mg2mg

Calciumcitrate/carbonate(PO) 1200-1500 mg/dayVitamin D(PO) 800units/dayIron(PO) 40-65mgelementaliron/day

Vitamin B12(PO,SL,IN,orIM) 500-1000mcg/daytablet1000mcgIM/month

Mechanik JI, Kushner RF, Sugerman HJ et al. Surg for Obes Rel Dis 2008;4:S109-S184

RecommendationsforSupplementation

MVI

What causes post-bariatric micronutrient deficiency?

1 Pre-bariatricsurgeryObesity(alterednutrienttransporter)PoordietqualityPre-operativeweightloss

Saltzman E, Karl JP. Annu Rev Nutr 2013;33:183-203

Nutrient PreoperativeObeseThiamin 0-29%Folate 3-4%Vitamin B12 3-8%VitaminC 43%Vitamin A 17%VitaminD 80-90%VitaminE 0%VitaminK NAIron 26%Zinc 14-30%Selenium 58%Copper NA

Specific pre-bariatric deficiencies

Strohmayer E,ViaMA,YanagisawaR.MountSinaiJMed2010;77:431-445

2 Post-bariatricsurgeryNonadherencetodiet/supplementsAlcoholorsubstanceabuseReducedfoodquality/intakeHormonalsatietyReducedgastricacidsecretionAlteredabsorption

What causes post-bariatric micronutrient deficiency?

Saltzman E, Karl JP. Annu Rev Nutr 2013;33:183-203

Duodenum Jejunum IleumStomach

WaterEthylAlcoholCopperIodideFluorideMolybdenumIntrinsicFactor

Thiamin CalciumRiboflavinPhosphorusNiacinMagnesiumPantothenate IronBiotinZincFolate ChromiumPyridoxine ManganeseVitCMolybdenumVitA,D,E,KAminoacidsSelenium

VitCFolateVitB12VitDVitKSeleniumMagnesiumBilesalts

NutrientAbsorptionintheGITract

colon

SCFAWaterSodiumVitKOther

CalciumIronPhosphorusMagnesiumCopperThiaminRiboflavinSeleniumNiacinBiotinFolateVitA,D,E,K

Slide borrowed and modified with permission from Robert G. Martindale MD PhD

2 Post-SurgicalMechanismsforMicronutrientDeficiency

DeMaria EJ. N Engl J Med 2007;356:2176-83

PeptideYYCCKGLP-1

GhrelinAltered

absorption

Reducedintakeandgastricacid

CASE1A 45-year old woman who was morbidly obese (BMI 45) underwentBPD with duodenal switch.

Two years after the procedure, her weight loss is sustained. Shecomplains of non-specific joint pain, fatigue, bruises easily, and hashad difficulty seeing at night.

Which micronutrient deficiency MOST LIKELY explains hersymptoms?

[A] Thiamine[B] Folate[C] Iron[D] Fat-soluble vitamins[E] Copper

VITAMINE PRE-OP POST-OP

Vitamin A 17% 10-69%

VitaminD 80-90% 30-100%

VitaminE 0% 0-22%

VitaminK NA 0-68%

Mechanik JI, Kushner RF, Sugerman HJ et al. Surg for Obes Rel Dis 2008;4:S109-S184

CASE1:FatSolubleVitaminDeficiencies

Saltzman E, Karl JP. Annu Rev Nutr 2013;33:183-203

CASE1:FatSolubleVitaminDeficiencies

DISORDER YEAR1 YEAR2 YEAR3 YEAR4LowvitaminA 52% 58% 70% 69%LowvitaminD 57% 55% 46% 63%LowvitaminK 14% 21% 13% 68%

Slater GH, Ren CJ, Siegel N et al. J Gastrointest Surg. 2004 Jan;8(1):48-55

CASE1:FatSolubleVitaminDeficiencies

Vitamin Symptoms Monitoring Repletion

Vitamin A Acne, dryeyes,nightblindness

Serumretinollevel Oral5000-1000 IU/day

VitaminD Muscle pain,fatigue,difficultywalking

Serum25-OH vitaminD Oral, dosingdependsonseverity

VitaminE Asymptomatic tosubtleneuromuscularsymptomsandanemia

Alpha-tocopherol to(cholesterol+triglycerides)ratio<0.5considereddeficient

Oral,800-1200IU/day

Vitamin K Easybruising,bleedinggums

Internationalnormalizedratio

Oral/IV,90-150mcg/day

Mechanik JI, Kushner RF, Sugerman HJ et al. Surg for Obes Rel Dis 2008;4:S109-S184

CASE1:FATSOLUBLEVITAMINDEFICIENCY

CASE2A 25-year old morbidly obese woman undergoes Roux-en-Yprocedure. She is taking a proton pump inhibitor for “acid reflux.”

She is inconsistent in taking supplements. One year later, shereports pain in both calves and falls at night. She is found to beanemic with an MCV of 105 fL.

Which micronutrient deficiency MOST LIKELY explains herfindings?

[A] Iron[B] Vitamin C[C] Vitamin A[D] Vitamin B12[E] Zinc

1

2 3

Stabler SP. N Engl J Med 2013;368:149-60

NUTRIENT SG LAGB RYBG BPD-DSVitamin B12 18% 0-19% 33-58% 22%Iron 14% 0-32% 25-50% 21-26%Folate 22% 10% 0-12% 5%

CASE2:VITAMINB12DEFICIENCY

Whole-bodystorageisgreaterof2000microgramsisgreaterthandailyneedof2micrograms/dayà thusdeficiencymaytakeyears

SYMPTOMS SIGNS LABORATORY PEARLParesthesia,numbness,abnormalgait,dementia

Pallor,jaundice,impairedsensation

50% falsepositiveandnegativeratewithserumvitaminB12alone

Methylmalonicacidofgreaterthan500nmol/Lis virtuallydiagnosticofB12deficiency

CASE2:VITAMINB12DEFICIENCY

Stabler SP. N Engl J Med 2013;368:149-60

NUTRIENT SG LAGB RYBG BPD-DSVitamin B12 18% 0-19% 33-58% 22%Iron 14% 0-32% 25-50% 21-26%Folate 22% 10% 0-12% 5%

CASE2:NUTRITIONALANEMIAS

Strohmayer E, Via MA, Yanagisawa R. Mount Sinai J Med 2010;77:431-445Mechanik JI, Kushner RF, Sugerman HJ et al. Surg for Obes Rel Dis 2008;4:S109-S184

Duodenum Jejunum IleumStomach

WaterEthylAlcoholCopperIodideFluorideMolybdenumIntrinsicFactor

Thiamin CalciumRiboflavinPhosphorusNiacinMagnesiumPantothenate IronBiotinZincFolate ChromiumPyridoxine ManganeseVitCMolybdenumVitA,D,E,KAminoacidsSelenium

VitCFolateVitB12VitDVitKSeleniumMagnesiumBilesalts

NutrientAbsorptionintheGITract

colon

SCFAWaterSodiumVitKOther

CalciumIronPhosphorusMagnesiumCopperThiaminRiboflavinSeleniumNiacinBiotinFolateVitA,D,E,K

Slide borrowed and modified with permission from Robert G. Martindale MD PhD

NUTRIENT SG LAGB RYBG BPD-DSVitamin B12 18% 0-19% 33-58% 22%Iron 14% 0-32% 25-50% 21-26%Folate 22% 10% 0-12% 5%

CASE2:NUTRITIONALANEMIAS

Strohmayer E, Via MA, Yanagisawa R. Mount Sinai J Med 2010;77:431-445Mechanik JI, Kushner RF, Sugerman HJ et al. Surg for Obes Rel Dis 2008;4:S109-S184

NUTRIENT CBC CLUE* TESTING REPLETIONVitamin B12 Macrocytosis B12, MMA IVorPOFolate Macrocytosis Folate POIron Microcytosis Ferritin IVorPO

Macrocytosis isalargeredbloodcell,greaterthan96femtoliters (10-15)Microcytosis isasmallredbloodcell,lessthan80femtoliters*Note:oneMICROCYTICandoneMACROCYTICanemiawillproduceaNORMOCYTICanemiawithMCV80-96femtoliters

Strohmayer E,ViaMA,YanagisawaR.MountSinaiJMed2010;77:431-445

CASE2:NUTRITIONALANEMIAS

CASE3A 55-year old obese with diabetes, hypertension, and alcohol abuseunderwent gastric banding. He was nauseated and had dailyvomiting.

Within two months after the procedure, he was progressivelyconfused and wife noticed he was “walking funny.”

Which micronutrient deficiency MOST LIKELY explains hersymptoms?

[A] Calcium[B] Thiamine[C] Iron[D] Fat-soluble vitamins[E] Zinc

CASE3:THIAMINDEFICIENCYThiamindeficiencymayoccurwithin3weekspostbariatricsurgery.

Absorbed:DuodenumandjejunumClinicalPresentations:

-AcutedeficiencyàWernicke’sencephalopathy-ChronicdeficiencyàBeriberi(dryandwetforms)

LaboratoryEvaluation:-Notnecessarybutcancheckerythrocytethiaminetransketolase activity(ETKA)

RecommendedintakeandManagementofDeficiency:-Dailyrequirementof1.1to1.2mgperday-IVthiamin100mgfollowedby100mgperdayfor5daysandsubsequentoralmaintenanceindeficiency

NUTRIENT SG LAGB RYBG BPD-DSThiamin 0% 0% 12% 0%

Mechanik JI, Kushner RF, Sugerman HJ et al. Surg for Obes Rel Dis 2008;4:S109-S184

CASE4A 40-year old morbidly obese woman undergoes BPD-DS procedure.She was given iron and zinc supplements.

She’s having tingling in both legs and reports falling. She’s found tohave a microcytic anemia. Ferritin levels are normal.

Which micronutrient deficiency MOST LIKELY explains herfindings?

[A] Folate[B] Copper[C] Thiamine[D] Vitamin A[E] Selenium

CASE4:COPPERDEFICIENCY

Absorbed:StomachandproximalduodenumClinicalPresentations:

-Fragilehairanddepigmentedskin-Muscleweakness-Neuropathy-Ataxia

LaboratoryEvaluation:-Microcyticanemia-Lowserumcopper(free<1.6ortotal<10micromol/L)

RecommendedintakeandManagementofDeficiency:-900mcgperdayforadults-IVorPOcoppersupplementationfordeficiency

NUTRIENT SG LAGB RYBG BPD-DSCopper NA NA NA 70%

Mechanik JI, Kushner RF, Sugerman HJ et al. Surg for Obes Rel Dis 2008;4:S109-S184

CASE5A 45-year old morbidlyobese woman undergoes BPD-DS procedure.She’s had numerous complications include strictures, bowelobstruction, and frequent nausea with vomiting.

During a clinic visit, she is found to have easily pluckable hair anddermatitis. She reports poor taste.

Which micronutrient deficiency MOST LIKELY explains herfindings?

[A] Vitamin C[B] Copper[C] Iron[D] Vitamin B12[E] Zinc

CASE5:ZINCDEFICIENCY

NUTRIENT SG LAGB RYBG BPD-DSZinc 34% NA 37% 10-50%

Strohmayer E,ViaMA,YanagisawaR.MountSinaiJMed2010;77:431-445

Absorbed:DuodenumandjejunumClinicalPresentations:

-Abnormaltaste-Skinchanges-Drybrittlehair-Impotence-Poorwoundhealing

LaboratoryEvaluation:SerumlevelsarenotusefulRecommendedintakeandManagementofDeficiency:

-Dailyrequirementof8mgperday-Aggressivesupplementationcaninducecopperdeficiency

OTHERMICRONUTRIENTDEFICIENCIES

VitaminB2

VitaminB3

VitaminB5

VitaminB7

VitaminC

RARE

SeleniumCasereportsofcardiacdiseaseandmuscledisease

TAKE-HOMEPOINTS

1.Obesityisanationalepidemic(markedincreaseinclassIVobesity).

2.Bariatricsurgeryistheonlyprovenmethodforsustainedweightloss.

3.Bariatricproceduresareclassifiedrestrictive,malabsorptive,ormixed.

4.Sleevegastrectomyhasover-takenRoux-en-YasthemostcommonprocedureperformedintheUnitedStates.

4.Micronutrientdeficienciesarehighlyprevalentpost-bariatricsurgeryduetopre-surgicalpost-surgicalfactors.

5.Themostcommonpre-surgicalmicronutrientdeficiencyisvitaminDdeficiency.

6.Post-surgicaldeficienciesdependonthetypeofsurgeryandassociatedcomplications.

7.Themostcommondeficienciesincludefat-solublevitamins,vitaminB12,iron,thiamin,copper,andzinc.

8.ConsidervitaminB12,folate,iron,andcopperinevaluatingpost-bariatricsurgeryanemia.

TAKE-HOMEPOINTS

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