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Bypassing more than the Stomach: Micronutrient Deficiencies after Bariatric Surgery Jayshil Patel, MD Associate Professor of Medicine Pulmonary & Critical Care Medicine Medical College of Wisconsin

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Page 1: Bypassing more than the Stomach: Micronutrient ... › ... › 08 › MicronutrientDeficiencyforWiSP… · Airway management Special equipment Vascular access Challenges Posed by

BypassingmorethantheStomach:MicronutrientDeficienciesafter

BariatricSurgeryJayshilPatel,MD

AssociateProfessorofMedicinePulmonary&CriticalCareMedicine

MedicalCollegeofWisconsin

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YouareaskedtoseeMr.Jonestoevaluateforpoorappetite…

Mr.Jonesisa50-yearoldmanwithahistoryofdiabetesandgastricbypassformorbidobesity.Heisadmittedtothehospitalafterhavingmultiplefalls,particularlyatnight.

Hehasapoorappetiteandisonlyabletoeatsmallmealsbeforefeeling“full.”Hefeelshe“loseshisbalance”aftergettingupandwalkingafewsteps.

CouldmicronutrientdeficienciesberesponsibleforMr.Jones’symptoms?

Whatdoeshishistoryofgastricbypasshavetodowithmicronutrientdeficiency?

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(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

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

A Brief History of Obesity

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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.

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

Where are the obese?

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Obesity and Race

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

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

A Growing Problem

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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

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

Why is Obesity a Problem?

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Page 12: Bypassing more than the Stomach: Micronutrient ... › ... › 08 › MicronutrientDeficiencyforWiSP… · Airway management Special equipment Vascular access Challenges Posed by

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”

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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

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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

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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

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MALABSORPTIVE: jejunoileal bypass

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

RESTRICTIVE: Sleeve Gastrectomy

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

MIXED: Roux-en-Y

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

MIXED: biliopancreatic diversion with duodenal switch

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Bariatric Surgery Worldwide

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

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Bariatric Surgery in USA

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

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

Open versus Laparoscopic

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Bariatric Surgery Outcomes

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

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

Bariatric Surgery Outcomes

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Bariatric Surgery Outcomes

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

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

Bariatric Surgery Outcomes

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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

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Complications of Bariatric Surgery

30DAYS

UlcersLeaks/StenosisObstructionBleedingPulmonaryDVT/PE

UlcersLeaks/Stenosis

VomitingBleedingDumping

NUTRITIONAL

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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

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Post-Bariatric Surgery Malnutrition

Macronutrients Micronutrients

Protein-caloriedeficiency

Vitaminsandtraceminerals

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

q Vitaminsareorganiccompoundsessentialfornormalmetabolism

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Vitaminsandtraceminerals

Fatsolublevitamins(A,D,E,K)

Watersolublevitamins(B1,B9,B12)

Traceminerals(Fe,Zn,Cu)

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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

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What causes post-bariatric micronutrient deficiency?

1 Pre-bariatricsurgeryObesity(alterednutrienttransporter)PoordietqualityPre-operativeweightloss

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

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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

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2 Post-bariatricsurgeryNonadherencetodiet/supplementsAlcoholorsubstanceabuseReducedfoodquality/intakeHormonalsatietyReducedgastricacidsecretionAlteredabsorption

What causes post-bariatric micronutrient deficiency?

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

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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

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2 Post-SurgicalMechanismsforMicronutrientDeficiency

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

PeptideYYCCKGLP-1

GhrelinAltered

absorption

Reducedintakeandgastricacid

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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

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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

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

CASE1:FatSolubleVitaminDeficiencies

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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

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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

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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

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1

2 3

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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OTHERMICRONUTRIENTDEFICIENCIES

VitaminB2

VitaminB3

VitaminB5

VitaminB7

VitaminC

RARE

SeleniumCasereportsofcardiacdiseaseandmuscledisease

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TAKE-HOMEPOINTS

1.Obesityisanationalepidemic(markedincreaseinclassIVobesity).

2.Bariatricsurgeryistheonlyprovenmethodforsustainedweightloss.

3.Bariatricproceduresareclassifiedrestrictive,malabsorptive,ormixed.

4.Sleevegastrectomyhasover-takenRoux-en-YasthemostcommonprocedureperformedintheUnitedStates.

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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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Thankyou