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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
Thankyou