B12 and Folate Deficiencies in VSG

B12 and Folate Deficiencies in VSG

On December 6, 2010, In Vitamins, Water Solubles, By Andrea

Cyanocobalamin Injection

I deal with folks of RNY and DS persuasion on a regular basis simply due to the fact that we know we have to do supplementation due to our malabsorption of micronutrients for the rest of our lives.

What AGBers and VSGers fail to understand is that they also need to supplement as well.  And in some cases, it is more than just a simple multivitamin and calcium.

A study was started in June of 2007 of VSG patients and conducted for 12 months afterwards to study the possibility of iron, B12, and folate deficiency with only taking an iron-free multivitamin.  A total of 61 patients were included in the study.  Parameters for those who don’t have access to the whole study (and, if you just read the abstract?  You’d not realize the significance of this study!!  It’s VERY SIGNIFICANT! for VSGers!) like I do.

Tests used to monitor deficiency were as follows:

• Iron deficiency / Anemia: CBC, soluble transferrin receptor (sTf-R), ferritin, iron, TIBC
• B12 – vitamin B12
• Folate – RBC folate (Andrea’s note – this is the definitive test for folate deficiency)

The multivitamin used was an iron-free multi containing 0.2 mg folic acid and 12 mcg cyanocobalamin (B12) for duration of the study.  Those who changed their vitamin regimen (including one SMART person who chose to take an iron-fortified multi) were taken out of the study and not included in the 61 patients listed above.

The things that stood out most about this study:

• Six months after surgery, 3 patients (2 females, 1 male) developed an iron deficiency.  One patient had elevated sTf-R level; second patient had combined low serum iron and low transferrin sat% and high sTf-R, and third patient had abnormally low levels of ferritin and iron level with low transferrin sat%.
• Twelve months after surgery, all three affected patients had elevated sTf-R levels.  One patient had low ferritin; low serum iron and transferrin sat% was noticeably decreased in another.
• The study considered the amount of iron deficiency in this study to be statistically insignificant.
• One patient with iron deficiency also had a B12 deficiency.
• Incidence of B12 deficiency increased “significantly" from 8.1% preoperatively to 26.2% 1 year after surgery.
• Six patients (9.8%) developed a folate deficiency 12 months postoperatively.  Significant decrease of RBC folate levels were seen at 6 months.
• Six months after surgery, four patients (3 females and one male) developed anemia.  2 remained anemic at 12 months.  At 1 year, 3 patients were anemic.

Thoughts the authors of the study had regarding this study and the results:

• Obesity is considered a low-grade chronic inflammatory condition.  Ferritin is an acute phase reactant that increases in inflammatory situations.  Therefore, the reduction of ferritin levels observed after bariatric surgery could be attributed in part to the resolution of the coexisting inflammatory state.
• A significant number of patients developed B12 deficiency after VSG.  Could be attributed to fundus resection, which is the most abundant part of the stomach with parietal cells that release Intrinsic Factor essential for B12 absorption.  Daily administration of 5x the RDA of oral B12 failed to prevent the development of B12 deficiency in patients.
• Folate deficiency was evident as early as 6 months after surgery.  Despite receiving a multivite with 0.2 mg folic acid following VSG, folate levels deteriorated throughout the study.  Could be attributed to dietary changes.  Patients might require more than the RDA of folic acid to maintain normal folate levels.

It is important to note that the authors of this study were out looking to prove VSG did not affect iron levels as much as RNY does.  And they did.  Thus they tended to downplay the B12 and folate results unless you read the entire study.  In fact, the article is “Impact of Laparoscopic Sleeve Gastrectomy on Iron Indicies: 1 Year Follow-Up" which goes to show that sometimes it really does pay to get our hands on the entire article.

Who wants to pay for my subscription to SOARD?

Due to my surgery type, I frequent both the DS and the VSG boards. I am constantly amazed (why it still amazes me, I do not know) at the number of folks who use "not having to rely on vitamins" as a reason for wanting the VSG in lieu of a malabsorptive procedure, not to mention the number of POST-VSG patients who throw caution to the wind and take a multi on occasion when they remember. ARGH!

I can't count on all my fingers how many times I've posted on the VSG boards about vitamin/mineral supplementation (though the ones who probably need this information most have me blocked because I'm an evil DSer, you know). I explain that removal of the outer curvateur of the stomach means you're producing WAY less intrinsic factor, which is required fo B12 absorption, so most folks will need a sublingual or injectable B12 supplement. I explain that with the much smaller stomach, there is much less acid, and most irons require an acidic environment for proper breakdown/absorption, so many will also need an iron supplement (in addition to their multivitamin since most take a multi and calcium at the same time).

This study you quoted was only for one year follow-up. The danger of the VSG, IMO, is that folks think if they've made it to year 1 or 2 without any vitamin issues, then they're in the clear. However, some of these issues can take longer to show up because it can be a slower lead time without the added intestinal malabsorption. A prestigious VSG surgeon has also been known to warn patients that he is seeing calcium deficiencies in VSG patients after a few years. Oh, and Vitamin D. 

Folate is just yet another to add to the list of increasing cases of deficincy post-VSG.

I just want to pull my hair out when I see someone state emphatically that they've only been taking Flinstones every day, and their numbers are "perfect." For startes, I KNOW they have no idea what "perfect" numbers really are and are simply smug because thier doc said they had no deficinecies. No deficiencies does NOT equate to "perfect." Next frustration is that I know those "perfect" labs are likely INCOMPLETE. I'm sure your calcium is fine, but what's your PTH? I'm glad your serum iron is normal, but what's your ferritin? Oh, they didn't check those? Of course not...

I'd love to take a survery of WLS patients by surgery type to see which surgery types have the highest and lowest rates of patients who get copies of their lab results, demand additional labs besides just what the doctor orders initially, and track lab trends over time for themselves. I have a hunch as to who would fall where in those survey results...

But don't worry - their surgeons are experts in nutrition (much, I'm sure, like the DS surgeon who has recently released a one-a-day multi for DSers that contains a whole 2500 IUs of D3)...

Rant over. Though I will add that this post is made out of general frustration and not as a sweeping generalization of all VSGers - as with anything, there are exceptions, though, based on my observations over the past 2 years, the above is generally the rule.

Trust me?  I GET IT.

I was told once, on the VSG board, that I didn't have a f'ing clue what I was talking about when it came to a lower acidic environment in the VSG.

Oh, and once?  That B-vitamins weren't necessary for iron metabolism.

So.  Well.  Yeah.

AGBers also need vitamins - so no excuse there, either.

 
I'm one of those people who throw caution to the wind and take vites when I think of it but it's not because I am arrogant enough to believe I don't need them, instead it is a neurotic hate of pills and capsules since my sleeve surgery.  I do have my labs tested and the only thing I have been low on is Vit D and that isn't due to my surgery type, that is because I am like a majority of the US population.  My last D level was 68 and I shoot for 80-100.  Still okay.

I do not supplement w/B12, my labs are already abnormally high and I will insist and demand to the very end that one CAN take too much B12 and we do NOT pee it all out.  I do not advocate taking B12 unless labs start going down.

And finally, while I am a nurse I am not an expert in nutrition so Andrea reviews my labs and give me a rubber stamp on them.

There is a difference between a VSGer not taking a handful of vites and a malabsorber.  I can get by with it and AM getting by with it thus far.  I could not if I had bypass or DS.  Perhaps the difference between me vs. others is that my diet is usually pretty darn good.  Sure, I have days where I don't eat anything I should be but they are not often.

Jill, I really like you and I respect the hell out of the majority of yoru posts but sometimes you do post as an absolute authority and you do treat VSG like DS.  They are not the same.  Not everyone has deficiencies and we are not all bloody idiots that need for you to tell us how utterly stupid we are.

I do not treat VSGers like DSers, and I never said anyone was stupid, but some people do behave stupidly when it comes to supplementation, and that's not merely an opinion, nor is it unsubstantiated (and it's not just patients, but often also the "professionals" telling the patients what to do). Whenever I post my supplementation schedule on the VSG board (some threads ask what everyone is supplementing), I always list everything I take, but I also note after each one if it's something I take due my malabsorption that most VSGers do not need to take; I also note the ones I take that have nothing to do with WLS at all (like my hair, nails & skin combo, the high vitamin C, and the alpha lipoic acid). And whenever I post suggestions to those on the VSG board asking what they should take, I always start with multi and calcium and then add that "many" or "most" (not ALL) VSGers also need sublingual or injectible B12, iron, and that most Americans are low in vit D so to be sure to have that checked. And I doubt I've ever written a post of supplement suggestions without including a statement such as to ADJUST SUPPLEMENTATION BASED ON YOUR LAB RESULTS.

You are clearly one of the ones I mentioned at the end of my post who is an exception - you DO see your own lab values (or else you wouldn't know how high your B12 was and wouldn't have Andrea take a look at them), and you know your own labs well enough to see if anything is trending in a negative direction (be it something trending high might need backing off or something trending lower that might need boosting).

No, not everyone has deficiencies, but I strongly believe that most (not all - we all know that sometimes, **** happens) who do could have prevented them had they been more proactive or aware of their own medical information. You can't deny that you've seen many VSGers (often pre-ops, anyway) say they don't want to have to take vitamins multiple times a day. Well, thanks to the beauty of calcium, almost everyone should be taking something (even if just calcium alone for certain doses) at least 3 times a day. Even with malabsorption, I only have to take supplements 3 times a day as well (though I still do 4 times a day because, even though I take a heme iron, I still separate it from calcium - force of habit and a habit I wanted to stay in in case I couldn't afford to continue the Proferrin).

But, if you'd rather ignore the obvious disclaimer statement at the end of my post and the note that I was posting out of frustration and would prefer to believe that I think all VSGers are "bloody idiots" and "utterly stupid," I can't help that. If that's how I felt, I wouldn't ever waste my time on the VSG board. And, as I also mentioned, ost of those who truly do fit the descriptive terms you've chosen have blocked me already since, as I've been told by some of my very favorite VSGers, I'm stupid white trash.

"as I've been told by some of my very favorite VSGers, I'm stupid white trash."

*chuckle*

Well knock my teeth out, dress me in a tube top and terrycloth shorts. 

I think its like the people who I KNOW I have even specifically told GETTING ALL YOUR PROTEIN IN DOES NOT MEAN YOU WILL NOT LOSE HAIR!

And then they get pissy when their hair starts its thing and NOBODY TOLD ME!!

Right.  Nobody.

Same with vitamins - except somebody told them a chewable vitafriend would be fine, and magical thinking is going to keep them well.

Like it kept them thin before surgery. 

I appreciate your input JillyPantz. 

heh, I had one girl flip out on me once (well, I'm sure it's happened more than once, but...) because she was so excited she'd bought the Nioxin shampoo to help keep her hair from falling out, and I explained to her the wonders of telogen effluvium and that the nioxin might help the new hair be nice and healthy, but the old hair would still fall out. FLIPPED OUT about why I had to be so negative. Life's a ***** when facts = negativity, eh?

and you are always nice as pie, Jillbean!  how people can get mad at you is beyond me but I've seen it first hand.

apparently, you are seen as trying to foul up some fantasy they are having. why they wouldn't rather know the truth I don't get!

heh, I wouldn't say nice as pie, but I do try to refrain from swearing, namecalling, and other silliness (unless someone else whips out the namecalling first - then it's on!).

Haven't seen you around much - how goes the clean eating?

ha, warm pie with a bit of ice cream melting on top!

well, clean eating remains a goal I sometimes aim for....

mostly I am here

www.obesityhelp.com/group/SA/