Bariatric Nutrition: Suggestions for the Surgical Weight Loss Patient (Summary Part 1)

I just finished the Bariatric Nutrition: Suggestions for the Surgical Weight Loss Patient article published recently (see http://download.journals.elsevierhealth.com/pdfs/journals/15 50-7289/PIIS1550728908001639.pdf ). I thought I'd highlight/summarize some of the stuff I found most interesting.  This is NOT COMPLETE and the article goes into MUCH more detail, but I'd thought I'd sumarize just SOME of the stuff I found most interesting (or thought I needed reinforcement of in my own life).  Most of it is related to RNY only because that's the parts I highlighted for myself (sorry lapbanders, DSers, VSGers, etc).  I just wanted to put this all somewhere where I could have it all in one place!  "Most characteristic physical findings are seen late in the course of nutrient deficiency."  In other words - by the time you are actually symptomatic of vitamin/nutrient deficiency, you have already been deficient for a while.   "Vitamins and minerals are essential factors and co-factors in numberous biologic processes that regulate body size.  The include appetitie, hunger, nutrient absorption, metabolic rate, fat and sugar metabolism, thyroid and adrenal function, energy storage, glucose hemeostasis, neural activites, and others."  In other words - if your are not getting the recommended doses of vitamins and/or minerals, your weight loss and/or weight maintenance will probably be at risk because your body cannot function like it is supposed to.   "Studies have found that 60-80% of morbidly obese PREoperative candidates have defects in vitamin D [19-22].  Such defects would reduce dietary calcium absorption and increase a substance known as calcitriol, which, in turn, causes metabolic changes that favor fat accumulation [23-25]."  In other words - vitamin deficiency may be part of WHY you were morbidly obese to begin with.   Supplements for RNY: 1) Multivitamin-mineral supplement - a high-potency vitamin containing 200% of daily value for at least 2/3 of nutrients - avoid time-released supplements - avoid enteric coating - choose a complete formula containing at least 18 mg iron, 400 ug folic acid, as well as selenium, and zine in each serving - avoid children's formulas that are incomplete - do not mix multivitamin containing iron with calcium supplement, take at least 2 hr apart 2) Additional elemental calcium (1500 - 2000 mg/d) - choose a brand that contains calcium citrate and vitamin D3 - split into 500 - 600 mg doses; be mindful of serving size on supplement label - space doses evenly throughout day - suggest a brand that contains magnesium, especially for BPD/DS - wait >= 2 hr after taking multivitamin or iron supplement - combined dietary and supplemental calcium intake > 1700 mg/d might be required to prevent bone loss during rapid weight loss 3) Additional elemental iron (18 - 27 mg/d elemental) - recommended for menstruating women and those at risk of anemia - do not mix iron and calcium supplements, take >= 2 hr apart - vitamin C may enhance absorption of non-heme iron sources 4) Optional B complex - B-50 dosage - avoid time released tablets - no known risk of toxicity "Iron deficiencies, which would significantly hinder energy use, have been reported in nearly 50% of morbidly obese PREoperative candidates [21]."  In other words - half of morbidly obese people can thank (in part) iron deficiency as a possible contributing factor to their obesity since their bodies cannot properly use the energy it is being given. "RYGB increases the risk of vitamin B12 and other B vitamin deficits."  In other words - since there is no know risk of toxicity (see above) and RNY post-ops are at an increased risk of vitamin B deficits, you are better off just to take a B complex daily.  Better safe than sorry considering the side effects of deficiency.   "It is important for the bariatric patient to take vitamin and mineral supplements, not only to prevent adverse health conditions that can arise after surgery, but because some nutrients such as calcium can enhance weight loss and help prevent weight regain."  In other words - making sure you take all the necessary vitamins and minerals helps you not only stay healthy, but lose the weight and MAINTAIN the weight loss.   Thiamin (vitamin B1): "Beriberi is a thiamin deficiency that can affect various organ systems, including the heart, gastrointestinal tract, and peripheral and central nervous systems.  Although the condition is generally considered rare, a number of reported and possibly a much greater number of unreported or undiagnosed cases, of beriberi have occurred among individuals who have undergone surgery for morbid obesity.  Early detection and prompt treatment of thiamin deficits in these individuals can help to prevent serious health consequences.  If beriberi is misdiagnosed or goes undetected FOR EVEN A SHORT PERIOD, the bariatric patient can develop IRREVERSIBLE neuromuscular disorders, PERMANENT defects in learning and short-term memory, coma, and EVEN DEATH."  In other words - take a B complex vitamin whether your surgeon recommended it or not.  (Yea, I really said that.)  Better safe than sorry with B vitamins. "Chronic or acute thiamin deficiencies in bariatric patients often present with symptoms of peripheral neurophathy or Wernicke's encephalopathy and Korsakoff's phychoses [21, 48 - 54]."  In other words - signs of B1/thiamin deficiency can include numbness in the extremities (hands or feet or arms or legs), hypothermia, memory loss, etc.   "A deficiency in thiamin for only a couple of weeks or less, caused by persistent vomiting, can deplete thiamin stores."  In other words - if you have a sickly spell, it is especially important that you make sure you get your B complex vitamins in.   B12: Preoperative Risk:  "Patients with obesity have a high incidence of gastroesophagela reflux disease (GERD), for which they take proton pump inhibitors, thus increasing the potential to develop a vitamin B12 deficiency."  In other words - if you take certain antacids, you are at an increased risk of B12 deficiency.  Note: It might be worth it for banders who may still have GERD issues to supplement B12 since it has no toxicity level?  "Factors that increase the risk of vitamin B12 deficiency relevant to bariatric surgery include the following: An inability to release protein-bound vitamin B12 from food, particularly in hypochlorhydria and atrophic gastritis Malabsorption due to inadequate IF, such as in pernicious anemia Gastrectomy and gastric bypass" In other words - you must supplement vitamin B12 because you cannot absorb through food the way you used to. "Gastric bypass patients have both a decreased production of stomach acid and a decreased availability of IF; thus, a vitamin B12 deficiency could develop without appropriate supplementation.  Because the typical absorption pathway cannot be relied on, the surgical weight loss patient must rely on PASSIVE absorption of B12, which occurs independent of IF."  In other words - you must supplement vitamin B12 in a passive way (such as sublingual or injection, etc) and NOT in simple pill form.   "Vitamin B12 deficiency has been frequently reported after RYGB.  Among these patients, the prevalence of vitamin B12 deficiency is estimated to be 12 - 33%."  "After the first postoperative year, the prevalence of vitamin B12 deficiency appears to increase yearly in RYGB patients [89]."  In other words - don't get lazy when it comes to taking your B12 (or any other supplments).   "Vitamin B12 deficiency after RYBG has been associated with megaloblastic anemia [92].  Some vitamin B12-deficient patients develop significant symptoms, such as polyneuropathy, paraesthesia, and permanent neural impairment.  On occasion, some patients may experience delusions, hallucinations, and even, overt psychosis [93]."  In other words - vitamin B12 deficiency could suck big time. "Deficiency of vitamin B12 is typically defined at levels < 200 pg/mL.  However, about 50% of patients with obvious signs and symptoms of deficiency have normal vitamin B12 levels [31]."  In other words - since B12 has no toxicity levels (meaning you can't OD on it), best to keep your B12 levels as high as possible.   "Supplementation of RYBG patients with 350-500 ug/d will prevent most post-operative vitamin B12 deficiency."  In other words -hose of you doing 2 sublinguals a week are NOT TAKING ENOUGH.  I don't do shots, but I do 2 sublinguals per DAY (1000 ug/d).   "Patients should be monitored closely for their lifetime, because severe anemia can develop with or without supplementation [98]."  In other words - get your labs done when you're supposed to, even if you feel fine and are doing all your supplements like you're supposed to.   Folate: "Boylan et al. [26] found folate deficiencies PREoperatively in 56% of RYBG patients studied."  In other words - it is more likely than not that you were probably folate deficient as a pre-op. "Folic acid stores can be depleted within a few months postoperatively unless replenished by a multivitamin supplement and dietary sources (i.e., green leafy vegetables, fruits, organ meats, liver, dried yeast, and fortified grain products)."   "Low serum folate levels have been cited at anywhere from 6% to 65% among RYGB patients [26, 86, 101].  Additionally, folate deficiencies have occurred postoperatively, even with supplementation.  Boylan et al. [26] found that 47% of RYGB patients had low folate levels 6 months postoperatively and 41% had low levels at 1 year.  This deficiency occurred despite patient adherence to taking a multivitamin supplement that contained at least the daily value for folate, 400 ug [26].  Postoperative bariatric patients with rapid weight loss and/or malnutrition might be at especially high risk of micronutrient deficiencies."  In other words - folate needs to be resupplied with supplements AND dietary sources.  Since it is difficult immediately post-op to get in some foods rich in folate, supplements become even more important - especially for the immediate post-op.  Also, since many go deficient with "at least the daily value for folate", this adds further support to their contention that RNY post-ops take vitamins with 200% of the daily value included daily.   "The folate contained in the multivitamin supplementation essentially corrects the deficiency in the vast majority of postoperative bariatric patients [103].  Therefore, persistent folate deficiency might indicate patient lack of compliance with the prescribed viatmin protocol [32]."  "It is gernally agreed that folate deficiency is corrected with 1 mg/d folic acid [32] and is preventable with the amount typically found in a multivitamin that provides 200% of the daily value (800 ug)."  In other words - take your vitamins like you're told and this crap won't happen to you.   "Patients with folate deficiency often present with forgetfulness, irritability, hostility, and even paranoid behaviors [29]."  In other words - if you are like me, then you won't even KNOW if you have symptoms unless you start experiencing paranoid behaviors.  The rest of that stuff is pretty normal.  So it's important to make sure you get your folate because (if you're like me) you may not even recognize "symptoms" of folate deficiency.   Iron: "In 1 retrospective study of consecutive cases, 44% of bariatric surgery candidates were iron deficient [21]... as determined by abnormal hemoglobin values."  "79% of younger patients versus 42% of older patients presented with preoperative iron deficiency, as determined by low serum iron values."  In other words - many of us were probably iron deficient as pre-ops.  The younger you are, the more likely you are to be deficient.    "The data have consistently pointed toward the risk of iron deficiency and anemia after bariatric procedures.  Iron deficiency is defined as a decrease in the total body content.  Iron deficiency anemia occurs when erythropoiesis is impaired as a result of the lack of iron stores.  In the absence of anemia, iron deficiency is usually asymptomatic.  Fatigue and a diminished capacity to exercise, however, are common symptoms of anemia."  In other words - you can be iron deficient without being anemic.  (Who knew?)  If you are iron deficient and not anemic, you probably have no symptoms.   "Iron deficiency is common after gastric bypass surgery, with reports of deficiency ranging from 20% to 49% [32, 98, 107, 108].  Up to 51% of female patients in 1 series were iron deficient, confirming the high-risk nature of this population [87].  Among patients with super obesity undergoing RYGB with varying limb length, iron deficiency has been identified in 49 - 52% and anemia in 35 - 74% of subjects up to 3 years postoperatively [84]."  In other words - anyone who had RNY is at risk for iron deficiency - especially women (which account for most bariatric procedures performed).  So almost ALL RNY post-ops should be taking additional iron supplements. "One randomized study of premenopausal RYGB women demonstrated that 320 mg of supplemental oral iron (ferrous sulfate) given twice daily prevented the development of iron deficiency but did not protect against the development of anemia [107].  Notably, those patients who developed anemia were not regularly taking their iron supplements (>= 5 times/wk) during the period preceding diagnosis.  In that study, a significant correlation was found between the resolution of iron deficiency and adhering to the prescribed oral iron supplement regimen."  "...suggesting dietary intake and 1 multivitamin (containing 18 mg iron) might be inadequate to maintain iron stores in RYBG patients."  "Two thirds (67%) of those who did develop iron deficiency later became anemic.  Their findings suggest that the amount of iron in a standard multivitamin alone is not adequate to prevent deficiency."  In other words - if you miss 2 days of iron supplements a week, you are at increased risk of iron deficiency and anemia.  In most cases, it's important to take a multvitamin with 18 mg iron IN ADDITION TO a seperate iron supplement. "Similarly, Avinoah et al. [38] found that at 6.7 years postoperatively, weight loss had been relatively stable for the preceding 5 years; however, the iron saturation, hemoglobin, and mean corpuscular volume values had declined progressively and significantly."  In other words - this isn't something that is going to resolve itself with time.  Supplement.  Period.  Forever.   "Although perhaps less detrimental than consuming starch or clay, the consumption of ice (pagophagia) is also a form of pica that might not be routinely identified."  In other words - eating ice is a form of pica (the ingestion of non-food substances).  Pica is often a symptom of iron deficiency.   "The use of 2 complete multivitamins, collectively providing 36 mg of iron (typically ferrous fumarate) is customary for low-risk patients, including men and postmenopausal women."  "In addition to the iron found in 2 multivitamins, menstruating women and adolescents of both sexes might require additional supplementation to achieve a total intake of 50-100 mg of elemental iron daily..."  In other words - if you don't eat lots of high iron foods (which can be hard after any WLS), you probably need an additional iron supplement in addition to your 200% daily value multivitamins.   Continued in Part 2 post. 

Wendy, you are AWESOME to do this for us!!!  This is so interesting.  I'm going to print this whole thing out and take it on the plane with me. It's one thing for Dr's and such to tell us to do all of this, it's another thing entirely to actually be told WHY we're supposed to do it. Thanks again

I've finally had some time to actually sit here and read these! So far so good. I guess walking around with my pockets full of vitamins is better than the alternative! My boss made a comment the other day(bless his heart, he's a man and doesn't understand women nor does he know I've had surgery) about all of my "drugs". I start out every morning with about 9 pills on my desk and take everything but iron spaced out through the morning. Then mid-afternoon I take my iron. He said that the next random drug screen might not be so random (joking of course). I told him no worries because I was the lucky winner of the last random drawing!!! Anyways...on to Part II

You only take 9?    My calcium for the day alone total 8.  (2 tablets of 250 mg each = 1 dose of 500 mg.  I take 4 doses per day to get up to the 2000 mg.) Then there's my 2 sublingual B-12, 2 vitamin B-complex, 1 Rx bariatric multivitamin, 2 probiotics and 1/2 lexapro.  (Plus 1 vitamin D3 on Sundays.)

I take 9 at work, but really I take:

~Calcium Citrate + D= 1260 mg Calcium and 800 IU Vitamin D
~20MG Nexium (to prevent ulcers)
~1500mg Metformin 1500mg; my PCP put my on the same dose that I was on pre-op for good measure
~125 mg Synthroid; the dreaded hypothyroidism
~1000mcg B12 Sublingual (not required by my doctor but just something I do on my own
~65mg Iron
~1 multivitamin(I won't go into detail about everyting that's in it, but it's just a normal multivitamin)

So that's really 12 pills total but I take my synthroid as soon as I get up before i go walking and I take my metformin just before bed!