Nutrient Deficiencies and Health Consequences

Part I: Gastric Restrictive Surgeries

 

Cynthia Buffington, Ph.D.

 

Beyond Change, July 2002

 

Nutrient deficiencies following bariatric surgical procedures can lead to serious health consequences if left unattended. The provision of knowledge to bariatric surgical candidates of the nutrient deficiencies associated with their particular surgical procedure and the steps necessary to avoid their occurrence is the responsibility of the bariatric surgeon and his/her staff. Taking those steps, however, is solely the responsibility of the patient.

 

Do you take your vitamin/mineral supplements on a daily basis and in the amounts recommended?  Is your body losing bone because you can’t remember to take your calcium?  Does your body feel tired and run down because you refuse to take iron?  Is your hair falling out and muscles diminishing in size because you eat too little protein or refuse to use protein supplements?

 

Do you realize that hair loss, reduced muscle and bone are only a few of the many health consequences of long-term nutrient deficiencies? that anemia is likely to develop with deficits in iron, B12, and folate intake or absorption? And, did you know that without sufficient levels of zinc, defects in immune function may occur? 

 

Are you aware that low intake or absorption of B-vitamins can lead to neurological defects and damage, some which are irreversible ****reatable)? Do you know that low anti-oxidant vitamin and minerals may increase the risk for cancer, heart disease, diabetes, hypertension, cataracts, other diseases, as well as promote aging?

 

What are the possible nutrient deficiencies that may occur with the particular surgical procedure you selected for weight loss and how can such deficiencies be prevented or treated?  

 

This month’s column discusses nutrient deficiencies that have been reported and the management of such deficiencies following bariatric surgeries that reduce the size of the stomach, i.e. vertical banded gastroplasty and adjustable gastric band. Next month’s column will examine nutritional consequences of surgeries that not only reduce the size of the stomach but also induce malabsorption via bypass of a portion of the gut, i.e. gastric bypass and biliopancreatic diversion with and without the duodenal switch. 

 

Nutrient management of the Bariatric patient actually needs to begin prior to surgery. Why? The morbidly obese have numerous metabolic aberrations and hormonal defects that may negatively influence nutrient status.  In addition, many morbidly obese patients have eating abnormalities, such a high carbohydrate craving, binge eating, and bulimia, that may cause nutrient deficits.

 

A number of studies found that obesity, among  adults as well as children, is associated with low intake, as well as low blood and tissue levels, of anti-oxidants, including vitamin E, beta-carotene, vitamin C, zinc, selenium, copper, manganese, molybdenum and others.  Several studies also reported low blood levels of B-complex vitamins, particularly folate, in morbidly obese surgical candidates. And, other investigators found that the morbidly obese, prior to obesity surgery, have low vitamin D. 

 

Since obesity surgery, secondary to calorie restriction or surgical technique, may cause nutritional deficits, it is of utmost importance that any pre-existing nutritional problem(s) be corrected prior to surgery. Such pre-existing deficiencies can usually be corrected by dietary supplements of vitamins and minerals at levels close to the RDI taken daily for a period of no less than 2 and preferably 6 weeks prior to surgery. 

 

The management of nutrient deficiencies following surgery depends upon the type of surgical procedure, whether it is purely gastric restrictive (reduces the size of the stomach only), such as gastric banding or gastroplasty (stomach stapling), or also contains a malabsorptive component (bypasses part of the gut) as does the gastric bypass, biliopancreatic diversion, or duodenal switch.

 

Gastric restrictive surgeries (gastric banding, gastroplasty) reduce the size of the stomach and the rate at which food leaves the stomach, all of which induce weight loss by reducing food consumption. Reports of calorie intake below 1000 per day are not unusual in the first few post-operative months following gastric restrictive surgeries. Such low energy intake may cause nutrient deficiencies, including vitamins and minerals deficits and protein malnutrition.

 

Nutrient deficiencies may also occur within the first few months following gastric restrictive surgery because most patients at this time are consuming soft foods and liquids instead of solids. Furthermore, during the early post-operative period, patients may frequently vomit until they have learned how to eat small food portions and chew their food well.

 

Frequent regurgitation can lead to serious nutrient deficiencies and eating abnormalities. Many patients, particularly those who have had a vertical banded gastroplasty with restrictive ring may become so fearful of vomiting that they drink their calories or eat processed or high-sugar containing foods rather than meat, fruits, and vegetables. Such behaviors may lead to long-term eating abnormalities and nutrient deficiencies.

 

Studies have reported that, within the early post-operative months following gastric restrictive surgeries, protein deficits occur, as do reduced intakes of a variety of vitamin and minerals, i.e. potassium, iron, zinc, phosphate, calcium, B-complex vitamins, and vitamins E, D, and A. 

 

Such deficiencies can be corrected by taking a daily oral supplement (chewable form in the early post-op period) with vitamin and mineral levels at, or close to, the RDI. Protein supplements or intake of foods high in protein (eggs, cheese, fish, other meats) may, in addition, help to prevent muscle or hair loss resulting from protein and nutrient deficiencies.

 

Some nutrient deficiencies may have serious health consequences, particularly in the early months following surgery. There have been multiple reports of neurological (nervous system) defects following gastric restrictive surgery, particularly for individuals who vomit frequently. Such neurological defects are attributable to vitamin B1 (thiamine) deficiency and often characterized by double vision, mental confusion or mild memory impairment, disorientation, severe weakness of the legs and other symptoms. Correction of such problems generally requires IV infusion of vitamin B1 and close follow-up medical supervision.

 

Studies have found that, 12 to 24 months following gastric restrictive procedures, nutrient intake improves in association with changes in the pouch, gastric emptying rates and the intake of solid foods. At this time, protein, vitamin and mineral deficiencies become far less common.

 

There are reports of long-term nutrient deficiencies, such as for calcium, following vertical banded gastroplasty in individuals not on dietary supplements. And, there are other reports of nutrient deficiencies in post-surgical patients whose diets are high in processed foods and sugar (crackers, bread, chips, cookies, cakes, etc.) and low in meat, fruits and vegetables.

 

The individual who has had gastric restrictive surgeries needs to alter their diets to include more protein and to reduce considerably their intake of carbohydrates high in sugar and processed grains. Such dietary changes will not only improve nutritional status but promote greater weight loss success, as well. In addition to changes in diet, it is recommended that the gastric restrictive bariatric surgical patient continue their daily intake of vitamin and mineral supplements long-term.

 

In summary, gastric restrictive surgeries can lead to nutrient deficiencies, i.e. vitamins, minerals, and protein malnutrition. Such deficiencies, if left unattended, can result in significant muscle loss, anemia, hair loss, extreme fatigue and even neurological disorders. The greatest risk for nutrient deficiencies occurs in the first few months following surgery and generally becomes less prevalent as solids are reintroduced into the diet.

 

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Nutrient Deficiencies and Health Consequences

 

Part II: Gastric Bypass and Duodenal Switch

 

Cynthia Buffington, Ph.D.

 

Beyond Change, August 2002

 

Nutrient deficiencies following bariatric surgical procedures can lead to serious health consequences if left unattended. In last month’s issue of Beyond Change, pre-operative nutritional deficiencies and those following gastric restrictive surgeries (gastric band, gastroplasty procedures) were discussed, along with suggestions for nutrient management. This month, nutrient deficiencies following surgeries that contain a malabsorptive component, such as the gastric bypass and duodenal switch, are addressed.

 

Gastric bypass combines both gastric restriction and malabsorption to induce massive and sustained weight loss. With the gastric bypass, the amount of food one can consume is reduced considerably by formation of a small gastric pouch (small stomach) that holds only 2-3 tablespoons of food. In addition, a ring with a small diameter is often placed at the junction between the stomach pouch and intestine to slow the rate that food leaves the pouch, causing one to feel ‘full’ for a longer period of time.

 

With the gastric bypass procedure, the part of the stomach that produces acid and digestive enzymes is bypassed (food no longer passes through), and the newly formed small gastric pouch produces negligible amounts of acid and digestive enzymes. Without stomach acid and digestive enzymes, certain foods are not adequately broken down to release their nutrient content.

 

The small stomach pouch also produces no intrinsic factor, an agent that must bind to vitamin B12 for its absorption from the gut into the body. The gastric bypass procedure, therefore, causes deficiencies in vitamin B12, the vitamin that assists in the metabolism of food (carbohydrate, fat, and protein), DNA replication and repair, nerve conductance and function, the formation of blood cells, and more.

 

The malabsorptive component of the surgery includes bypass of the upper portion of the intestines (the duodenum) along with a portion of the jejunum (the second major segment of the gut). Bypass of the duodenum causes malabsorption of, and therefore deficiencies in, iron, calcium, zinc, and folate. Other B-complex vitamins are also reduced with gastric bypass, both as a result of decreased absorption and to reduced nutrient intake and digestion. Furthermore, the gastric bypass procedure reduces fat absorption which may, consequently, cause deficiencies of fat-soluble vitamins, including vitamins D, E, K, and A.

 

Studies have shown that daily multivitamin and mineral supplements, at amounts close to the RDI (Recommended Daily Intake), correct most micronutrient deficiencies following gastric bypass surgery, with the exception of zinc, calcium, iron, folate, and vitamin B12. These vitamins and minerals generally require supplementation at amounts greater than the RDI.

 

Several studies have found that, even with supplementation, iron deficiencies occur in 30% to 60% of the gastric bypass population.  Iron deficiencies occur for males, as well as females, but are more common among pre-menopausal females.  Within the first two years following surgery, 30-40% of gastric bypass patients have been reported to suffer from anemia secondary to poor iron absorption.

 

Iron deficiencies may be prevented with iron taken at amounts given to women during pregnancy, ~40 mg. Iron as ferrous fumerate or chelated to amino acids are the most readily absorbable forms of supplemental iron. And, heme iron, obtained from eating meat, is far more readily absorbed by the gut than is non-heme iron from plants or supplemental sources.

 

Approximately 20% of the gastric bypass population is likely to develop folate deficiencies. Such deficiencies can be corrected or prevented by intake of supplemental folate at 800 to 1000 micro-grams (µg) per day or approximately 200% the RDI. 

 

Vitamin B12 deficiencies occur in up to 70% of patients, with as many as 30% of patients having such deficiency while on supplements that meet the B12 RDI.  As mentioned earlier, the small gastric pouch does not produce intrinsic factor necessary to bind B12 for its absorption out of the gut and into the body.

 

Studies have found that B12 deficiencies, for the majority of gastric bypass patients, can be prevented or effectively treated with B12 supplements in amounts that are high enough to cause passive diffusion of B12 across the gut in the absence of intrinsic factor. B12 supplemented at amounts far in excess of the RDI (as high as 100 to 350 micrograms) have been found to prevent B12 deficiencies in >95% of post-surgical gastric bypass patients.

 

Sublingual B12 (under the tongue) taken daily may also be effective in the prevention of B12 deficiencies since the vitamin is absorbed into the blood stream and does not need to bind to intrinsic factor for absorption. B12 shots taken daily or monthly are also effective in bypassing impaired B12 absorption and in preventing and treating B12 deficits.

 

Defects in folate and B12 may cause anemia (pernicious anemia), as well as elevated production of homocysteine and concomitant increased risk of cardiovascular disease. Symptoms of folate deficiency include: weakness, headache, palpitations, forgetfulness, hostility, irritability, paranoid behavior, apathy, sore tongue, gastrointestinal tract disturbances and diarrhea. 

 

B12 deficiencies may also cause gastrointestinal disorders, such as diarrhea, cramping, constipation, as well as palpitations, shortness of breath, and extreme fatigue. Neurological deficits secondary to B12 deficiencies include impaired bladder control, numbness, tingling of the extremities, moodiness, agitation, disorientation, insomnia, confusion, dimmed vision and even delusions and hallucinations.  Some of these neurological deficits caused by B12 deficiencies may be irreversible.

 

Calcium deficiencies occur following gastric bypass for several reasons.  First, the portion of the gut where calcium is actively absorbed (the duodenum) is bypassed by the surgical procedure. Secondly, there is insufficient acid produced by the small stomach pouch to provide enough acid in the gut for appropriate calcium absorption. Third, changes made in the mixing of food with pancreatic juices may alter vitamin D absorption. And, finally, some patients become lactose intolerant after surgery and avoid dairy products.

 

Low calcium is known to cause bone loss. Recent studies have also found that low calcium intake is associated with weight gain. Calcium supplements may, therefore, not only prevent bone loss but also assist in promoting weight loss and preventing weight regain following bariatric surgery.

 

Calcium supplements of 1200 mg to 2000 mg taken in 400-500 mg aliquots 3 times per day are recommended for individuals who have had gastric bypass surgery. Calcium citrate, rather than calcium carbonate, is more readily absorbed in the non-acidic environment of the gut of the gastric bypass patient. Absorption is further enhanced by calcium supplements that include vitamin D or magnesium.

 

The high risk for B12, folate, iron deficiencies following gastric bypass requires that the individual have periodic tests (annually) for blood levels of ferritin (iron), folate and B12.  Blood tests for measurement of blood calcium are unreliable. When blood calcium is low, the body ‘borrows’ calcium from bone and teeth so that levels may appear ‘normal’. Thus, it is wise for the gastric bypass patient to occasionally have a bone scan, a bone demineralization test, or some other test that can be used as a marker for low calcium.

 

Protein deficiencies are common with gastric bypass and occur secondary to: 1) low calorie intake, 2) avoidance of meat, 3) negligible acid and digestive enzymes produced by the stomach, and 4) reduced absorption of protein by the bypassed gut.  Low protein intake after surgery can cause muscle loss which, in turn, leads to a reduction in basal metabolic rate (reduced amount of calories burned at rest), interfering with maximal weight loss success. The heart is also a muscle and can lose tissue with severe protein deficiencies. For these reasons, protein supplements and high intake of protein is encouraged for all gastric bypass patients - and for life.

 

More and more patients in the United States are choosing the biliopancreatic diversion with the duodenal switch for weight loss surgery. The individual who has had the duodenal switch can eat normally because the portion of the stomach that produces digestive enzymes and acids is reduced but not bypassed. Weight loss with this procedure is caused primarily by malabsorption through bypass of a larger portion of the gut.

 

Possible nutrient problems following the duodenal switch which may occur without nutrient supplementation include the following: protein deficiencies, low levels of fat-soluble vitamins (A, E, D, K), low amounts of B-complex vitamins, low minerals and, in particular, calcium, iron, and folate deficiencies. Such deficiencies can lead to muscle and bone loss, anemia, neurological defects, high oxidative stress and associated risk for disease, and more. To avoid such nutrient deficits with the duodenal switch, high protein diets or protein supplements and daily vitamins and minerals are required for life.

 

In summary, nutrient deficiencies following the gastric bypass and duodenal switch are common and can lead to serious health consequences if left unattended. Increased intake of protein or protein supplementation is necessary long-term following these procedures. Vitamin and mineral supplements at RDI levels for most micronutrients, or greater than RDI for specific ones (calcium, iron, folate, zinc, B12), are required for life. Because nutrient deficiencies have very serious and often irreversible health consequences, periodic vitamin and mineral blood tests are necessary on a periodic basis, i.e. usually annually.

 

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Do you have lab results?? mvi may be ok but too much vit a for instance can be as bad as too little..2 calcium what dose what form? calcium citrate is rnyers choice for absorbtion normies need 1,000mg day we my need double that calcium can only be absrbed 500-6oomg elemental  tim so taking that 2-3-4x day is needed not with iron or caffeine/tea...heres ore info.. have u had a dexascan to see bone densityz// Vitamins supplements go on labs You will probably hear MANY different responses because each bariatric program has different guidelines, as well vit/minerals postop are individual based on a persons response to surgery and their pre-existing needs as well. This is why follow-up and labs are crucial... Most need at least a Centrum type complete multivitamin, Calcium in the form of citrate for Rnyers to best absorb amount depends on labs/dexascan/comorbid conditions, and Sublingual B12. With that said some need more supplements like; VIT A, D, E, K, ZINC, SELENIUM, COPPER, IRON *USUALLY FEROUS GLUCONATE OR FERROUS FUMARATE OR POLYSACCHARIDE IRON, IRON CHELTE OR CARBONYL IRON, KEEP FROM FERROUS SULFATE IT CAN BE MOST HARSH ON POUCH AND NOT AS READILY ABSORBED. (oops sorry cap loc****xtra magnesium, thiamin (B1), B6, folate, potassium etc. Preop have your levels been drawn? They are finding many Morbidly obese deficient preop now interestingly in things like Vit D especially. IMHO FWIW there is no need to buy expensive vitamins UNLESS You find you do not absorb others, there is no 'bariatric vitamin' there can not be because we all respond differently to a bypass, yes we know certain typical deficiencies happen but our labs all differ slightly to greatly, so no manufacturer can formulate one for all patients, so save the cash do your on research on what works best for your body and pocketbook! Beware of gimmicks or providers pushing a product for they MAY be getting financial incentives to do so also.... Starting a multivit isn't a bad idea now preop, be aware also too much supplements of certain things is as bad or worse than too little, things like iron vit A especially. Other things u can not OD on like B12 as it is water soluble and no no toxic effects of too much is known...risk is only wasting money! Here is what I take: Wal-Mart brand multivit Centrum like 300 tabs are less than $9 Upcal D 500mg Calcium citrate powder w/ vit D in 1 scoop 227 servings I just found it for $13.99 HERE http://www.colonialmedical.com/product.php?productid=20018&c at=0&page=1 I use 2 doses a day of this and 2 doses a day of Citrical (calcium citrate) one bottle 180 tabs (2 tabs dose=500mg) is about $9 ***Wal-Mart has a generic now as well, calcium is one of the more expensive supplements. UpcalD is far the most inexp calcium citrate I found! nice fine powder mixes in anything! I need 2,000mg calcium a day due to my labs (calcium/parathyroid/dexascan) even thought I am 34 and exercise daily and have no other issues I lost bone density on less, gained 3% last yr! Springvalley B12 complex sublingual 60 doses of B12 1,200mcg is $6 Wal-Mart I do one dose day bottle lasts 2 mo I became anemic after plastic surgery 2 yrs out wls, I need ferrous gluconate 300mg tab (is 35mg elemental iron) 100 tabs is $6 I get at Wal-Mart n pharmacy w/o script I take vit C 500mg w/it bottle 500 is cheap I can not recall like 45-6 or so..lasts a year! Yearly total would be $10 or so for multivit $36 for upcal d using 2 doses day I need 3 bottles year +/- $72 for citrical I need 4 tabs day or 8 bottles a yr of the 180 count at $9/bottle $36 for b12 I need 6 bottles a year $20 for iron I need just over 3 bottles $5 for vit c I need 1 bottle ~~~~~~~~~~~~~~~ $179/yr for MY NEEDS I absorb these vits per lab....May not be for everyone, would a more expensive vit work? perhaps but I cannot see why I'd go there. Luckily there are many choices and we can each make one for ourselves, this is regimen I have used so far at 5 yrs out, works for me, what works for others they can tell you about..... Be well. Hugs