How to Know When You Are Nutrient Deficient

How to Know When You Are Nutrient Deficient
by Katie Jay

Traveling around the country meeting weight loss surgery (WLS)
patients has been one of the best parts of my job. I enjoy a lot of email correspondence, but there is nothing like looking into the eyes of another survivor -- another person who has taken the plunge into the radically new way of life offered to us with WLS.

Most of the time, it is a purely silly exchange of stories about slips falling off in public and shopping misfires, like trying on clothes that look too small only to find they hang like drapes on a now-small frame. Every time I meet with a group of WLS patients, however, I encounter at least one person who looks almost desperate. I hear the signs of deficiencies, like:

"I feel obsessed with chewing. I can't stop eating ice."

"When does the energy come back? I am two years out and I still feel horrible."

"I feel so foggy and my memory is shot. My boss is getting fed up with me."

The anxious faces are heartbreaking, because I know that the most likely reason for these problems is nutritional deficiency.

Correct Knowledge Is Power

While most surgeons educate their patients about the nutritional aspect of their surgery, the information can be misunderstood, lacking, or outdated. And for laypeople there is often no way for them to assess the quality of the information they are receiving.

The potential for misunderstanding or misinformation is why it is critical for all WLS patients to take responsibility for and completely understand their nutritional, vitamin, and supplement needs.

It's All About the Lab Work

Ideally, a WLS patient will get every possible, relevant type of lab work done before surgery. Doing this allows you to have a baseline, partly so that you can correct any deficiencies before you even have surgery. After WLS the Lab Work Becomes Essential!

Don't assume that just because your lab numbers are in the normal range that you are okay. Be aware that for most people, shortages will not show up immediately. A downward trend in a lab value can be in the normal range so that
you don't even realize you're slipping.
You Have to Compare Results

Many times I have heard people say to me, "I don't need all that stuff [meaning supplements]. I feel good and my labs are fine." Your iron can drop 30 points and still be in the normal range. Your B12 can drop 100s of points and still be in the normal range. The trend in your lab work is where you need to focus.

Many people use an excel spreadsheet to track their lab work. It's simple to do, and will allow you to identify a negative trend before you become dangerously depleted and get permanent damage.

Some Common Deficiencies

Protein, iron, calcium, zinc, B1 (Thiamin), B12 and the vitamins A, D, and E, commonly show a downward trend in lab work. People are starting to report other deficiencies as well, so staying current on research about weight loss surgery is critical. It's far better to assume you have deficiencies and look for them before they become critical.

Deficiencies Will Vary According to Surgery Type

Those who have had the lapband procedure are less likely to have A and D deficiencies, for example, but should still be tested.

For those who have Roux-en-Y gastric bypass and bileo-pancreatic diversions with or without the duodenal switch, nutritional deficiencies can vary depending on how short the Y-shaped part of their intestine is.

If it's really short, there's a lot less absorption and you need more supplementation of almost all vitamins.

The bottom line is nutritional needs vary from surgery type to surgery type and from person to person. Never just assume you're okay, no matter what type of surgery you have had.

Vitamins and Supplements Require a Strategy

Go over your schedule of nutrients with your surgeon or dietitian to make sure you are optimizing what you take. For example, when you take iron with calcium, vitamins, minerals, medicines, dairy, caffeine, eggs, or whole grains, you can lower your iron absorption. Sometimes, the type of supplement will influence your absorption. Calcium is best taken in citrate form, otherwise you increase the
risk of kidney stones and other problems.

Sometimes how you take a supplement makes a difference. For example, B12 has to be sublingual (under the tongue), or by injection. And don't assume you don't need B12 if your procedure is merely restrictive.

Check with Your Surgeon or WLS Nutritionist, But Don't Blindly Surrender to Them

As always, please check with your surgeon or nutritionist before adding to or changing your vitamin and supplement regimen. And be sure to get your labs done, learn how to read them, and advocate for yourself.

Finally, general practitioners do the follow up care for many WLS patients, and that's okay, but they do not have training in this specialized area and often do not stay up on the latest literature. You must be educated and in turn educate your general practitioner, if necessary.

Always Advocate for Yourself

Never let a strong-willed doctor or surgeon, WLS specialist or not, pronounce that you are okay when you either feel poorly, or see a downward trend in your labs.

Note: NAWLS has a dietitian available to answer members' questions. Sally Myers, RD, CPT, has worked with WLS patients for more than a decade and is co-author of the book, "Caring for the Surgical Weight Loss Patient," which can be purchased from Amazon.

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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Follow-Up of Nutritional and Metabolic Problems After Bariatric Surgery
http://www.rednova.com/news/display/?id=126050

Over the next several years, the number of patients who will have had bariatric surgery for morbid obesity will reach close to a million. Several well-described nutritional problems such as B12 and iron deficiency will be noted in these patients. Many of these patients will be lost to the original surgeon and will now be in the care of the "other physicians." These and other mineral and vitamin problems will need to be screened and treated. If these problems are left undiagnosed, severe and irreparable problems can result. Early problems, such as vomiting and dumping syndrome, will be easily recognized and treated, but other long-term problems, such as changes m bone metabolism, will need to be monitored. Again, if some of these long-term problems are not addressed in a timely fashion, then eventual treatment becomes much more difficult. This commentary will cover the common as well newer problems that are now developing in the patient who has had bariatric surgery. Patients who have undergone bariatric surgery require medical follow-up for reasons that are often determined by the type of surgical procedure performed. The majority of this review will deal with patients who have had the standard Roux-en-Y gastric bypass, which is a primarily restrictive procedure with a mild component of noncaloric malabsorption. At the end of this report, a short section will be devoted to the problems associated with the malabsorptive procedures.
Diabetes Care 28:481-484, 2005
Follow-up of the morbidly obese patient who has had gastric bypass can conveniently be divided into two areas: the issues of surgical complications and weight loss during the first year, and the nutritional and metabolic issues that arise after the first year.
ISSUES DURING POSTOPERATIVE YEAR 1 - The vast majority of weight loss after gastric bypass is accomplished at or around 1 year after surgery (1,2). Twelve to 18 months after surgery, some patients continue to lose a small amount of weight while others begin to maintain their lower weight. At eighteen to 24 months after surgery, almost all patients have stopped losing weight and most patients are maintaining or regaining weight.
Vomiting and dumping syndrome
Vomiting almost always occurs during the first few months after surgery and is often described as "spitting up food that is stuck." It typically happens one to three times a week and is usually due to overeating or not chewing food adequately. Patients need to adjust to the much smaller gastric pouch that now receives food from the esophagus; bariatric surgery has diminished the stomach's ability to grind food into small particles. Vomiting is well tolerated by most patients. If vomiting becomes more frequent, low potassium and/or low magnesium levels often occur, requiring oral replacement. Liquid forms of potassium are available but are not well tolerated by patients due to palatability; fortunately, by postoperative month 1, pills are usually able to pass through the anastomotic or restricted portion of the stomach. To ensure that the potassium can traverse the 1-cm anastomoses, smaller pills or capsules are often prescribed.
Vomiting can signal other problems and is associated with strictures and stomal stenosis. Intolerance for solid foods is a key symptom; if this develops, then endoscopic evaluation should be strongly considered. If intolerance to solid food develops 6 months after surgery, then the diagnosis of stenosis is very high. In one study, abnormal findings at endoscopy showed stomal stenosis in 39% of patients with nausea, vomiting, or dysphagia referred for endoscopy (3). Such stenosis can usually be treated by balloon dilation at the time of diagnosis. Many of these patients will require repeat dilations, determined by their ability to tolerate most solid foods.
Dumping syndrome is an extremely common, and somewhat intentional, problem after gastric bypass. High-osmolarity foods (e.g., foods high in sugar content), after bypassing much of the stomach undigested, cause an osmotic overload upon entering the small intestine. This osmotic overload brings fluid into the lumen of the small intestine, resulting in a vagal reaction. Patients will often complain about lightheadedness and sweating after eating a high-glucose meal or drinking fluid with a meal. This is a very uncomfortable feeling and is accompanied by impressive fatigue. Diarrhea may or may not occur, as there is usually sufficient distal bowel to absorb such food, and nutritional problems are rare. Foods that are identified in our clinic as causing dumping syndrome include ice cream and pastries.

Dehydration occurs frequently and is due to multiple factors. The very small surgically created gastric pouch makes it extremely difficult for patients to hold much fluid. Because dumping syndrome occurs if fluids are mixed with food, patients also must drink fluids separately from meals. (Fluid with a meal can solubilize food and increase osmolarity.) As a result, patients must constantly sip fluid throughout the day to meet their fluid requirements. Brief hospitalizations or urgent care visits for dehydration are very common during the first 6 months after surgery. Water consumption is the best method to prevent dehydration. If rehydration is needed, salty broths or liquids containing salt work well. Many patients can tolerate sports fluid replacement drinks, either diluted 50% or occasionally full strength. Many gastric pouches after gastric bypass are #8804;50 ml in size, and patients must learn to constantly sip fluid and not drink large gulps.
While protein malnutrition was very common with the truly malabsorptive surgical procedures of the past, it is rare after gastric bypass or any of the current restrictive surgeries. If protein malnutrition develops after gastric bypass, one needs to look at the total food intake of the patient and determine whether the patient is meeting his/her caloric and protein needs (4). Protein supplements are very helpful, and with the current trend of Americans eating high-protein diets, numerous high-protein low- carbohydrate supplements are readily available. Hair loss, or telogen effluvium, is seen frequently 3-6 months after surgery. Patients note diffuse shedding of normal hair. Lasting as long as 6-12 months, it can be terribly distressing to the patient. The stress of weight loss disrupts the normal growth cycle of individual hairs, resulting in large numbers of growing hair simultaneously entering the dying (telogen) phase. Although there is no known treatment, it usually reverses without intervention (5).
Gallstone formation is very common during weight loss (6), and surgery-induced weight loss is no exception. In one study of bariatric surgery patients, 71% developed gallstones, despite the fact that two-thirds of the patients received preventative treatment (7). Of those patients who formed gallstones, 41% were symptomatic. Bariatric surgery patients presenting with right upper quadrant abdominal pain should thus be appropriately evaluated. At our own institution, all symptomatic patients undergo an ultrasound of the gallbladder before surgery. If patients have gallstones, these are removed either before or at the time of surgery. After surgery, all patients with an intact gallbladder will be placed on a gallstone- solubilizing agent for at least 6 months after surgery.
ISSUES AFTER POSTOPERATIVE YEAR 1
B12 deficiency
As weight loss begins to slow down, the risk of other nutritional problems increases. B12 and iron deficiency are two of the most common problems and often do not respond to typical multivitamin supplementation (8-10). Such nutrient issues are primarily seen with gastric bypass and any of the malabsorption procedures. Because food now bypasses the lower stomach, B12 deficiency is frequently observed. If B12 is not supplemented above and beyond a multivitamin, 30% of patients will be unable to maintain normal levels of plasma B12 at 1 year (9). After 1 year, the prevalence of B12 deficiency appears to increase yearly and has been reported to be between 36 and 70% in the long term (11,12).
Over the counter oral and sublingual forms of vitamin B12 are available for use (13,14). Optimal close and efficacy have not been well studied, but doses of 25,000 units sublingual B12 twice a week are usually sufficient to maintain normal plasma levels of B12. Some (up to 10%) patients will not respond to high-dose sublingual or oral B12 and will require monthly intramuscular B12 injections.
Iron deficiency
Iron deficiency after gastric bypass is usually only seen in menstruating women. Ferritin or iron levels and erythrocyte counts need to be monitored, as iron deficiency can develop early after surgery or years later; one study found that iron stores continuously declined up to 7 years after bypass surgery (15). Due to bypass of the lower stomach, it is very difficult for iron- deficient patients to absorb sufficient oral iron. Intramuscular iron can be impractical over the long run. At our institution, intravenous iron dextran or iron sucrose is used regularly; many patients require intravenous iron several times a year. This is done as an outpatient procedure and is well tolerated by patients.

Ulcers, NSAIDs, and abdominal pain
Patients with persistent iron loss should be e\valuated for blood loss through the gastrointestinal tract. Ulcers at the margin of the anastomoses between the stomach pouch and the small intestine are a common cause of blood loss. All NSAIDs (nonsteroidal anti- inflammatory drugs), including aspirin, and COX-2 (cyclooxygenase- 2) inhibitors, have the potential to cause ulcers; use of these drugs is to be avoided at all costs in gastric bypass patients. A study of gastric bypass patients referred for endoscopy found that marginal ulcers were present in 27% of patients (3). In our clinic, gastric bypass patients with abdominal pain are considered to have an ulcer until proven otherwise. Not all marginal ulcers will bleed significantly but most will have pain.
LONG-TERM METABOLIC ISSUES AFTER GASTRIC BYPASS- Several articles are starting to surface regarding problems with bone mineralization in gastric bypass patients (16-18). With increasing numbers of patients undergoing bariatric surgery (an estimated 100,000 procedures annually), long-term follow-up of this growing and aging population will need to monitor bone health and metabolism. While it is recommended that bone density be measured after bariatric surgery, there are no specific guidelines for treatment and follow- up. In our clinic, we are currently following vitamin D, calcium, and parathyroid hormone levels, as well as bone densitometry.
Secondary hyperparathyroidism
One form of bone demineralization, secondary hyperparathyroidism, has been reported by several groups to occur in patients who have had gastric bypass (19-21). While the prevalence is unclear, it appears to be more common than previously thought. At our institution, we studied 65 consecutive patients seen for follow-up after gastric bypass. Time since surgery varied from 1 to 9 years; parathyroid hormone, calcium, and vitamin D levels were measured. Twenty-nine percent of patients were found to have elevated parathyroid hormone levels. Although the study group was small, patients at >4 years' postsurgery had a much higher rate of secondary hyperparathyroidism. Average 25(OH)D level in patients with secondary hyperparathyroidism was 21 ng/ml, whereas patients with normal parathyroid hormone levels had an average 25(OH)D level of 30 ng/ ml (normal 20-57 ng/ml). The majority of the patients with secondary hyperparathyroidism has responded to pharmacologic replacement of vitamin D, with normalization of parathyroid hormone levels. It should be noted that vitamin D and calcium supplementation at the usual recommended daily requirements did not normalize parathyroid hormone levels in at least one study (20).
Malabsorptive bariatric surgery
Currently, Roen-en-Y gastric bypass, which is a restrictive procedure with minimal to no malabsorption, comprises the vast majority of bariatric surgeries. Several decades ago, a bariatric procedure known as the biliopancreatic diversion or Scopinaro procedure was popular. It is still occasionally performed in morbidly obese patients and is intended to cause fat malabsorption to produce massive amounts of weight loss. The procedure involves a gastric restriction and diverts bile and pancreatic juice into the distal ileum (22). This leaves a very short segment of small bowel to absorb all the nutrients that require biliary and pancreatic juices. Variations of this procedure (biliopancreatic diversion with duodenal switch) causing malabsorption are still performed. In addition to the above-mentioned nutritional issues, patients who have this procedure often have other more severe problems related to protein and fat malabsorption.

Protein deficiency is easy to recognize by following albumin. Fat malabsorption manifests its presence by loss of fat-soluble vitamins. Patients can present with a number of problems after this procedure. In our clinic, the most common presenting complaint is fractured bones or a bone density study showing "severe bone loss." Due to fat malabsorption, severe vitamin D deficiency will develop along with an already reduced ability to absorb calcium (23). In general, fat-soluble vitamins A, D, and K will be deficient in two-thirds of these patients within 4 years after surgery. Up to 50% will have hypocalcemia, and all of these patients with low vitamin D levels will have secondary hyperparathyroidism (24,25). Manifestations of all the different fat-soluble vitamins can be seen, ranging from unusual rashes, to osteomalacia, to easy bruising. Fortunately, there is a rather simple solution: pancreatic enzyme replacement. When pancreatic enzymes are replaced, there is some weight regain, and physicians often observe patient noncompliance as a result. The hyperparathyroidism may be difficult to treat and may require separate treatment or even surgery.
Other problems associated with this type of procedure include severe hair loss, liver disease (usually transient), kidney disease, and unusual body odors (26). The lifestyle after this procedure can be difficult due to the frequent bowel movements (over 10 times a day) and the foul-smelling stool that the fat malabsorption causes.
SUMMARY - Despite billions of dollars spent on weight loss treatment, the number of morbidly obese patients continues to increase. The only treatment option shown to have any type of success in this population is bariatric surgery. Over 100,000 bariatric surgeries are performed annually, with gastric bypass being the most common surgery. Compliance with long-term follow-up is vital, as nutritional and metabolic problems can be easily treated or avoided. With increasing numbers of patients undergoing bariatric surgery, physicians other than the initial surgeon will need to become involved in the follow-up of such patients (27).
References
1. Fujioka K, Toussi RH, Brunson ME, Mendes RA: Health care utilization before and alter bariatric surgery, the managed care experience. Obes Res 9 (Suppl. 3):93S, 2001
2. Kral JG: Surgical treatment of obesity. Med Clin North Am 73:251-264, 1989
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KEN FUJIOKA, MD
From the Department of Endocrinology, Scripps Clinic, San Diego, California.
Address correspondence and reprint requests to Ken Fujioka, MD, Director of Nutrition and Metabolic Research, Scripps Clinic, Suite 317, 12395 El Camino Real, San Diego, CA 92130. E-mail: fujioka.ken@ scrippshealth.org.
Received for publication 12 October 2004 and accepted in revised form 19 October 2004.
2005 by the American Diabetes Association.
Copyright American Diabetes Association Feb 2005
Published: 2005/02/09 03:00:26 CST
© Rednova 2004