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الرئيسية   |   مجموعة فيديو للدكتور محمد نضال عبيدو   |   06 October 2012 م
Preventive Nutrition After Bariatric Surgery
Preventive Nutrition After Bariatric Surgery

Jacqueline Jacques, ND
Chief Science Officer: Bariatric Advantage
Long-term nutritional care for bariatric surgery patients should start with prevention. The cornerstones of prevention are: dietary modification, nutritional supplementation, routine testing and patient adherence.
Our knowledge about the appropriate levels of nutrients from diet and from supplements required to prevent deficiency and maintain nutritional well-being in bariatric surgery patients is very limited. At this time of this writing, there is a set of guidelines authored by Aillis, et al (1), available from the American Society of Metabolic and Bariatric Surgery (ASMBS) as well as guidelines contained in a joint paper from the American Association of Clinical Endocrinologists, the Obesity Society, and the ASMBS authored by Mechanick, et al (2). While both papers attempt thorough coverage of the territory, it would be fair to say the authors are hampered by the available data and, ultimately, the majority of the evidence used to create our current guidance is still relative low level, with much reliance on expert agreement. It is advisable for clinicians who are caring for weight loss surgery patients to be familiar with both of these documents, which are available as free downloads on the ASMBS.com website. Both sets of guidelines offer baseline recommendations for Adjustable Gastric Band (LAGB), Roux-en-Y Gastric Bypass (RYGB) and Bilo-pancreatic Diversion the duodenal switch variant (BPD/DS). Neither currently offers recommendations for the Vertical Sleeve Gastrectomy (VSG), though it is likely that some guidance for this procedure is forthcoming.
To date, almost no existing studies ask the question of what levels of any given nutrient would prevent deficiency in most patients with a given bariatric procedure most of the time. The existing data do tell us that relying on dietary intake alone does not appear to be adequate for any procedure. Colossi, et al (3), conducted a 2-year study of 210 RYGB patients to compare their actual dietary intakes of nutrients to basic requirements or Dietary Reference Intakes (DRIs). They found that no patients were able to achieve minimal daily requirements for vitamin A, Vitamin C, Calcium, Iron, B1, B3, B6, Folate, Biotin or Pantothenic Acid. While patients were able to achieve minimal intakes of B12 and riboflavin (B2), B12 deficiency was still common indicating inadequacy of dietary intake. Ledoux, et al (4) compared the nutritional consequences of medical weight loss, LAGB and RYGB. As only the RYGB group was supplemented, the LAGB group can help to teach us about deficiencies that may arise if this group is left unsupplemented. There were 51 LAGB patients included in this paper, from 6 to 60 months post-operative. While there was less deficiency in the LAGB patients than in the RYGB patients, deficiencies reported in the LAGB group included: B1, B12 Folate, vitamin A, vitamin E, and iron. Studies in which patients have been instructed to take a multivitamin after surgery have not shown consistent results for prevention of common nutritional problems. This is likely due to multiple factors including, but not limited to: variations of procedure, dietary nutrient content, and patient adherence, and the non-standard definition of a multivitamin. Table 1 summarizes the basic recommendations for preventive supplementation.
Table 1: Brief Summary of Preventive Nutrition (Adapted from references 1,2)
* As there are no current guidelines for VSG it is being included with RNY
Nutrient/Product
AGB
RNY/VSG*
BPD-DS
Notes
Multivitamin
Multivitamin with minerals 1-2 times daily
Multivitamin with minerals and at least 400mcg folate 2x/day
Multivitamin with minerals and at least 400mcg folate 2x/day
The guideline documents define a multivitamin differently
Calcium
1200-2000mg calcium per day with vitamin D
,200 to 2000 mg/d calcium citrate with 400-800 IU Vitamin D
,200 to 2000 mg/d calcium citrate with 400-800 IU Vitamin D
Guidelines differ slightly
Iron
Mechanick et al recommend only in menstruating women
Minimum 18 to 27 mg/day.40 to 65mg for menstruating women
Minimum 18 to 27 mg/day.40 to 65mg for menstruating women
ASMBS does not recommend over and above the level in diet/multi
B12
Mechanick, et al suggest a dose of at least 350mcg PO/day or 500mcg/week intranasal, or 1000mcg/month IM, or 3000mcg/3months IM
Guidelines suggest a dose of at least 350mcg PO/day or 500mcg/week intranasal, or 1000mcg/month IM, or 3000mcg/3months IM
Guidelines suggest a dose of at least 350mcg PO/day or 500mcg/week intranasal, or 1000mcg/month IM, or 3000mcg/3months IM
ASMBS does not recommend B12 over and above the level in a multi with AGB
Protein
ASMBS: 50-80g/dayAACE/TOS/ASMBS: 60-120g/day
ASMBS: 50-80g/dayAACE/TOS/ASMBS: 60-120g/day
ASMBS: At least 90g/dayAACE/TOS/ASMBS: 60-120g/day
 
Other
 
 
For BPD-DS, additional amounts of the fat-soluble vitamins A,D, E and K are recommended. Zinc is also a common deficiency and these patients may require more than the level in a multivitamin.
 
Regular scheduled laboratory assessments are important for the identification of nutritional issues that may arise. While nutritional deficiencies can present symptomatically, many have no early symptoms or symptoms such as fatigue or general malaise that are too vague to be tied to any specific nutrient and are easily dismissed by both patient and clinician. The AACE/TOS/ASMBS Bariatric Surgery Guidelines (2) give recommendations for the intervals and the specific tests to be run by procedure. These guidelines are based on the most commonly reported deficiencies, which at this time are clearly the most important. That said, as we have reports in literature of a wide array of “less common” nutritional problems, clinicians should always consider additional testing if a symptomatic patient has normal values for the usual suspects. For example, a patient with a glove and stocking neuropathy who has normal B12 and folate should be tested for thiamine and copper deficiency. Table 2 outlines some of the current guidelines for screening labs.
Table 2: Recommendations for Screening Labs and Frequency (Adapted from references 1,2)
* As there are no current guidelines for VSG it is being included with RNY
Nutrient
Test(s)
AGB
RNY/VSG*
BPD-DS
Notes
 
 
 
 
 
 
B1 (thiamine)
Serum or whole blood thiamine
PRN
Optional/PRN
Optional/PRN
Transketolase activity test can be useful if available, especially to track recovery.  Many programs screen at least once in the first 6 months for all procedures. Some check preop
B6
PLP
Need unknown
With non-resolving anemia
With non-resolving anemia
May also be a useful screen for vitamin adherence
B12
Serum B12
Every 6 months in the first year then annually
Ever 3-6 months x 2 years then annually
Every 3-6 months for life
Other tests can include MMA and homocysteine
Folate
Serum or RBC folate
Optional
Optional
Every 3-6 months for life
Homocysteine can also be helpful. Important to consider in pregnancy. May be elevated in SIBO.
Iron
Iron studies, Ferritin
Every 6 months in the first year then annually
Ever 3-6 months x 2 years then annually
Every 3-6 months for life
Remember that ferritin can be elevated with inflammation for any source or from pregnancy. 
Zinc
Plasma zinc
Need unknown
PRN
Annually or PRN
Can be a cause of PICA/hair loss, low testosterone. Plasma zinc may be unreliable with inflammation.
Copper
Serum copper
PRN
PRN
PRN
With symptoms of B12 myeolneuropathy and normal B12/folate studies. With unresolved anemia especially with neutropenia.
Selenium
Glutathione peroxidase activity
Need unknown
PRN
Annually or PRN
Meaning of deficiency in this population is somewhat controversial.  Consider with unresolving anemias
Calcium
24-hr Urine or adjusted serum calcium
See notes
Ever 3-6 months x 2 years then annually
Every 6-12 months
Consider bone Alk Phos, N-telopeptide, DXA. N-telopeptide may be a very valuable test with AGB for assessing bone loss
Bone
iPTH
PRN – see notes
Ever 3-6 months x 2 years then annually
Every 3-6 months for life
Metabolic bone disease is an issue with all procedures. The AACE/TOS/ASMBS guidelines offer additional guidance on prevention and treatment that clinicians should be familiar with.
Vitamin D
25(OH)D
Every 6 months in the first year then annually
Ever 3-6 months x 2 years then annually
Every 6-12 months for life
Many programs now test pre-operatively.   AACE/TOS/ASMBS Suggests it is best to maintain levels at least 30-60 ng/mL
Vitamin A
Plasma retinol
Need unknown
PRN
Every 6-12 months for life
Consider with non-correcting microcytic anemia, eye symptoms
Vitamin E
Plasma tocopherol
Need Unknown
PRN
Every 6-12 months for life
Very little data on deficiency in any procedures
Vitamin K
K1 and INR
Need unknown
PRN
Every 6-12 months for life
 
Protein
Albumen and Prealbumen
PRN
PRN
Every 3-6 months for life
 
Carnitine and EFAs
By chromatography method
Need unknown
Need unknown
PRN
Little supportive data on utility of this testing
Adherence to dietary and supplemental recommendations may well be the great Achilles’ heel when we consider obstacles to maintaining nutritional health in bariatric surgery patients. Studies of longer than one year frequently show high attrition rates and poor compliance with dietary supplements. It hardly needs to be said that in the absence of routine follow up and general patient adoption of preventive nutrition, there will be an unfortunate number of problems that might otherwise have been avoidable. In their 2006 study, Ledoux and colleagues (4) rightly concluded:
Efforts should be made to sensitize patients to the importance of taking their prescribed vitamin substitution, but also to sensitize medical staffs to the need for adequate lifelong surveillance to prevent nutritional deficiencies in patients who have undergone bariatric surgery.
While we have a good distance to go before we have more solid evidence-based recommendations for preventive nutrition after bariatric surgery, the current guidelines offer a solid basis to grow from. By incorporating a program of both preventive diet and supplementation together with regular follow-up and testing, clinicians should be able to help patients best avoid potentially harmful nutritional consequences of surgery.
References:
  1. Aillis L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surgery for Obesity and Related Diseases. 2008 May: 4(5): S73-S108.
  2. Mechanick J, Kushner R, Sugarman H, Gonzalez-Campoy M, Collazo-Clavell M, Guven S, Spitz A, Apovian C, Livingston E, Brolin R, Sarwer D, Anderson W, Dixon J. AACE/TOS/ASMBS Bariatric Surgery Guidelines, Endocr Pract. 2008;14 (Suppl 1).
  3. Colossi FG, et al. Need for Multivitamin Use in the Post-Operative Period of Gastric Bypass. Obes Surg. 2008 Feb;18(2):187-91.
  4. Ledoux S, Msika S, Moussa F, Larger E, Boudou P, Salomon L, Roy C, Clerici C. Comparison of nutritional consequences of conventional therapy of obesity, adjustable gastric banding, and gastric bypass. Obes Surg. 2006 Aug;16(8):1041-9.

الكاتب : Jacqueline Jacques, ND Chief Science Officer: Bariatric Advantage

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Preventive Nutrition After Bariatric Surgery