Monday, February 22, 2010

Am I at risk for developing vitamin and mineral deficiencies if I have Bariatric surgery?

An adjustable gastric band or a gastric sleeve operation are NOT likely to cause any vitamin or mineral deficiencies since the small intestine has not been reoriented in any way. It is still a good idea to take a multivitamin and calcium each day especially for women but it is not absolutely necessary if you chose to have either of these operations.
Also, it is very unlikely that a person that has a Roux en-Y gastric bypass will develop deficiencies IF they take a multivitamin each day and have yearly checkups with laboratory evaluation to check their vitamin and mineral levels. However it is very important that a gastric bypass patient is willing to take their vitamins and calcium every day.
The reason this is so important is that a Roux en-Y gastric bypass excludes the first part of the small intestine from the flow of nutrients and therefore the B vitamins need to be supplemented and levels checked periodically since htis is where the B vitamins are best absorbed. Otherwise vitamin B1 deficiency can cause numbness or memory loss and vitamin B12 and vitamin B6 could lead to anemia.
Also it is important that a calcium supplement be taken each day. This should be taken as calcium citrate (800mg / day) since calcium citrate is nearly 100% absorbed. Unfortunately calcium carbonate, the usual form of calcium supplement, is not absorbed well since a gastric bypass patient does not produce very much acid in the gastric pouch which is necessary to help make the calcium available to be absorbed. Of course, calcium is not absorbed well in the absence of adequate vitamin D. Although a gastric bypass is not likely to interfere with vitamin D absorption, persons of size often have vitamin D deficiency and they need vitamin D supplementation regardless if they have had surgery or not. This may be from not being out in the sun much or there may be other reasons we are not yet aware of. We check all of our patients for vitamin D deficiency when they first are seen even before their operation. If they have a low vitamin D level we will start them on Ergocalciferol, (the active form of vitamin D), at 50,000 units monthly or weekly depending on the severity of the deficiency. I believe a bone density study should be done every 2 years for postmenopausal women and women who have had a total hysterectomy and have had a gastric bypass operation. Osteoporosis can be avoided if a gastric bypass patient follows these directions.
Iron deficiency is unlikely except in menstruating women. If a woman has heavy periods it may be difficult for them to keep up with their iron needs. If they begin to be anemic we will check their iron stores by checking a Ferritin level and if this is found to be low we will start them on an iron supplement. This supplement should be Ferrous Fumarate or Ferrous Glucanate since the usual for of iron supplementation, Ferrous Sulfate, will not be absorbed well since like calcium carbonate it needs acid to make the iron available for absorption and since the new small gastric pouch makes very little acid, Ferrous Sulfate is likely to pass out in the stool without being absorbed. You any need to remind your family doctor about this since they are so used to writing for Ferrous Sulfate and may forget you need a different form of Iron. Occasionally iron supplementation is not enough so a patient may be referred to their gynecologist for further evaluation and hormone treatment or surgery such as an endometrial ablation or hysterectomy. Of course, a full work up for anemia may be in order in certain circumstances. Remember the years of obesity may place a patient at increased risk for colon polyps or colon cancer. Therefore, a colonoscopy may be in order. My patients are always pleased when I recommend that study!
Early in my bariatric surgery practice I checked for vitamin and obtained a blood count at 3 and 6 months after surgery. However, it seems that it take about a year to see any of these changes except in unusual circumstances. Therefore I usually wait for 1 year before I check these lab tests unless there is a good reason the check before.
I also check a vitamin A level yearly although like vitamin D a gastric bypass is unlikely to be the cause of vitamin A deficiency.
I should make a comment regarding another bariatric operation that has a much greater risk of vitamin and mineral deficiencies. that is the "duodenal switch" or bileopancreatic bypass. This operation leaves the patient with only about 2 feet of small intestine to be used to absorb nutrients. This often causes much more difficulty with maintaining appropriate vitamin levels including vitamins A, D, B1, B6, B12 and sometimes K. Although this operation is performed well and safely by several of my bariatric surgery colleagues, I personally feel this is a more radical operation than necessary for most patients and I have chosen not to perform these operations. If this is of interest to you I would suggest doing a Google search for "Duodenal Switch" and finding an experience bariatrics surgeon to do this operation for you. By the way, the surgeon that is moat associated with this operation is Dr. Douglas Hess from Bowling Green, Ohio. Dr. Hess trained at the Riverside Methodist Hospital where I am now the Director of Bariatric Surgery. Dr. Hess is now retired but he is a wonderful man and has helped many persons of size resolve their obesityand their obesity related medical problems.
The "take home" message is this: if you chose to have a gastric bypass operation, take a multivitamin and calcium citrate 800 mg each day and see your bariatric surgeon or a primary care provider that is comfortable following you for these matters YEARLY and you are very unlikely to have a significant vitamin or mineral deficiency. I hope this is helpful.
Please feel free to make a comment or ask a question about this or any other issue by clicking on the yellow word "comments" at the end of this posting.


4 comments:

  1. Hello,

    I have to do an IV vitamin Nutrient treatment every 4-5 months since I don't absorb vitamins...I have been a great challenge to my PCP since seeing him for 5 yrs...It's unfortunate that my Bariatric surgeon will not see me or return my calls because I can't possibly exist...Yes, I have all the other complications, but it's not because I dont' take my vitamins..It's just my body type...

    Berrigirl
    www.bariatriccommunity.com

    ReplyDelete
  2. With all due respect, I think you have a few things wrong here:

    1) The active form of vitamin D, D3, is cholecalciferol; ergocalciferol is the inactive form of D, D2.

    2) The RDA for calcium for normal, non-malabsorbing adults is 1000mg. Why would you recommend an amount less than that for someone who is malabsorbing a portion of that dose? Additionally, there is no way we will absorb 100% of that calcium citrate dose after surgery, despite it's higher bioavailability profile to calcium carbonate. This is why the ASMBS recommends 1500-2000mg of calcium citrate per day and 200% of the RDA of most everything (except the B's and iron).

    3) As an RNY patient that is 5 1/2 years out, I have been D deficient (to the tune of osteomalacia), K deficient (with low PT/PTT times to prove it), A deficient (low serum retinol), and extremely anemic (with ferritin in the single digits). While I applaud your cautionary tale of "be prepared to take your supplements" I do not believe you are putting enough emphasis or follow-up on the long-term implications that many of us very long-term-out patients have as our daily lives. On online WLS communities, iron and D deficiencies are discussed *daily* as surgeons are not addressing them adequately initially. Many of my deficiencies are due to a similar attitude to nutritional follow-up from my own surgeon and I did not know better until it was too late.

    Please do not take this as undue criticism -- I am thankful you are there to help save people from the disease of obesity, but please take heed from the fact that the nutritional advice you give here is simply not enough long-term. I speak from experience as someone who lives the life, not from someone who does the cutting.

    ReplyDelete
  3. Berrigirl.
    I can certainly understand your fruatration if you are not able to communicate with your surgeon. I want to apologize for your bariatric surgeon if he/she is not willing to be responsible for assisting in your care for life and being available for you to contact him/her in your distress. I believe a surgeon that performs a bariatric operation must provide the follow up care necessary to that patient for life. That is why at Fresh Start Bariatrics I see patients at 1,3,6 weeks,3,6,12 months and at least once a year after that. In fact every patient I operate on recieves my personal cell phone number so they are to call me as they need me. In fact,I am very unhappy with them if they do not call if they have a problem. Patients do not abuse this service except on very rare occations. I feel access to your bariatric surgeon is extremely important to your optimum health and your safety. I am very sorry you do not have the access you deserve.
    To address your specific issue I would need to understand the specific operation you had and any other gastrointestinal problems you might have. I have never had a patient that neaded to be maintained on IV vitamins that had a standard gastric bypass, sleeve or gastric band. If you had a BPD or duodenal switch keeping your vitamin levels up will be much more of a challenge and could require a revision.

    ReplyDelete
  4. Andrea,
    You are certainly correct that I may have "a few things wrong".

    1). Ergocalciferol mat not be the most active form but is an effective oral agent that is able to be converted into the active form at the doses I described. Maybe I should have used the term effective instead of active.

    2). I was at the ASMBS meeting a few years ago when data was presented regarding excellent absorption of calcium citrate (at 100%) comparing this agent to the very low absorption af calcium citrate. The reason I recommend 800 mg is that I expect my patients will be taking the daily recommended calcium in their diet and the calcium citrate is a supplement and not a replacement. The most inportant thing is not the absolute amount taken but the end effect. If a person with a RNY gastric bypass is maintaining or improving their bone density level there would be no reason for them to take more calcium. It is most important that RNY gastric bypass patients have close follow up with frequent bone density studies. Also all the calcium in the world will not help if the vitamin D level is not appropriate because it is vitamin D that assists in absorption of calcium. A person's vitamin D level must be checked amd maintained in the normal range. Finally an N-telopeptide level will be able to determine whether a person is actually using the calcium to build stronger bones if there is a question as to whether a person is taking enough calcium and incorporating it into bone. It is a measure as to the balance of taking calcium out of bone and building it into bone.

    3). A standard length RNY does not cange the portion of the small intiestine that absorbs "fat soluable" vitamins such as vit D, Vit K, and Vit A. I still think these should be checked each year for optimum health but there may be other reasons a person may have problems with these vitamin levels such as "short gut symdrome" and Crhon's disease to mention two. Also many patients with a long history of obesity develop cirrhosis leading to an elevated Protime which is not necessarily related to vit K deficiency. (By the way a PT is not abnormal when it is low but when it is hgh and a PTT is not related to vitanim K deficiency.)

    Finally I agree with you that close follow up and early intervention is the key to preventing these problems. I hear your frustration with bariatric surgeons that do not provide the care required to maintain optimum health for their patients. That is why as the founder of Fresh Start Bariatrics at Riverside I can tell you we are committed to our patients for life as long as they are willing to continue to have us engaged in their health care. We also work hard to keep our patient's primary care doctors informed, with written follow up to the doctor each time we see one of their patients in the office, so they are able to assist in this care.
    I certainly wish you the very best as you continue your jouney to better health.

    ReplyDelete