1. Dr : Reem Murad

2. page 2  “Bariatric surgery should be considered for adults with BMI ≥ 35 kg/m 2 and type 2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy.”  – American Diabetes Association (2009)  “When indicated, surgical intervention leads to significant improvements in decreasing excess weight and co-morbidities that can be maintained over time.” – American Heart Association (2011)  “Bariatric surgery is an appropriate treatment for people with type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies”  – International Diabetes Federation (2011)  “The beneficial effect of surgery on reversal of existing DM and prevention of its development has been confirmed in a number of studies”  – American Association of Clinical Endocrinologists (2011) Sources: American Diabetes Association. Standards of medical care in diabetes – 2009. Diabetes Care 2009; 32(S1):S13-S61, Poirier P, Cornier M-A, Mazzone T et al. Bariatric surgery and cardiovascular risk factors: A scientific statement from the American Heart Association. Circulation 2011; 123:00-00. International Diabetes Federation. Bariatric surgical and procedural interventions in the treatment of obese patients with type 2 diabetes. 2011. Handelsman Y, Mechanick JI, Blone L et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for developing a diabetes mellitus comprehensive plan. Endocr Prac 2011; 17(Suppl 2).

3. LAP-BAND Roux-en-Y Gastric Bypass

4.  Type 2 diabetes mellitus  Hypertension  Hyperlipidemia  Degenerative joint disease  Sleep apnea  GERD  5% to 10% weight reduction is associated with significant decrease in risk  Weight loss from surgery reduces or eliminates medications  Improves severity or resolves co-morbid disease

6.  Protein  Carbohydrates  Fat

7.  Iron  Calcium and Vitamin D  Vitamin B 12  Folic acid  Thiamin  Zinc

8.  Stomach  Water, ethyl alcohol, copper, iodide, fluoride, molybdemum, intrinsic factor  Duodenum  Calcium, iron, phosphorus, magnesium, copper, selenium, thiamin, riboflavin, niacin, biotin, folate, vitamins A, D, E, K

9.  Jejunum  Thiamin, riboflavin, niacin, pantothenate, biotin, folate, vit B6, vit C, vit A, D, E, K, dipeptides, tripeptides, calcium, phosphorus, magnesium, iron, zinc, chromium, manganese, molybdenum, amino acids  Ileum  Vit C, folate, vit B12, vit D, vit K, magnesium, bile salts/acids

11. Common Nutrient Deficiencies  Gastric Bypass:  Most common: Iron, Vitamin B-12, Folic acid, Fat soluble Vitamins A, D, & E  Thiamin (seen in patients with frequent vomiting)  Calcium  Protein malnutrition  Gastric Banding:  Except for folate, nutrition deficiencies are less commonly seen post gastric banding  Sleeve Gastrectomy  Possible B-12

12. RYGB ▫ Malabsorption of Vit B 12, Vit B 1 (thiamin), Vit D, Vit K, Folate, Iron, Calcium LAGB ▫ Folic Acid deficiency BPD and BPD/DS ▫ Vit A, D, E, and K deficiency, Protein-Calorie Malnutrition, Malabsorption of Calcium, Zinc, Selenium, Sodium, Potassium, Chloride, Phosphorus, Magnesium

13.  Common following RYGB  As high as 49% of patients  Multifactorial cause  Low gastric acid levels prohibit iron cleavage from food  Absorption inhibited because no nutrient exposure to duodenum or proximal jejunum  Decrease in iron-rich food consumption due to intolerance  Treat with oral supplementation of ferrous sulfate or ferrous gluconate

14.  iron deficiency can develop early after surgery or years later  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. intravenous iron dextran or iron sucrose is used regularly; many patients require intravenous iron several times a year.

15.  Patients with persistent iron loss should be evaluated for blood loss through the gastrointestinal tract.  Ulcers at the margin of the.  All NSAIDs, including aspirin have the potential to cause ulcers

16.  Absorption of thiamin occurs primarily in the proximal small intestine  Thiamin deficiency after RYGB surgery can occur in up to 49% of patients  Thiamin deficiency mainly affects the central nervous system, potentially leading to beriberi and Wernicke encephalopathy which can develop into Wernicke-Korsakoff syndrome (WKS).  The classic triad of symptoms of WE involves ocular abnormalities, gait ataxia, and mental status changes

17.  For severe cases of thiamin deficiency,  patients should be treated with 500 mg/d of intravenous (IV) thiamin for 3–6 days, followed by 250 mg/d for 3–5 days or until symptoms resolve. Afterward, an oral dose of 100 mg/d is encouraged indefinitely or until risk factors resolve  patients should be treated with IV thiamin, 100 mg/d, for 7–14 days

18.  Niacin/Vitamin B 3 Niacin deficiency after bariatric surgery is rare

19.  Folate absorption occurs in the proximal portion of the small intestine, Complete absorption requires B12  Absorption dependent on HCl and upper 1/3 stomach  postoperative deficiency up to 40% patients  It is recommended that patients consume 200% of the daily value (800 mcg) of folic acid daily

20.  Up to 70% of patients  Lack of hydrochloric acid and pepsin in stomach  Manifestation of vitamin B 12 deficiency is more likely to develop years after surgery due to the body’s B 12 reserve capacity.  Oral supplementation usually adequate, otherwise, IM injections used

21.  Recommended treatment for maintenance levels is 1000 mcg/d.  Several treatment options exist(daily, weekly, monthly) and method of intake (oral, intramuscular, nasal)

22.  Roen-en-Y gastric bypass: protein and fat malabsorption..  Fat malabsorption manifests its presence by fat-soluble vitamins A, D, and K

23.  Vitamin D absorption occurs primarily in the distal small intestine.  a suggested dose is 50,000 international units of ergocalciferol taken orally, once weekly, for 8–12 weeks  recommended supplementing 3000 international units of vitamin D 3 daily

24.  Calcium absorption occurs mainly in the duodenum and proximal jejunum and is dependent on vitamin D levels  To support optimal bone health throughout weight loss, calcium supplementation should be given at 1200–1500 mg/d along with regular consumption of calcium-rich foods.

25.  Vitamin D deficiency is common among obese people  Calcium absorption decreased because duodenum is bypassed  Intolerance to dairy, foods high in calcium  Vitamin D is required for Ca ++ absorption  Prolonged deficiencies lead to  Bone resorption, osteomalacia, osteoporosis

26.  Vitamin A :risk for vitamin A deficiency those with BPD and DS due to the limited available absorptive area and changes with fat absorption after surgery  recommended that 50,000–100,000 international units of vitamin A be given intramuscularly for 3 days followed by 50,000 international units per day intramuscularly for 2 weeks  Treatment for vitamin A deficiency without corneal changes is 10,000– 25,000 international units per day orally until clinical improvement is seen.

27.  Protein:  Hair loss, Fatigue, Leg swelling  Calcium  Bone pain  Iron  Fatigue  Zinc  Brittle nails  Vit A  Decreased night vision

28.  Vit E  Poor wound healing  Vit K  Easy bruising  Vit B1 (thiamine)  Numbness and tingling in hands and feet  Vit B12 (Methylcobalamin)  fatigue

29.  Calcium: bone pain  Iron: fatigue  Zinc: brittle nails  Vitamin A: inability to see in the dark  Vitamin E: poor wound healing  Vitamin K: easy bruising  Vitamin B1 (Thiamin): numbness and tingling in the hands and feet  Vitamin B12 (Methylcobalamin): fatigue

30.  ” Due to fat malabsorption, severe vitamin D deficiency will develop along with an already reduced ability to absorb calcium  fractured bones  a bone density study “severe bone loss”

31.  or telogen effluvium, is seen frequently 3–6 months after surgery.  Lasting as long as 6–12 months  it can be terribly distressing to the patient.  Although there is no known treatment, it usually reverses without intervention

32.  As weight loss begins to slow down, the risk of other nutritional problems increases.  B 12 and iron deficiency are two of the most common problems and often do not respond to typical multivitamin supplementation.  are primarily seen with gastric bypass  Because food now bypasses the lower stomach, B 12 deficiency is frequently observed. If B 12 is not supplemented above and beyond a multivitamin, 30% of patients will be unable to maintain normal levels of plasma B 12 at 1 year.  After 1 year, the prevalence of B 12 deficiency appears to increase yearly and has been reported to be between 36 and 70% in the long term  Over the counter oral and sublingual forms of vitamin B 12 are available for use.Optimal dose and efficacy have not been well studied, but doses of 25,000 units sublingual B 12 twice a week are usually sufficient to maintain normal plasma levels of B 12.  Some (up to 10%) patients will not respond to high-dose sublingual or oral B 12 and will require monthly intramuscular B 12 injections.

33.  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  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.

35.  Thiamin (vitaminB1) :Goal Female, 30–160 mcg/dL Male, 30–300 mcg/dL  Treatment: Confirm patient taking 2 MVIs daily (1 MVI LAGB) each containing 100% RDA thiamin.   Parenteral supplementation 100 mg/d for 7.14 d, then 50 mg/d until levels are normal or symptoms resolve  500 mg/d IV thiamine should be given for severe deficiency, followed by 250 mg/d for 3.6 d or until symptoms resolve

36.  Cobalamin (vitamin B 12 ) :200–1000 pg/mL  Confirm patient taking 2 MVIs (1 MVI LAGB).  Confirm patient (except LAGB) is taking vitamin B 12 : up to 1000 mcg/d orally or 500 mcg/wk intranasally, or 1000 mcg/mo IM.  œ If <200 pg/mL -IM injections or supplement with 350.1000 mcg/d orally. 

37.  Vitamin D, 25-hydroxyvitamin D :>30 ng/mL (insufficiency = 25–30 ng/dL) If <20 mg/mL, start ergocalciferol or cholecalciferol 50,000 units/wk orally ~ 8 wk. maintenance dose of vitamin D3, 3000 international units daily if level is persistently low Supplementation for vitamin maintenance is recommended a 1000.2000 i u per day

38.  Calcium and intact PTH Serum :  Ca: 9–10.5 mg/dL Ionized Ca: 4.5–5.6 mg/dL iPTH <65 pg/mL  Confirm patient taking calcium citrate 1200.1500 mg/d.

39.  Folic acid RBC folate: 280–791 ng/ mL Serum folate: 11–57 mmol/L, 5.3–99 ng/mL  Confirm patient taking 2 MVIs (1 MVI LAGB) daily with 400 mcg of folic acid. œ Supplement with 1000 mcg/d orally if serum levels are low, up to 5 mg/d possibly needed with severe malabsorption. (RBC folate is a more sensitive marker than serum folate, which reflects dietary intake).  Encourage consumption of folate-rich foods.

40.  Iron Serum :iron: 37–170 mcg/ dL  Confirm patient taking 2 MVIs each containing at least 18 mg of iron.  Menstruating women and those at risk of anemia may require additional supplementation.   If oral iron therapy has failed to improve laboratory values, then refer to hematology for IV iron replacement.  After iron infusions, patients should be encouraged to continue with goal iron intake of 50.100 mg/d to prolong period between infusions

41.  Vitamin K : PT: 10–13 Seconds  Confirm patient taking 2 MVIs daily.  1 mg/d vitamin K supplementation recommended when INR values are >1.4. 

42.  Vitamin A Plasma retinol: 20–80 mcg/dL  Without corneal changes: 10,000. 25,000 international units of vitamin A per day orally until clinical improvement.  With corneal changes: 50,000.100,000 international units of vitamin A IM for 3 d followed by 50,000 international units per day IM for 2 wk.

43.  Zinc 0.66–1.1 mcg/ mL  Confirm patient taking 2 MVIs containing zinc.

44.  Copper : 0.75–1.45 mcg/ mL  Confirm patient taking 2 MVIs that provide at least 2 mg/d copper.  Patients should be referred to dietitian.  Ensure 1 mg copper for every 8.15 mg of oral zinc intake.

45.  Patients require lifelong vitamin and mineral supplementation  regimens following bariatric surgery.  Routine biochemical monitoring for nutrition status

46.  Multivitamin with iron  Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)  Oral vitamin B 12 (500-1000 mcg)  Iron (65 mg/day in elemental form)  Vitamin C (to increase absorption of Iron)  Thiamin (10 mg/day)