1. Nutrition Deficiencies in Bariatric Surgery Bruce M. Wolfe MD Professor of Surgery Oregon Health & Science University

2. Potential Conflict of Interest Allergan Covidian EnteroMedics Ethicon Endosurgery

3. Deficiency due to: Decreased intake Vomiting Malabsorption

4. Protein-Calorie Malnutrition Uncommon/rare after LAGB, RYGBP Prevented by 40-80g protein/day May occur: – Dysfunctional eating habits/anorexia – Protracted vomiting – Malabsorptive procedure

5. Shikora: Nutr Clin Prac 2007;22:35

6. Nutritional Deficiency LAGB: – Vomiting RYGBP: – Iron – Calcium – Vitamin B12 Malabsorption: – Protein – Fat-soluble vitamins – Minerals (Na, K, Mg, Zn)

7. Dehydration Poor intake, difficulty catching up Decreased sodium intake from food Symptoms increased by medications

8. Thiamine May be deficient pre-op Vomiting is the usual cause Encephalopathy, neuropathy Replace, then glucose

9. Iron Absorbed in duodenum and jejunum in acid medium Measure serum Fe, TIBC Deficiency may precede anemia, heart failure

10. Vitamin B12 RYGBP deficiency 26-70% Macrocytic anemia, thrombocytopenia Neurologic derangements Oral or sublingual supplement

11. Hollick MF; N Engl J Med 2007, 357;3:269

13. Vitamin D, Calcium and Bone Calcium absorption PTH inversely related Bone Calcium Supplement use leads to decreased fractures

14. Hollick MF; N Engl J Med 2007, 357;3:272

15. Non-skeletal Actions of Vitamin D Cancer Autoimmune disease Diabetes CV disease Schizophrenia, depression Pulmonary function, asthma

16. Vitamin D – Cancer <20 ng/ml increases by 30-50% the risk for: – Colon – Prostate – Breast

17. Vitamin D CV disease: – HTN – CHF Autoimmune disease: – TIDM – MS Muscle function, athletic performance Others

18. Vitamin D IOM recommendations: – 200 IU/d <50y – 400 IU/d >50y – Inadequate sun: 800-1000 IU/d Replacement: – 50,000 IU weekly x 8 weeks, then q 2-4 weeks Or – 1000 IU D₃/d or 3000 IU D₂/d

19. Bariatric Surgery Recommendations Pre-operative routine: – Iron – Vitamin D levels – Others as clinically indicated – Pre-operative supplementation – Treatment deficiency