MUCH ADO ABOUT NUTRITION PREVENTION AND MANAGEMENT OF THE NUTRITIONAL CONSEQUENCES IN BARIATRIC SURGERY. Sue Cummings, MS, RD

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1 MUCH ADO ABOUT NUTRITION PREVENTION AND MANAGEMENT OF THE NUTRITIONAL CONSEQUENCES IN BARIATRIC SURGERY Sue Cummings, MS, RD

2 Improving Surgical Outcomes

3 Nutritional Complications 2000¹ 2014² Iron deficiency 9% Hypomagnesium.7% Malnutrition ( albumin).3% Iron deficiency 17-45% Hypomagnesium 32% Malnutrition ( albumin) 3-18% 1. Schauer PR, et al. 2. Stein J, et al

4 Are we okay with this? Surgical Complications Nutrition Complications¹ ¹Parrot, J et al.

5 Complications: Micronutrient Deficiency Vitamin D Vitamin B12 Iron Thiamin Pre-Op Rates Post-Op Rates Folate Zinc % 1. Stein et al 2. Parrot et al

6 Obesity is a known risk factor for nutrient deficiencies Inflammation associated with obesity induces the production of hepcidin, an acute phase protein made in the liver, which blocks iron absorption in the intestine Metformin affects the absorption of vitamin B 12 in the ileum Associated with decreased serum folic acid levels B12 and folic acid depletion also increases homocysteine levels Hyperinsulinemia is associated with excessive urinary excretion of zinc The bioavailability of vitamin D is reduced in the obese state, because vitamin D is sequestered in adipose tissue. Iron Fe TIBC Hb/hct Vitamin B12 B12 cobalamin Serum methylmalonic acid (optional) Folic Acid Homocysteine Zinc Vitamin D Vitamin D, 25-OH PTH REPLETE PRE-SURGERY AS NEEDED Decker, et al, Am J Gastro, (2007), 102, Bauman WA, Shaw S, Jayatilleke E, et al Diabetes Care. 2000;23(9):

7 Iron Status Serum folate Ferritin TIBC Thiamin (B1) B12 cobalamin methylmalonic acid (optional) Folate Vitamin D, 25-OH Serum Calcium PTH Alkaline phosphatase Vitamin A Vitamin E* Vitamin K* Hemoglobin A1c Phosphorus Magnesium Zinc Copper* Selenium* PreSurgery Source adapted from Mechanick, et al, SOARD : ; Moize, et al; Parrott et al, SOARD 2017 * = with specific findings; check mark means check; x means not to check; Shaded areas indicate that it is not necessary unless indicated by physical assessment/specific findings; there is not data regarding copper or selenium post-sg Source adapted from Mechanick, et al, SOARD : ; Moize, et al; Parrott et al, SOARD 2017 x

8 MBS Micronutrient Deficiencies Post-MBS nutrition related deficiencies may be prevented with appropriate supplementation ⁵ˉ⁶ 1. Gudzune KA, et al. 2. Gehrer S, et al. 3. Bal BS, et al. 4. Peterson LA, et al. 5. Pournaras D, et al 6. Saltzman E, et al 7. Nadkarni et al 8. Avani et al 9. Brolin, et al.

9 POST-MBS SUPPLEMENT PROTOCALS Using micronutrient supplementation protocols w/in your individual practice is foundational in protecting patients Protocols should be based on evidence based research See final reference slide

10 Updated Guidelines ASMBS Integrated Health Nutritional Guidelines for The Surgical Weight Loss Patient 2016 Update:Micronutrients. Surgery for Obesity and Related Diseases, May (5): Review of 402 publications Parrot J, Frank L, Dilks R, et al.

11 Iron Nutrient Minimum daily level to prevent deficiencies (oral doses) mg Vitamin B mcg All procedures Comments Folate mcg Childbearing F Thiamin mg New (All procedures) Calcium mg Vitamin D 3,000 IU (titrate to >30ng/mL serum D, 25(OH) Vitamin A 5,000-10,000 IU New Vitamins E / K 15 mg / mcg New Zinc / Copper 8-22 mg / 1-2 mg Zn:Cu important at high levels of zinc repletion Selenium high potency MVI New Magnesium Additional B-vitamins Multivitamin contains magnesium % DV Trace Minerals complete in minerals Molybdenum, Manganese, Chromium, etc. Based on Available Guidelines Recommendations based on procedure type and patient specific demographics

12 Routine Nutrient Supplementation* Supplement Dosage Multivitamin/multi-mineral 1-2 daily Vitamin B Complex should contain % RDA Zn and Cu Folate: mcg of folate/day; women childbearing age: 800-1,000 mcg; Thiamin 12 mg/day At least 50 mg thiamin Calcium Citrate/Carbonate X 2-3/day Ca: 1,200-2,400 mg/d: DIVIDED DOSES (from all sources) Vitamin D 3,000 IU daily (from all sources) Elemental iron not to be taken with calcium Vitamin B mg/d elemental mg/d menstruating females ug/d orally/sublingual, nasal or 1,000 mcg/mo intramuscularly *Patients with preoperative or post-operative biochemical deficiency states are treated beyond these recommendations

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14 Post-Metabolic and Bariatric Surgery (MBS) 1. Adherence rates to directives from HCP s as patients progress from surgery¹ Adherence to micronutrient supplementation is low⁷ˉ⁸ 10 year data found 33% adherence; 8% never taking supplements⁹ 2. Risk of nutrition deficiencies as patients progress from surgery² 3. Nutritional deficiencies can lead to irreversible consequences³ 1. Larjani S, et al. 2. Matrana M, et al. 3. Gletsu-Miller N, et al

15 Improving Nutrition Deficiencies 1. Focused Patient Education Most frequently sited reasons for not taking supplements are: forgetting to take; not liking pills; cost. Addressing barriers: Pill organizers / Timer on phone / computer Tolerance: Chewable / liquid forms are available Making recommendations that are Individualized based on labs, make recommendations that take into consideration cost; feasibility 1. Hood M, et al. 2. Olbers T, et al.

16 POST SURGERY LABORATORY MONITORING Iron Status Serum folate Ferritin TIBC 2 Months Post-Surgery Post Month 6 Thiamin (B1) B12 cobalamin methylmalonic acid (optional) Folate Post Yearly Vitamin D, 25-OH EDUCATE PRIMARY CARE PROVIDERS Serum Calcium PTH Alkaline phosphatase Vitamin A BPD/DS BPD/DS Vitamin E* Vitamin K* Hemoglobin A1c Phosphorus Magnesium Zinc Copper* RYGB; BPD/DS RYGB; BPD/DS Selenium* RYGB; BPD/DS RYGB; BPD/DS Source adapted from Mechanick, et al, SOARD : ; Moize, et al; Parrott et al, SOARD 2017

17 Monitoring Labs Lifelong Biochemical surveillance typically begins 2-3 months post-op Some deficiencies can manifest in days while others take years Use physical signs/symptoms to detect deficiencies Using a Nutrition Focused Physical Exam B12 Thiamin

18 Vitamin and Mineral Deficiencies Laboratory work up If labs are low normal and sign/symptoms present may need to do laboratory assessment of more sensitive markers

19 Nutrition Focused Physical Exam (NFPE) The NFPE is a systematic head-to-toe examination of a patient's physical appearance and function and can help in determining nutritional status by uncovering any signs of malnutrition, nutrient deficiencies, or nutrient toxicities.

20 SITES OF NUTRIENT ABSORPTION Stein, et al

21 Common Deficiencies Calcium Vitamin D Iron Vitamin B12 Thiamine (B1) Vitamin A Vitamin E Vitamin K Zinc Copper

22 Iron B12 Folic Acid Zinc (ZN) Copper (Cu SIGNS AND SYMPTOMS Fatigue, low productivity, spoon shaped nails / vertical ridges, glossitis Numbness / tingling fingers and toes, glossitis, fatigue, depression, dementia, gait ataxia Palpitations, fatigue, Neural Tube Defects, changes in skin pigmentation Skin lesions, poor wound healing, hair loss, taste changes Unsteady gait, tingling in hands / feet, poor wound healing, paralysis SERUM MARKERS Iron: <50 µg/dl TIBC: >450 µg/dl Ferritin:<20 µg/l ( H/H MCV TSAT stfr ZPP) Serum MMA >0.56 mmol/l Serum B12 (may miss 30%-50% of def) <400pg/mL suboptimal <200pg/mL deficiency Homocysteine, H/H MCV Serum Folate <340 ng/ml RBC Folate, Homocysteine H/H MCV (Normal serum MMA) Plasma Zinc < 11 µmol/l RBC or WBC zinc Urinary zinc Serum Copper: 11 µmol/l Serum Ceruloplasmin

23 Vitamin D Calcium Mg SIGNS AND SYMPTOMS Depression, muscle pain, involuntary muscle movements, osteoporosis Low bone density, osteoporosis, muscle contractions, spasms, pain Muscle contractions, pain, spasms, osteoporosis SERUM MARKERS 25 (OH)D <20ng/mL (def); 20-30ng/mL Alk Phos ipth DEXA Ionized Ca <4.48 mg / dl Alk Phos ipth DEXA Serum Mg <1.5 (1.8?) urinary Mg Stein J, et al.

24 Thiamin SIGNS AND SYMPTOMS SERUM MARKERS Dry Beriberi: convulsions, muscle weakness, pain of lower/ upper extremities, brisk tendon reflexes Wet Beriberi: tachycardia or bradycardia, lactic acidosis, dyspnea Neuropsychiatric: confusion, ataxia, paralysis Wernicke encephalopathy: ophthalmoplegia, ataxia, confusion, hallucinations, psychosis Serum Thiamin <80 µg/l Severe: <10 µg/l~ urinary thiamin excretion RBC transketolase Lactic acid or pyruvate * Cummings S, et al. # Mechanick, J. et al. ^ Bays H, et al. ~Stein J, et al., Parrot J, et al.

25 Fat soluble vitamins SIGNS AND SYMPTOMS Vitamin A Loss of nocturnal vision itching dry hair Xerophthalmia Keratinization, xerosis, Decreased Immunity / poor wound healing SERUM MARKERS Plasma retinol <.70 micromoles/l (20 mcg/dl) Inadequacy micromoles/l Serum vitamin A lmol/l Retinol binding protein Vitamin K Easy bruising Plasma vit K Vitamin E Hyporeflexia/ weakness, gait ataxia Plasma alpha tocopherol < 5 µg/ml Stein J, et al.

26 Summary: How can we improve nutrition outcomes? 1. Assess Know what to look for / when to measure Understand that deficiencies exist and are becoming more prevalent Understand that the risk of deficiencies increase as a patient progresses from surgery 2. Recommend Develop protocols in your clinic based on published MBS guidelines Include: prevention and treatment dosages 3. Adhere Educate patients at each visit around risks of deficiency Understand how to help patients choose a regimen that they are able and willing to follow

27 THANK YOU

28 Accessed 2/3/

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