Bariatric surgery has emerged as the cure for morbid

BARIATRIC NURSING AND SURGICAL PATIENT CARE Volume 7, Number 2, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/bar.2012.9980 RESOURCE SECTION Vitamin and Mineral Supplementation for the Bariatric Patient: Why, What, When, and How? Kim Joyner, RN, CNOR Purpose: To enhance the vitamin and mineral supplementation knowledge base of all bariatric surgery care providers. Significance: Bariatric surgery patients require ongoing nutritional counseling during their weight loss surgery experience. It is not the sole responsibility of the dietician. A multidisciplinary approach is paramount. This article will discuss the common bariatric procedures performed in the U.S. and their respective vitamin and mineral deficiencies based on the surgical physiology. In addition, basic vitamin and mineral charts are provided that list basic information (why, what, when, and how) all bariatric care providers must be familiar in order to assure optimal preoperative and postoperative care. Introduction Bariatric surgery has emerged as the cure for morbid obesity and subsequent comorbid factors. With this cure, however, comes a lifetime of nutritional recommendations that must be followed. Each bariatric surgical procedure has its own set of recommendations based on physiology and the technique used to achieve the desired surgical weight-loss outcome. In order to provide a baseline knowledge level of the various procedure types and the physiology associated with each, we will explore the three classifications of the common bariatric surgical procedures performed in the United States. These include: 1. Malabsorptive procedures Biliopancreatic diversion with duodenal switch (BPD/DS) 2. Restrictive procedures Vertical banded gastroplasty Sleeve gastrectomy Adjustable gastric banding 3. Malabsorptive and Restrictive Procedures Gastric bypass Roux-en-Y Malabsorptive The biliopancreatic diversion with duodenal switch (BPD/DS) requires consistent long-term nutritional followup and monitoring as it is a purely malabsorptive procedure. A portion of the stomach is resected, creating a smaller stomach pouch. The distal small intestine, or ileum, is then connected to the pouch. The duodenum (first 10 15 inches of small intestine) and the jejunum (middle of the small intestine) are bypassed. This bypassed small intestine is the basis for the decreased absorption of calories, protein, vitamins, and minerals that occur post BPD/DS. Patients who undergo this procedure must have consistent follow-up lab studies performed in order to assure that nutritional requirements are within normal limits. There are far fewer BPD/DS procedures performed compared to other weight loss procedures due to the need for long-term follow-up and monitoring. There is no restrictive component as with gastric bypass, thus patients can eat larger quantities during snack and mealtimes. As with all malabsorptive procedures, BPD/DS patients do not effectively absorb micronutrients such as iron, calcium, vitamin B12, and folate. Due to the bypass of the duodenum and the jejunum, these patients are especially vulnerable to deficiencies in the fat-soluble vitamins A, D, E, and K. Restrictive The vertical banded gastroplasty, or stomach stapling, is a purely restrictive procedure. A portion of the stomach is stapled to create a small pouch. A small, non-adjustable polyurethane band is placed below the pouch. Vomiting and severe discomfort occur when food is not properly chewed. Healthy, more fibrous foods can be difficult to digest, while highly refined foods cause little discomfort. This can easily promote ingestion of junk foods, as opposed to foods that are considered to be healthy choices. This procedure is rarely performed today, as adjustable gastric bands are less invasive and have better results. Furthermore, reversal of this procedure is considered very dangerous and should only be considered when there are major complications. The vertical banded gastroplasty is included in this section to promote awareness due to its popularity in the 1980s and 1990s. New Hanover Regional Medical Center, Wilmington, North Carolina. 87

88 JOYNER The sleeve gastrectomy is a purely restrictive procedure in which the stomach is reduced to about 15% of its original size. Eighty-five percent of the stomach is removed, thus rendering the procedure irreversible. This reduced stomach is achieved via stapling along the major curve of the stomach, and the open edges are attached together with staples, sutures, or a combination of both. The new stomach resembles a banana in shape and thus appears as a tube or a sleeve. Despite the reduction in size, the stomach tends to function normally and enables the patient to consume most food items, as long as portions are smaller. The pylorus is preserved, thus dumping syndrome is greatly reduced. Since the bowel is not resected and there is no small intestine anastamosis or staple line, there is no ulcer formation. Preserving the duodenum allows for less anemia, osteoporosis, and protein and vitamin deficiencies. The sleeve gastrectomy, or gastric sleeve, is a more appealing option for patients with existing anemia, Crohn s disease, irritable bowel syndrome, or the need for chronic steroid or non-steroidal anti-inflammatory (NSAID) drug use. The adjustable gastric banding procedure, also known as the LapBand Ò or Realize Ò Band, is also considered a restrictive procedure. A silastic, adjustable band is placed around the top portion of the stomach, creating a small pouch just above the band. This band is connected to a port via silastic tubing. The port is placed just under the skin so that it can be accessed and saline can be added or removed in order to provide adequate restriction. This restriction results in decreased hunger and resultant weight loss. Patients with the LapBand do not have absorption issues but do have a decrease in food consumption. A daily multivitamin is important to assure that the recommended daily allowance of specific vitamins and minerals are being met. Eating foods that are gummy in consistency, such as bread or asparagus, may induce vomiting in the LapBand patient. Chronic vomiting may lead to a thiamine deficiency. Any multivitamin taken by this population of patients must have the recommended daily allowance of thiamine to assure thiamine levels are maintained. Table 1. FDA Dietary Reference Intakes (DRI): Recommended Dietary Allowances and Adequate Intake, Elements Vitamin A (lg/d) 700 900 Vitamin E (lg/d) 15 Vitamin K (lg/d) 90 120 Thiamine (mg/d) 1.1 1.2 Riboflavin (mg/d) 1.1 1.3 Niacin (mg/d) 14 16 Vitamin B6 (mg/d) 1.3 1.7 Pantothenic Acid (mg/d) 5 Choline (mg/d) 425 550 Vitamin B12 (lg/d) 2.4 Folate (lg/d) 400 Calcium (mg/d) 1000 1200 Copper (lg/d) 900 Iron (lg/d) Males 8 Ferrous Fumurate Females 18 FDA, Food and Drug Administration. Malabsorptive and Restrictive By design, the gastric bypass Roux-en-Y is both a restrictive and malabsorptive procedure. A small stomach pouch is created with a stapler device, and then this pouch is connected to the distal small intestine, or jejunum. The upper part of the small intestine is then reattached in a Y-shaped configuration. This new configuration allows for a restrictive reservoir for food and liquids and a narrow outlet from which the food travels into the remainder of the digestive tract and out in the normal manner, bypassing the duodenum. This bypass impacts digestion as the duodenum is intricately involved in the digestive process. The primary role of the small intestine is absorption of vitamins and minerals, proteins (amino acids), carbohydrates, fats (lipids), enzymes, and water. Absorption is altered when digestion is incomplete. Thus patients having gastric bypass must take vitamin supplements for the rest of their lives. Furthermore, patients who have had this procedure will require 200% of the recommended daily allowances for vitamins and minerals. In review, patients having a restrictive bariatric procedure such as laparoscopic gastric banding, vertical banded gastroplasty, and sleeve gastroplasty will benefit from one multivitamin daily with 100% of the recommended daily allowances (RDAs). Patients having a malabsorptive and/or restrictive procedure such as gastric bypass Roux-en-Y and biliopancreatic diversion with duodenal switch will benefit from two multivitamins per day or 200% of the recommended daily allowances (RDAs). See Table 1 for further explanation of daily requirements. What, When, and How? If we must recommend vitamin and mineral supplements to our patients, we must also have a basic understanding of how they function in the body. This next section will focus on various vitamins and minerals recommended for the bariatric patient and the key contributions they make to homeostasis. Water-soluble B vitamins are essential for energy production, immune system function, and heart health. They are absorbed quickly, are not stored in the fat cells, and therefore must be replaced every day. See Table 2 for the seven B vitamins (B- Complex) with their functions, food sources, and signs and symptoms of deficiency. Interestingly, although the body can synthesize or make vitamins, it cannot manufacture one single mineral. Minerals must come from food sources or supplementation. Furthermore, vitamins are dependent upon minerals for adequate absorption. For example, vitamin D must be present in order for calcium to be absorbed. See Table 3 for a list of various minerals, their function, food sources, and signs and symptoms of deficiency. In recent years, vitamin D has received a great deal of attention among healthcare providers and the media. Flanebaum et al. 1 completed a retrospective analysis of 379 preoperative gastric bypass patients and found 68.1% were deficient in 25-hydroxyvitamin D. Ybarra et al. 2 found 80% of a screened population of patients presented with similar patterns of low vitamin D levels. One mechanism for this deficiency is the decreased bioavailability of vitamin D due to enhanced uptake and clearance by adipose tissue. Thus the decreased availability of vitamin D is secondary to the preoperative fat mass. Reduced dietary calcium absorption increases a substance known as calcitrol, which in turn, causes metabolic changes that favor fat accumulation. Many bariatric centers now choose to preoperatively screen their patients for

Table 2. Vitamin B Reference Table Vitamin Function Foods Signs/Symptoms of deficiency Vitamin B12 Maintains healthy nerve cells Meats Anemia/pernicious anemia Maintains healthy red blood cells Fish Decreased energy/fatigue Supports higher energy levels Poultry Shortness of breath Supports emotional stability and mental clarity Eggs Palpitations Aids in production of DNA Milk Tingling, numbness in extremities Supports lower homocysteine levels Fortified breakfast cereals Spasticity/irritability (Higher homocysteine levels increase risk of coronary artery disease, stroke, osteoporosis, and Alzheimer s) Depression Memory loss/dementia Diarrhea/constipation Abdominal pain Excessive flatulence Burning sensation tongue Anorexia weight loss Age-related hearing loss Alzheimer s disease Vitamin B1/Thiamine Promotes normal appetite Whole grain cereals Fatigue and irritability Helps fight morning sickness Bread Sensitivity to noise Improves mental attitude Red meat Loss of appetite Speeds healing process Egg yolks Constipation Essential in conversion carbs into glucose for energy Green leafy vegetables Depression Legumes Slow wound healing Sweet corn Low blood pressure Brown rice Shortness of breath Berries Risk factors for thiamine deficiency Wheat germ Crash dieting Alcohol abuse Liver dysfunction Excessive consumption of sweets, soft drinks, and highly processed foods Excessive vomiting Vitamin B2/Riboflavin Aids in breakdown of carbs, fats, and proteins Whole gains Skin disorders Maintenance of skin, cornea, nerve sheaths Milk Inflammation of soft tissue around corner of mouth Prevents oxidation Eggs Glossitis or inflammation of tongue Cheese Peas Vitamin B3/Niacin Metabolism of food Meats Diarrhea Maintenance of skin, cornea, nerve sheaths, and gastrointestinal tract Brewer s yeast Dermatitis Milk Dementia Eggs Mouth can also be affected by Pellagra, causing the inside of the cheeks/tongue to become red and painful Cheese Peas (continued) 89

Table 2. (Continued) Vitamin Function Foods Signs/Symptoms of deficiency Vitamin B6/Pyridoxine Breakdown of carbs, proteins, and fats Grains Skin disorders Aids in production of red blood cells Dairy/eggs Neuropathy Builds amino acids/protein Shellfish Confusion Potatoes Poor coordination Nuts Insomnia Legumes Inflammation of edges of tongue, lips, and mouth Spinach Deficiency is rare, as B6 is found in many, many foods. The exception is alcoholism. Bananas/avocados Vitamin B9/Folic acid Interacts with Vitamin B12 in cell production (DNA) Liver Poor growth in children Aids in breakdown of proteins Dried herbs Irritation of mouth Aids in formation of hemoglobin and oxygen capacity Sunflower seeds Folic acid is present in nearly all natural foods but can Edamame/legumes be destroyed during the cooking process Dark leafy vegetables Bean sprouts Vitamin B5/Pantothenic acid Aids in breakdown of carbs, fats, and amino acids Meats There is no deficiency disorder known, as it is produced by Legumes bacteria in the intestines Whole grain cereals 90

Table 3. Mineral Reference Table Mineral Function Foods Signs/Symptoms of deficiency Calcium Key component of bone and teeth Dairy products Osteomalacia or softening of bone Essential for vital metabolic processes such as nerve function, muscle contraction, and blood clotting Fortified juices Osteoporosis Rickets Tetany Iron (Fe) Essential for transfer of oxygen between tissues in the body Eggs/peas Anemia Green leafy vegetables Increased susceptibility to infections Fortified foods such as cereals Liver Nuts/whole grains Magnesium (Mg) Essential for healthy bones Eggs Anxiety Proper function nerve and muscle tissue Leafy green vegetables Fatigue Needed for the function of approximately 90 enzymes Shellfish Insomnia Dairy Muscular problems Nuts Nausea Whole meal flour PMS Phosphorous (P) Bone formation Dairy Anemia/weakness Energy production Most fruits Demineralization of bone Meats Nerve disorders Leafy green vegetables Respiratory problems Weight loss Potassium (K) Main base ion of intracellular fluid Cereals/whole grain flour Generalized muscle paralysis Nerve and muscle function Coffee Metabolic disturbances Fresh fruits/vegetables Meat Salt substitutes Sodium (Na) Volume control extracellular fluid Processed baked goods Low blood pressure Maintains body ph Table salt Generalized muscle weakness Function of nerve and muscle tissue Cured products such as ham Mild fever Respiratory problems Chromium (Cr) Skeletal muscle function Cereals/whole meal flour Confusion Cheese/fresh fruit Irritability Meat Weakness Nuts Copper (Cu) Present in enzymes Cocoa Changes in hair color and texture/hair loss Present in red blood cells and plasma Liver Disturbances to the nervous system Fresh fruit Bone disease Meat Serious deficiency can lead to Menkes s Syndrome Nuts Whole meal flour Manganese (Mn) Antioxidant Avocados/nuts Unusual but can lead to: Formation strong bone, nerves and muscle Tea Bone deformities Vegetables Rashes Whole grain cereals Skin conditions Reduced hair growth Selenium (Se) Egg yolk Cardiomyopathy Garlic Kaschin-Beck disease (affects the cartilage at joints) Seafood Whole wheat flour Zinc (Zn) Needed for function of more than 200 enzymes Dairy/egg yolk Deficiency is rare but may lead to: Strong immune system Liver/red meat Skin lesions Seafood Cornea lesions Whole grain flour 91

92 JOYNER vitamin D deficiency. Certainly, vitamin D levels must be checked postoperatively to assure healthy levels are being achieved through supplementation. Continued research may prove that vitamin D contributes to a normal body weight, brain health, reduced symptoms of rheumatoid arthritis, and improved immune system function. Supplementation for the bariatric patient is not just the responsibility of the dietician. Surgeons, advanced practice nurses, physician assistants, nurses, psychologists, and primary care providers must have a basic knowledge and understanding of vitamin and mineral therapy as it relates to various bariatric procedures. The American Society of Metabolic and Bariatric Surgeons has established nutrition guidelines for the bariatric patient, accessed via their website www.asmbs.org under Resources/Guidelines: Aills, L et al. 3 Lifetime nutritional support via vitamin and mineral therapy is critical for the continued health of all bariatric patients. Bariatric centers must continually use evidencebased research to establish guidelines for their respective practices. Education of healthcare providers must transfer to the individual patient to assure long-term compliance. Appropriate, ongoing nutritional education will empower patients to maintain their nutritional health long term. Disclosure Statement No competing financial interests exist. References 1. Flanebaum L, Belsley S, Drake V, et al. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg 2006;10:1033 1037. 2. Ybarra J, Sanchez-hernandez J, Vich I, et al. Unchanged hypovitaminosis D and secondary hyperparathyroidism in morbid obesity after bariatric surgery. Obes Surg 2005;15: 330 337. 3. Aills L, Blankenship J, Buffington C, Furtado M, Parrot J, et al. ASMBS allied health nutritional guidelines for the surgical weight loss patient. Obes Surg 2008;4:S73 S108. Address correspondence to: Kim Joyner, RN, CNOR Bariatric Coordinator New Hanover Regional Medical Center 2131 S. Fifth Street Wilmington, NC 28412 E-mail: kim.joyner@nhrmc.org