Disclosure Information
Bariatric Education 2010
Joyce Schone, RD, LD
Vitamins and Minerals in the Bariatric Patient
• I have no financial relationships to disclose.
• I will not discuss off label use and/or investigational use in my presentation.
The B Vitamins
University of Minnesota Medical Center – Fairview
Joyce Schone, RD, LD
“Vitamins”
Water Soluble vs. Fat Soluble
• Water Soluble (B vitamins and vitamin C):
• Are a number of organic compounds that are essential for metabolic reactions that cannot be synthesized by human tissue cells.
– They dissolve in water when they are ingested, then go into the bloodstream.
– Body keeps what it needs and excess amounts are excreted.
– Not normally stored in the body in appreciable amounts ; thus , a daily supply is desirable to avoid deficiency.
• Need to be ingested in the diet in small quantities to prevent disorders of metabolism.
• Fat Soluble (Vitamins A,D,E, and K):
– Are absorbed with other lipids, and efficient absorption requires the presence of bile and pancreatic juice.
– The body uses what it needs at that time and stores the rest for future use.
• They are divided into water‐soluble and fat‐
soluble vitamins.
The B Vitamins
Thiamine (Vitamin B1)
• Water Soluble
• Include:
–
–
–
–
–
–
–
–
• Food sources:
– Fortified grains, whole grains, legumes, nuts, and lean meats (especially pork).
Thiamine (B1)
Riboflavin (B2)
Niacin (B3)
Pyridoxine (B6)
Folic Acid
Cyanocobalamin (B12)
Biotin
Pantothenic acid
• Recommended Dietary Allowance:
– 1.1 – 1.2 mg/day
1
Thiamine
Preoperative Risk For Deficiency
Thiamine Deficiency
• Cleveland Clinic of Florida – 2005
• Mechanisms of deficiency include:
–
–
–
–
– 15 % incidence of deficiency
Reduced gastric acid production
Absorption primarily in the proximal small bowel
Reduced dietary intake
Frequent vomiting
• Flancbaum et al – 2006
– 29 % incidence of deficiency
– Significant difference between ethnicity
• 6.7% of whites
• 31% of African Americans
• 47% of Hispanics
• Humans cannot synthesize and vitamin not stored in large quantities in the body – adequate daily intake is essential.
• Body stores – 30 mg (skeletal muscles and liver, heart, kidneys, and brain). Half‐life of thiamine in the body is 9‐18 days.
• In dietary deficient state, body stores can be depleted in 2‐3 weeks.
• Results suggest a need for preoperative thiamin testing, as well as thiamin repletion by diet or supplementation to reduce risk for deficiency post‐operatively.
Thiamine Deficiency
Thiamine Deficiency
• Thiamine deficiency is known as beriberi.
• Deficiency can be present in one of two forms:
• Incidences of deficiency have been published over the past decade , with the majority associated with persistent vomiting or hyperemesis.
– Chang et al cited 40 cases of deficiency in a total of 168,010 cases reported in a survey by members of ASBS (2004).
– Singh et al (2007) – 32 cases of Wernicke’s encephalopathy in a search of the literature.
– Neurologic beriberi (dry beriberi)
• Wernicke‐Korsakoff syndrome
• More common in procedures involving bypass or removal of part of the stomach, although cases have been reported after adjustable gastric banding.
• Usually presents 4 to 12 weeks after surgery, however, can occur as early as 2 weeks after surgery. Some cases noted years after surgery.
• Biochemical parameters may be normal and cannot be used to exclude a deficiency. MRI is useful in confirming diagnosis – 93% specificity.
– Cardiac beriberi (wet beriberi)
• Early diagnosis of signs and symptoms is extremely important.
• Even if treatment is initiated, recovery can be incomplete.
Thiamine Supplementation
Folate
• In most cases, adherence to multivitamin supplement will prevent deficiency.
• In suspected deficiency:
• Food sources: green leafy vegetables, fruits, organ meats, liver, dried yeast, and fortified grain products.
– B‐complex supplement
– Early symptoms of neuropathy – 20 – 30 mg/d until symptoms disappear.
– More advanced neuropathy or individuals with protracted vomiting – 50 – 100 mg/d IV or IM may be necessary for resolution or improvement of symptoms or for the prevention of such.
– WKS ‐ > 100 mg IV for several days or longer, followed by IM thiamine or high doses of oral until symptoms have resolved or significantly improved.
• Preoperative risk for deficiency:
– Bentley et al (2006)reported that the proportion of women aged 15‐
44 y.o.(in the general population) who meet the RDA of 400 mcg/day folate varies between 23% and 33%.
– Increasing popularity of high protein/low carbohydrate diets, one cannot assume adequate intake of good dietary sources.
– Boylan et al (1988) found folate deficiencies preoperatively in 56% of RNYGB patients studied.
2
Folate Deficiency
Folate Supplementation
• Another potential complication of bariatric surgery. Incidence has been cited from 6 – 65% among RNYGB patients. Increased risk has also been noted among LAGB patients.
• Mechanisms of deficiency include:
• Multi vitamin (400 mcg) prevents deficiency in most cases.
• 400 additional mcg with pregnancy or women expressing a desire to become pregnant. (Most prenatal vitamins provide 1 mg).
• Recent movement towards 800 mcg (200% RDA) for all patients who have bariatric surgery.
• Folate supplemented in doses of 1 mg/day should correct deficiencies within 2 to 3 months.
– Absorption facilitated by hydrochloric acid in the stomach.
– Primary site of absorption – upper 1/3 of small intestine, however, if bypassed can adapt to absorb along entire length of small bowel.
– Vit B12 act as a coenzyme in absorption process – deficiency in vit B12 may cause subsequent folate deficiency.
– Reduced dietary intake or noncompliance with vitamin supplementation.
• Serum folate reflects recent dietary intake rather than folate
status; RBC folate more sensitive marker.
• Signs/symptoms: megaloblastic anemia, thrombocytopenia, leukopenia, and glossitis.
• Serious threat for women who become pregnant – risk for neural tube defects.
Vitamin B12
Preoperative Risk For Deficiency
Vitamin B12
• Madan et al (2006) found that 13% (n = 59) of patients presenting for a RNYGB were deficient in vitamin B12.
• Food sources:
– Fish, liver, poultry, meat, milk, and shellfish
• Skourbis et al (2006) found that patients presenting for either RNYGB or BPD had low‐normal vitamin B12 levels in both groups.
• Recommended Dietary Allowance:
– 2.4 mcg/day
Vitamin B12 Deficiency
Vitamin B12 Deficiency
• Documented to occur in 12 – 75% of RNYGB patients. Majority of reports citing deficiency at ~ 35%.
• Substantial body storage (1‐5 mg) compared to daily needs (1‐
2 mcg).
• Despite high incidence to low serum levels, few develop symptoms.
• Absorption significantly altered following RNYGB
– Usually not an issue with purely restrictive procedures (LAGB, VBG, sleeve gastrectomy) or DS secondary to preservation of more gastric mucosa.
– > 300 – unlikely (1‐5%)
– < 200 – likely (95+% specificity)
– 200 – 300 – possible (check Methyl Malonic Acid – MMA & Homocysteine levels
• Mechanisms of deficiency include:
– Altered gastric acid prevents cleavage of vitamin B12 from food
– Inadequate secretion of intrinsic factor
– Decreased vitamin B12 consumption due to intolerances –
meats and milks (2 primary sources)
• Signs/symptoms: macrocytic anemia and neurologic deficits, including weakness, paresthesias, leg weakness, gait instability, apathy, irritability, personality changes, and dementia.
• If deficiency persist, irreversible neuropathy can occur.
3
Vitamin B12 Supplementation
Other B vitamins
• Oral supplement – 500 mcg/day. (Several studies have shown that oral supplementation in doses of 300‐500 mcg/day were sufficient to correct deficiencies).
• Intramuscular injections –
1000 mcg/month. (Recommendations in the literature range from 100 mcg/month to 1000 mcg every 6 months).
• Nasal spray – 500 mcg/week or 50 mcg/day
• Vit B12 patch – one patch (1000 mcg) per week
• Little published on deficiency in the bariatric population.
• Turkki et al (1990)
– Recognized that riboflavin requirements of women after a gastroplasty tended to be slightly higher than the RDA (1.3 mg/day) at the time of the study. Supplemental intake of 1.7 mg/day prevented tissue depletion.
• Boylan et al (1988) and Turkki et al (1989) – Concluded that supplementing patients with the RDA for Pyridoxine ‐B6 (1.6 mg/day) should maintain vitamin levels within the normal range.
ASMBS Allied Health Nutritional Guidelines ‐ 2008
B‐Complex Supplements
• Literature has been published that addresses the effect of malabsorptive, restrictive, and combination surgical procedures on acute and long‐term nutritional status.
• Few have included the necessary components to evaluate absorption of a prescribed and/or monitored diet in a controlled setting.
• Members of the medical team need to increase their awareness of the nutritional complications and challenges that lie ahead for their patients.
• Are suggesting the addition of a B – complex supplement daily for all weight loss patients to protect against the possibility of vitamin ‐ B deficiencies.
Bariatric Supplement
•
•
•
•
•
•
•
•
Is your weight loss surgery program currently screening for preoperative vitamin B deficiencies?
1. Yes
2. No
Thiamine ‐ 50 mg
3333% DV
Folic Acid – 400 mcg 100% DV
Vit B12 – 250 mcg 4167% DV
Riboflavin – 50 mg 2940% DV
Niacin – 50 mg 250% DV
Pyridoxine – 50 mg 2500% DV
Biotin – 500 mcg 167% DV
Pantothenic Acid – 50 mg 500% DV
Vitamin B‐50 Supplement
•
•
•
•
•
•
•
•
Thiamine – 50 mg
3333% DV
Folic Acid – 400 mcg
100% DV
Vit B12 – 50 mcg
833% DV
Riboflavin – 50 mg
2,940% DV
Niacin – 50 mg
250% DV
Pyridoxine ‐ 50 mg
2,500% DV
Biotin – 50 mcg
17% DV
Pantothenic Acid – 50 mg 500% DV
How is your weight loss surgery program currently using B‐complex supplements?
1. Used for all patients who have had surgery.
2. Used only for patients who have had malabsorptive procedures (RNYGB, DS).
3. Used only for the treatment of vitamin B deficiencies.
4. Not currently using B‐complex supplements.
4