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VITAMIN AND MINERAL SUPPLEMENTATION AFTER BARIATRIC SURGERY Adam Bryant, B.Sc, B.A.Sc, RD Bariatric Program St Joseph’s Healthcare Hamilton

VITAMIN AND MINERAL SUPPLEMENTATION AFTER BARIATRIC …cabps.ca/Conference2012/POSTCONFERENCE/PDF/Fri... · Plasma retinol < 0.70 umol/L indicates vitamin A deficiency* ! Treatment

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Page 1: VITAMIN AND MINERAL SUPPLEMENTATION AFTER BARIATRIC …cabps.ca/Conference2012/POSTCONFERENCE/PDF/Fri... · Plasma retinol < 0.70 umol/L indicates vitamin A deficiency* ! Treatment

VITAMIN AND MINERAL SUPPLEMENTATION AFTER BARIATRIC SURGERY Adam Bryant, B.Sc, B.A.Sc, RD

Bariatric Program

St Joseph’s Healthcare Hamilton

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Disclosures

¨  I have no disclosures to make

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Overview

¨  Bariatric Surgery in Ontario

¨  Etiology and prevalence of micronutrient deficiency

¨  Managing micronutrient deficiency ¤  Prevention ¤  Treatment ¤  Practical Considerations

¨  Future Research

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Bariatric Surgery in Ontario

Roux-en-Y Gastric Bypass (RYGB)

Vertical Sleeve Gastrectomy (VSG)

Duodenal Switch (DS)

Image source: Ethicon Endo-Surgery, INC.

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Etiology of Micronutrient Deficiency

Micronutrient Deficiency

Type of Surgery

Reduced Absorption

Reduced Availability from Food Sources

Reduced Dietary Intake

Food Intolerances

Lack of balance in

post-op diet

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Common Deficiencies

Micronutrient VSG RYGB DS

Vitamin A ? + ++

Vitamin B1* + + +

Vitamin B12 ++ ++ ++

Vitamin D ? ++ +++

Iron** + ++ ++ * Increased with persistent vomiting

** Rates higher for menstruating women

? Unclear

+ Low prevalence

++ Moderate prevalence

+++ High prevalence

Adapted from :

1)  Kushner - ASPEN 2012 presentation

2)  Stohmayer, E et al (2010). Metabolic Management following Bariatric Surgery. Mt Sinai Journal of Medicine. 77:431.

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Clinical Practice Guidelines

¨  Aills, L., et al. ASMBS Guidelines: ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. SOARD. 2008(4); S73-S108.

¨  Mechanick, JI., et al. AACE/TOS/ASMBS Bariatric Surgery Guidelines, Endocr Pract. 2008;14(Suppl 1):1-83.

¨  Ziegler, O., et al. Medical follow up after bariatric surgery: nutritional and drug issues. General recommendations for the prevention and treatment of nutritional deficiencies. Diabetes & Metabolism. 2009;35:544-557.

¨  Heber, D., et al. Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 2010; 95(11):4823-4843.

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Managing Micronutrient Deficiency

¨  Micronutrient deficiencies are predictable and preventable

¨  Supplementation is for life

¨  Routine screening is imperative

¨  Educating patients and staff about signs/symptoms of deficiency is important

¨  CPG documents offer similar prevention/treatment recommendations though doses vary

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Routine Daily Supplementation

Supplement RYGB DS

Multivitamin 200% DRI 200% DRI

Additional Iron* 40-65 mg 40-65 mg

Calcium 1200-2000 mg 1800-2400 mg

Vitamin D 400-800 IU 2000 IU

Vitamin B12 350-500 mcg 350-500 mcg

Vitamin A - 10,000 IU

Vitamin E - 400 IU

Vitamin K - 300 mcg

B complex optional optional

* For menstruating women

Adapted from Aills et al. 2008 & Mechanick et al. 2008

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Thiamin (B1)

¨  Prevention ¤  Multivitamin providing 200% DRI recommended for prevention

¤  Persistent vomiting over weeks/months can precipitate deficiency

¨  Screening ¤  Diagnosis often based on clinical presentation

¤  Can test serum thiamin and erythrocyte transketolase activity to confirm

¨  Treatment ¤  Prophylactic supplementation for patients with persistent vomiting

n  50-100 mg/day oral thiamine OR 100 mg IM thiamine

¤  Aggressive medical intervention for patients presenting with symptoms

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Iron

¨  Prevention ¤  1-2 adult multivitamins daily, each containing at least 18 mg iron ¤  Menstruating women need additional iron

n  40-65 mg elemental iron (in addition to iron in MVI)

¨  Screening ¤  First detected through decreased serum ferritin

¤  Other iron indices change with advancing deficiency

¨  Treatment ¤  300 mg ferrous sulfate up to 3x/day

¤  Advanced deficiency may require IV iron infusions

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Vitamin B12

¨  Prevention ¤  350-500 mcg/day crystalline B12, either orally or sublingually

¤  or 1000 mcg/month IM injection

¨  Screening ¤  Serum B12

¤  Increased homocysteine and/or methylmalonic acid

¨  Treatment ¤  1000 mcg/week IM x 8 weeks

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Calcium and Vitamin D

¨  Prevention ¤  1200-2000 mg calcium citrate

¤  400-800 IU vitamin D

¨  Screening ¤  25-OH vitamin D

¤  PTH, alkaline phosphatase, bone mineral density scan?

¨  Treatment ¤  Mild deficiency – 4000-6000 IU/day

¤  Advanced deficiency – 50,000 IU/week vitamin D2 x 8 weeks

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Vitamin A

¨  Prevention ¤  Routine multivitamin (no additional A for RYGB)

¨  Screening ¤  Plasma retinol < 1.05 umol/L indicates sub-optimal vitamin A status*

¤  Plasma retinol < 0.70 umol/L indicates vitamin A deficiency*

¨  Treatment ¤  Mild deficiency – 10,000 IU/day oral vitamin A x 1-2 weeks

¤  Advanced deficiency may require high-dose IM vitamin A

* Sommer A, Davidson FR. Assessment and control of vitamin A deficiency: the Annecy Accords. Journal of Nutrition, 2002, 132: 2845S–2850S.

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Practical Considerations

¨  Patient tolerance and preference

¨  Practical dosing

¨  Correct timing

¨  Cost to patient

¨  Brands & Availability

Time Sample Supplement Schedule

Breakfast Multivitamin x 2 Vitamin B12

Lunch Calcium (500-600 mg) Vitamin D (200-400 IU

Mid-Afternoon Calcium (500-600 mg) Vitamin D (200-400 IU)

Supper Calcium (500-600 mg) Vitamin D (200-400 IU)

Bedtime If needed

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Future Research

¨  Incidence of micronutrient deficiency after VSG

¨  Optimal formulations/doses/timing for micronutrient replacement

¨  Establishing clear guidelines for “deficiency” and when to start treating

¨  Factors influencing compliance with supplements

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Future Research in Ontario

¨  Ontario Bariatric Network Dietitian Task Force ¤  “Consensus Recommendations for Vitamin and Mineral Supplementation after

RYGB Surgery”

¨  A. Buckley, K. MacKinnon, T. Marcoux and K. Loney ¤  “A Systematic Literature Review of Iron Supplementation for Post-Roux-en-Y

Gastric Bypass Patients”

¨  Chart reviews

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Summary

¨  Micronutrient deficiency is a predictable and preventable consequence of bariatric surgery

¨  Routine supplementation is crucial

¨  Understanding how to screen for, identify and treat deficiencies is also crucial

¨  Future research will hopefully help to standardize prevention and treatment strategies

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Acknowledgements

¨  Dr Mehran Anvari

¨  Stephanie Kirsic, RD

¨  Lori Hollett, RD

¨  Jennifer Brown, RD

¨  Sue Ekserci, RD

¨  OBN Dietitian Task Force