What Condition Is Your Nutrition In?

Most patients are elated with their weight loss and their new perspective on life after weight loss surgery. Sometimes they are feeling so good, they decide to quit taking their supplements or for some reason decide they are not necessary. Unfortunately, it is well documented that nutrient deficiencies can occur after gastric restrictive and malabsorptive procedures.

What do I mean by restrictive and malabsorptive? Restrictive means the size of the space the food goes into is limited. RYGB (roux-en-y gastric bypass) patients no longer have a stomach that can hold almost a quart after surgery. This means they cannot eat enough nutritious foods to get all the vitamins and minerals their body needs to function correctly because of the limited size of their stomach. Patients can no longer skip meals all day, eat one big meal, and hope to stay healthy the rest of their life. Malabsorptive means that you do not absorb all the nutrients from your food because a small or large section of your small intestine is bypassed which is where most nutrients are absorbed. The RYGB, BPD (biliopancreatic division) and BPD/DS (biliopancreatic division/duodenal switch) are malabsorptive operations.

I’m always surprised at the number of patients who do not know the type of surgery they had or how much of their small intestine was bypassed. You should know and understand your surgery and possible nutrition deficiencies associated with it. If you do not know or understand, sit down with the appropriate member of your bariatric team and find out. Following are some of the more common deficiencies associated with gastric weight loss surgeries.

B12 (cobalamin) Several studies have cited that > 30% of patients may become B12 deficient. In comparison, thirty percent of the general population of the U.S. has been reported as being B12 deficient. RYGB patients are at higher risk than the general population because the mechanism of B12 absorption has been altered by surgery. There are several options for B12 supplementation. Oral crystalline B12 taken daily in doses of at least 350 ug (micrograms), sublingual B12 (under the tongue) 500 ug daily, 1,000 ug shot monthly which can the patient can learn to give his/herself, or a nasogel spray taken weekly. Our patients using sublingual are doing well, sometimes even running a little higher than the range (*200 to 1100 pg/ml). If so, I just have them cut back and monitor their labs to keep them in a middle range of around 600. There is no known toxicity level for B12 at this point in time.

Iron (ferritin) Iron deficiency has been reported at 33 to 55% with most of the deficiencies occurring in menstruating females. The major site of absorption for iron is the duodenum, which is the first section of the small intestine. Minerals like iron and calcium need acid to break them down and there is little or no acid secretion in the small pouch with the possible exception of the BPD/DS. Menstruating females should be receiving 40 to 65 mg of iron on a daily basis. This can be accomplished through a prenatal vitamin/mineral supplement or a separate iron supplement like ferrous sulfate, fumerate, or gluconate. These are all iron salts so the actual amount of elemental iron in 325 mg of ferrous sulfate is 65 mg. In our bariatric practice, our patients take a daily multivitamin/mineral supplement with iron and menstruating females take 65 mg of additional iron daily. Even this dosage does not always keep some patients levels from going to low. A recently released study stated that women’s levels of ferritin should not fall below 40 ug/ml. Some patients decide not to take iron because it is too constipating and their iron levels (serum ferritin) often fall below seven (*normal range is 20 to 140). A few of our patients actually had to have IV infusions because their levels dropped so low. If iron is making you constipated or upsetting your stomach, try another brand or form. Ask your dietitian for suggestions and keep trying until you find something that works. Taking the iron in smaller doses and with meals is sometimes helpful. Some surgeons will prescribe Trinsicon, which contains folate, iron, and B12.

Folate Folate deficiency occurs much less often. I initially have our patients on 800 ug the first six months, then cut them back to the RDA (recommended dietary allowance) of 400 ug after 6 months. Most of our patients have been actually running a little on the high side, 14.7 average, (*normal range > 2.6 mg/ml), so I have not seen this to be an issue at this point. By six months out, most patients can incorporate good sources of folate in their foods in addition to their vitamin/mineral supplement such as green leafy vegetables and fortified cereals.

Calcium Bone disease is a possible long term risk. There are no statistics or studies done on this issue but there are currently at least three surgery centers undertaking this task. Again, let’s look at the general population. Almost half of all women over 50 in the U.S. have osteoporosis (brittle bones). If you have this disease, sneezing can cause ribs to break or falling can cause a hip fracture. You are much more likely to get osteoporosis than breast cancer where the risk is 1 out of every 9 women. Once you are diagnosed with osteoporosis, there are medications they can give you and there are some promising treatments on the horizon, but why go there. Some RYGB patients have lactose intolerance, especially distal patients as well as do some BPD patients. Deficiency can occur because of low intake of calcium and Vitamin D rich foods like milk and yogurt, lack of sunlight, bypass of the duodenum, (the major site of absorption for calcium), and the malabsorption of fat that occurs in BPD and BPD/DS. Vitamin D is needed to absorb calcium. In BPD/DS, the patient can eat fairly normal amounts, but is not absorbing much fat. Vitamin D is a fat-soluble vitamin. When fat is passed through the intestinal tract, it often includes other nutrients besides the fat-soluble vitamins A, D, E, and K like zinc and calcium. With the distal RYGB with a common channel of 150 cm or less, BPD, and BPD/DS, water-soluble forms of Vitamins A and D should be taken and monitored along with other nutrients that can be effected with fat malabsorption.

The AI (adequate intake) of calcium for men and women under age 50 is 1,000 mg daily and 1,200 mg for men and women age 50 and older. The AI for Vitamin D for men and women under 50 is 200 IU, 400 IU for men and women between age 50 and 70, and 600 IU for men and women over 70. Vitamin D is considered safe or non-toxic up to 2,000 IU daily. Calcium is considered safe up to 2,500 mg per day. Remember, as we age, our cells don’t absorb nutrients as well so needs may rise after age 68 for certain nutrients.

The RDA is being replaced with the DRI (dietary reference intake). The DRI includes the EAR (estimated average requirement), the RDA, the AI, and the UL (tolerable upper intake level). The DRI is a tool used by nutrition health professionals to plan and assess diets for the healthy population. The EAR serves as a foundation for setting the RDA. If not enough scientific data is available, an AI is set instead of a RDA. The RDA is the average daily dietary intake level that is sufficient to meet the nutrient requirements of about 98% of all healthy individuals in a life stage and gender group. The RDA by itself is used only as a goal, not as an assessment or planning tool. The UL is the maximum daily intake of a nutrient that is likely to pose no risk of adverse effects or toxicity. Sometimes weight loss surgery patients may even surpass the upper limit to maintain adequate blood levels of nutrients like iron, calcium, and Vitamin D.

To learn more about the DRI, go to www.cc.nih.gov/ccc/supplements or www.nap.edu. The National Academy of Sciences publishes the DRI. To learn more about the different nutrients and what they do for your body, go check out a nutrition book at your local library or take a course at your community college. Two great articles from journals are: Managing the Obese Patient After Bariatric Surgery: A Case Report of Severe Malnutrition and Review of the Literature, Robert Kushner, Journal of Parenteral and Enteral Nutrition, pages 126 – 132, Volume 24, Number 2, 2000 and a review article by Francis Cannizzo, Jr. and John G. Kral in the journal, Current Opinion in Clinical Nutrition and Metabolic Care, titled, Obesity Surgery: A Model of Programmed Undernutrition, Volume 1(4), July 1998, pages 363-368.

As you can see, follow-up after surgery with your bariatric team is important to maintain good health for the rest of your life. Your labs must be monitored to make sure your blood levels are sufficient in all areas, and if not, supplemented to keep problems from occurring. Even though you may not be having clinical signs of severe deficiency like rickets or beriberi, you could have mild deficiencies that are enough to cause problems. Remember, thin is not healthy. We are all responsible for good self-care which includes eating nourishing foods to get the proper amount of protein, vitamins, minerals, fiber, etc., staying physically active, getting enough rest, and taking time to relax everyday. Please note that lab values may differ between different laboratories.