More on vitamins - long read

Nutrient Deficiencies and Health Consequences

Part I: Gastric Restrictive Surgeries

Cynthia Buffington, Ph.D.

Beyond Change, July 2002

Nutrient deficiencies following bariatric surgical procedures can lead to
serious health consequences if left unattended. The provision of knowledge
to bariatric surgical candidates of the nutrient deficiencies associated
with their particular surgical procedure and the steps necessary to avoid
their occurrence is the responsibility of the bariatric surgeon and his/her
staff. Taking those steps, however, is solely the responsibility of the
patient.

Do you take your vitamin/mineral supplements on a daily basis and in the
amounts recommended? Is your body losing bone because you can't remember to
take your calcium? Does your body feel tired and run down because you refuse
to take iron? Is your hair falling out and muscles diminishing in size
because you eat too little protein or refuse to use protein supplements?

Do you realize that hair loss, reduced muscle and bone are only a few of the
many health consequences of long-term nutrient deficiencies? that anemia is
likely to develop with deficits in iron, B12, and folate intake or
absorption? And, did you know that without sufficient levels of zinc,
defects in immune function may occur?

Are you aware that low intake or absorption of B-vitamins can lead to
neurological defects and damage, some which are irreversible ****reatable) ?
Do you know that low anti-oxidant vitamin and minerals may increase the risk
for cancer, heart disease, diabetes, hypertension, cataracts, other
diseases, as well as promote aging?

What are the possible nutrient deficiencies that may occur with the
particular surgical procedure you selected for weight loss and how can such
deficiencies be prevented or treated?

This month's column discusses nutrient deficiencies that have been reported
and the management of such deficiencies following bariatric surgeries that
reduce the size of the stomach, i.e. vertical banded gastroplasty and
adjustable gastric band. Next month's column will examine nutritional
consequences of surgeries that not only reduce the size of the stomach but
also induce malabsorption via bypass of a portion of the gut, i.e. gastric
bypass and biliopancreatic diversion with and without the duodenal switch.

Nutrient management of the Bariatric patient actually needs to begin prior
to surgery. Why? The morbidly obese have numerous metabolic aberrations and
hormonal defects that may negatively influence nutrient status. In addition,
many morbidly obese patients have eating abnormalities, such a high
carbohydrate craving, binge eating, and bulimia, that may cause nutrient
deficits.

A number of studies found that obesity, among adults as well as children, is
associated with low intake, as well as low blood and tissue levels, of
anti-oxidants, including vitamin E, beta-carotene, vitamin C, zinc,
selenium, copper, manganese, molybdenum and others. Several studies also
reported low blood levels of

B-complex vitamins, particularly folate, in morbidly obese surgical
candidates. And, other investigators found that the morbidly obese, prior to
obesity surgery, have low vitamin D.

Since obesity surgery, secondary to calorie restriction or surgical
technique, may cause nutritional deficits, it is of utmost importance that
any pre-existing nutritional problem(s) be corrected prior to surgery. Such
pre-existing deficiencies can usually be corrected by dietary supplements of
vitamins and minerals at levels close to

the RDI taken daily for a period of no less than 2 and preferably 6 weeks
prior

to surgery.

The management of nutrient deficiencies following surgery depends upon the
type of surgical procedure, whether it is purely gastric restrictive
(reduces the size of the stomach only), such as gastric banding or
gastroplasty (stomach stapling), or also contains a malabsorptive component
(bypasses part of the gut) as does the gastric bypass, biliopancreatic
diversion, or duodenal switch.

Gastric restrictive surgeries (gastric banding, gastroplasty) reduce the
size of the stomach and the rate at which food leaves the stomach, all of
which induce weight loss by reducing food consumption. Reports of calorie
intake below 1000 per day are not unusual in the first few post-operative
months following gastric restrictive surgeries. Such low energy intake may
cause nutrient deficiencies, including vitamins and minerals deficits and
protein malnutrition.

Nutrient deficiencies may also occur within the first few months following
gastric restrictive surgery because most patients at this time are consuming
soft foods and liquids instead of solids. Furthermore, during the early
post-operative period, patients may frequently vomit until they have learned
how to eat small food portions and chew their food well.

Frequent regurgitation can lead to serious nutrient deficiencies and eating
abnormalities. Many patients, particularly those who have had a vertical
banded gastroplasty with restrictive ring may become so fearful of vomiting
that they drink their calories or eat processed or high-sugar containing
foods rather than meat, fruits, and vegetables. Such behaviors may lead to
long-term eating abnormalities and nutrient deficiencies.

Studies have reported that, within the early post-operative months following
gastric restrictive surgeries, protein deficits occur, as do reduced intakes
of a variety of vitamin and minerals, i.e. potassium, iron, zinc, phosphate,
calcium, B-complex vitamins, and vitamins E, D, and A.

Such deficiencies can be corrected by taking a daily oral supplement
(chewable form in the early post-op period) with vitamin and mineral levels
at, or close to, the RDI. Protein supplements or intake of foods high in
protein (eggs, cheese, fish, other meats) may, in addition, help to prevent
muscle or hair loss resulting from protein and nutrient deficiencies.

Some nutrient deficiencies may have serious health consequences,
particularly in the early months following surgery. There have been multiple
reports of neurological (nervous system) defects following gastric
restrictive surgery, particularly for individuals who vomit frequently. Such
neurological defects are attributable to vitamin B1 (thiamine) deficiency
and often characterized by double vision, mental confusion or mild memory
impairment, disorientation, severe weakness of the legs and other symptoms.
Correction of such problems generally requires IV infusion of vitamin B1 and
close follow-up medical supervision.

Studies have found that, 12 to 24 months following gastric restrictive
procedures, nutrient intake improves in association with changes in the
pouch, gastric emptying rates and the intake of solid foods. At this time,
protein, vitamin and mineral deficiencies become far less common.

There are reports of long-term nutrient deficiencies, such as for calcium,
following vertical banded gastroplasty in individuals not on dietary
supplements. And, there are other reports of nutrient deficiencies in
post-surgical patients whose diets are high in processed foods and sugar
(crackers, bread, chips, cookies, cakes, etc.) and low in meat, fruits and
vegetables.

The individual who has had gastric restrictive surgeries needs to alter
their diets to include more protein and to reduce considerably their intake
of carbohydrates high in sugar and processed grains. Such dietary changes
will not only improve nutritional status but promote greater weight loss
success, as well. In addition to changes in diet, it is recommended that the
gastric restrictive bariatric surgical patient continue their daily intake
of vitamin and mineral supplements long-term.

In summary, gastric restrictive surgeries can lead to nutrient deficiencies,
i.e. vitamins, minerals, and protein malnutrition. Such deficiencies, if
left unattended, can result in significant muscle loss, anemia, hair loss,
extreme fatigue and even neurological disorders. The greatest risk for
nutrient deficiencies occurs in the first few months following surgery and
generally becomes less prevalent as solids are reintroduced into the diet.

http://bbvitamins. com/physicians_ Articles_ 1.aspx

Nutrient Deficiencies and Health Consequences

Part II: Gastric Bypass and Duodenal Switch

Cynthia Buffington, Ph.D.

Beyond Change, August 2002

Nutrient deficiencies following bariatric surgical procedures can lead to
serious health consequences if left unattended. In last month's issue of
Beyond Change, pre-operative nutritional deficiencies and those following
gastric restrictive surgeries (gastric band, gastroplasty procedures) were
discussed, along with suggestions for nutrient management. This month,
nutrient deficiencies following surgeries that contain a malabsorptive
component, such as the gastric bypass and duodenal switch, are addressed.

Gastric bypass combines both gastric restriction and malabsorption to induce
massive and sustained weight loss. With the gastric bypass, the amount of
food one can consume is reduced considerably by formation of a small gastric
pouch (small stomach) that holds only 2-3 tablespoons of food. In addition,
a ring with a small diameter is often placed at the junction between the
stomach pouch and intestine to slow the rate that food leaves the pouch,
causing one to feel 'full' for a longer period of time.

With the gastric bypass procedure, the part of the stomach that produces
acid and digestive enzymes is bypassed (food no longer passes through), and
the newly formed small gastric pouch produces negligible amounts of acid and
digestive enzymes. Without stomach acid and digestive enzymes, certain foods
are not adequately broken down to release their nutrient content.

The small stomach pouch also produces no intrinsic factor, an agent that
must bind to vitamin B12 for its absorption from the gut into the body. The
gastric bypass procedure, therefore, causes deficiencies in vitamin B12, the
vitamin that assists in the metabolism of food (carbohydrate, fat, and
protein), DNA replication and repair, nerve conductance and function, the
formation of blood cells, and more.

The malabsorptive component of the surgery includes bypass of the upper
portion of the intestines (the duodenum) along with a portion of the jejunum
(the second major segment of the gut). Bypass of the duodenum causes
malabsorption of, and therefore deficiencies in, iron, calcium, zinc, and
folate. Other B-complex vitamins are also reduced with gastric bypass, both
as a result of decreased absorption and to reduced nutrient intake and
digestion. Furthermore, the gastric bypass procedure reduces fat absorption
which may, consequently, cause deficiencies of fat-soluble vitamins,
including vitamins D, E, K, and A.

Studies have shown that daily multivitamin and mineral supplements, at
amounts close to the RDI (Recommended Daily Intake), correct most
micronutrient deficiencies following gastric bypass surgery, with the
exception of zinc, calcium, iron, folate, and vitamin B12. These vitamins
and minerals generally require supplementation at amounts greater than the
RDI.

Several studies have found that, even with supplementation, iron
deficiencies occur in 30% to 60% of the gastric bypass population. Iron
deficiencies occur for males, as well as females, but are more common among
pre-menopausal females. Within the first two years following surgery, 30-40%
of gastric bypass patients have been reported to suffer from anemia
secondary to poor iron absorption.

Iron deficiencies may be prevented with iron taken at amounts given to women
during pregnancy, ~40 mg. Iron as ferrous fumerate or chelated to amino
acids are the most readily absorbable forms of supplemental iron. And, heme
iron, obtained from eating meat, is far more readily absorbed by the gut
than is non-heme iron from plants or supplemental sources.

Approximately 20% of the gastric bypass population is likely to develop
folate deficiencies. Such deficiencies can be corrected or prevented by
intake of supplemental folate at 800 to 1000 micro-grams (?g) per day or
approximately 200% the RDI.

Vitamin B12 deficiencies occur in up to 70% of patients, with as many as 30%
of patients having such deficiency while on supplements that meet the B12
RDI. As mentioned earlier, the small gastric pouch does not produce
intrinsic factor necessary to bind B12 for its absorption out of the gut and
into the body.

Studies have found that B12 deficiencies, for the majority of gastric bypass
patients, can be prevented or effectively treated with B12 supplements in
amounts that are high enough to cause passive diffusion of B12 across the
gut in the absence of intrinsic factor. B12 supplemented at amounts far in
excess of the RDI (as high as 100 to 350 micrograms) have been found to
prevent B12 deficiencies in >95% of post-surgical gastric bypass patients.

Sublingual B12 (under the tongue) taken daily may also be effective in the
prevention of B12 deficiencies since the vitamin is absorbed into the blood
stream and does not need to bind to intrinsic factor for absorption. B12
shots taken daily or monthly are also effective in bypassing impaired B12
absorption and in preventing and treating B12 deficits.

Defects in folate and B12 may cause anemia (pernicious anemia), as well as
elevated production of homocysteine and concomitant increased risk of
cardiovascular disease. Symptoms of folate deficiency include: weakness,
headache, palpitations, forgetfulness, hostility, irritability, paranoid
behavior, apathy, sore tongue, gastrointestinal tract disturbances and
diarrhea.

B12 deficiencies may also cause gastrointestinal disorders, such as
diarrhea, cramping, constipation, as well as palpitations, shortness of
breath, and extreme fatigue. Neurological deficits secondary to B12
deficiencies include impaired bladder control, numbness, tingling of the
extremities, moodiness, agitation, disorientation, insomnia, confusion,
dimmed vision and even delusions and hallucinations. Some of these
neurological deficits caused by B12 deficiencies may be irreversible.

Calcium deficiencies occur following gastric bypass for several reasons.
First, the portion of the gut where calcium is actively absorbed (the
duodenum) is bypassed by the surgical procedure. Secondly, there is
insufficient acid produced by the small stomach pouch to provide enough acid
in the gut for appropriate calcium absorption. Third, changes made in the
mixing of food with pancreatic juices may alter vitamin D absorption. And,
finally, some patients become lactose intolerant after surgery and avoid
dairy products.

Low calcium is known to cause bone loss. Recent studies have also found that
low calcium intake is associated with weight gain. Calcium supplements may,
therefore, not only prevent bone loss but also assist in promoting weight
loss and preventing weight regain following bariatric surgery.

Calcium supplements of 1200 mg to 2000 mg taken in 400-500 mg aliquots 3
times per day are recommended for individuals who have had gastric bypass
surgery. Calcium citrate, rather than calcium carbonate, is more readily
absorbed in the non-acidic environment of the gut of the gastric bypass
patient. Absorption is further enhanced by calcium supplements that include
vitamin D or magnesium.

The high risk for B12, folate, iron deficiencies following gastric bypass
requires that the individual have periodic tests (annually) for blood levels
of ferritin (iron), folate and B12. Blood tests for measurement of blood
calcium are unreliable. When blood calcium is low, the body 'borrows'
calcium from bone and teeth so that levels may appear 'normal'. Thus, it is
wise for the gastric bypass patient to occasionally have a bone scan, a bone
demineralization test, or some other test that can be used as a marker for
low calcium.

Protein deficiencies are common with gastric bypass and occur secondary to:
1) low calorie intake, 2) avoidance of meat, 3) negligible acid and
digestive enzymes produced by the stomach, and 4) reduced absorption of
protein by the bypassed gut. Low protein intake after surgery can cause
muscle loss which, in turn, leads to a reduction in basal metabolic rate
(reduced amount of calories burned at rest), interfering with maximal weight
loss success. The heart is also a muscle and can lose tissue with severe
protein deficiencies. For these reasons, protein supplements and high intake
of protein is encouraged for all gastric bypass patients - and for life.

More and more patients in the United States are choosing the biliopancreatic
diversion with the duodenal switch for weight loss surgery. The individual
who has had the duodenal switch can eat normally because the portion of the
stomach that produces digestive enzymes and acids is reduced but not
bypassed. Weight loss with this procedure is caused primarily by
malabsorption through bypass of a larger portion of the gut.

Possible nutrient problems following the duodenal switch which may occur
without nutrient supplementation include the following: protein
deficiencies, low levels of fat-soluble vitamins (A, E, D, K), low amounts
of B-complex vitamins, low minerals and, in particular, calcium, iron, and
folate deficiencies. Such deficiencies can lead to muscle and bone loss,
anemia, neurological defects, high oxidative stress and associated risk for
disease, and more. To avoid such nutrient deficits with the duodenal switch,
high protein diets or protein supplements and daily vitamins and minerals
are required for life.

In summary, nutrient deficiencies following the gastric bypass and duodenal
switch are common and can lead to serious health consequences if left
unattended. Increased intake of protein or protein supplementation is
necessary long-term following these procedures. Vitamin and mineral
supplements at RDI levels for most micronutrients, or greater than RDI for
specific ones (calcium, iron, folate, zinc, B12), are required for life.
Because nutrient deficiencies have very serious and often irreversible
health consequences, periodic vitamin and mineral blood tests are necessary
on a periodic basis, i.e. usually annually