Vitamin Deficiencies and Weight Loss Surgery

Nutritional and Vitamin deficiencies following bariatric surgery.

While we are all thinking of finding some healthy holiday meals, and enjoying some excellent holiday recipes, let’s not forget our important vitamins!

Modern weight loss surgery is a highly successful intervention by almost any measure. In numerous studies modern weight loss surgery is demonstrated to prolong life, improve quality of life, and reduce the incidence and impact of many health conditions including diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, degenerative joint disease and many others. But weight loss surgery can lead to vitamin and nutritional deficiencies in some cases. These deficiencies can be serious, so it’s important for patients to prevent them by remembering to take the vitamin supplements your bariatric surgeon recommends!

Some overweight individuals have preoperative vitamin and nutritional deficiencies before they ever even attend a weight loss seminar. After bariatric surgery, the most common deficiencies occur in the operations which have a “malabsorptive” component, in which some of the intestine is bypassed, and some of the nutrients are not absorbed. In some intestinal bypasses performed prior to the 1970s, numerous nutritional deficiencies occurred that in some cases led to liver failure and hurt the reputation of weight loss surgery (despite the deficiencies, however, patients who had jejunoileal bypass markedly outlived their obese counterparts who did not undergo weight loss surgery).

Today, the frequency and severity of vitamin deficiencies is least after LapBand surgery (which usually requires only the Omni Bariatric Vitamin supplement), then increases with Gastric Bypass (which requires the vitamin supplements listed in the table below), followed by further increases with Biliopancreatic diversion or long limb gastric bypass (even more nutritional/vitamin supplements needed – email us for a list). In the vast majority of cases, vitamin deficiencies can be prevented by taking the vitamin supplements your bariatric surgeon recommends. iMeatbolic makes all of these supplements, made in FDA-inspected labs, available on their website at www.imetabolic.com.

VITAMIN SUPPLEMENTS NEEDED AFTER GASTRIC BYPASS

Symptoms if deficient To Prevent deficiency, take:
Iron Fatigue, pale skin, cold intolerance and glossitis. FeSO4 325 mg daily
B12 Hand/foot numbness, tingling, fatigue Daily sublingual B12 or monthly injections
Calcium-Vit D Bone weakness Ca-Vit D supplemet daily
B complex, trace minerals Various symptoms possible Omni Bariatric Chewable Multivitamin

Iron

Iron deficiency anemia is among the most common nutritional abnormalities. Many female preoperative have iron deficiency, as high as 44% of patients in recent studies, including one in the Journal of Gastrointestinal Surgery. After Roux-en-Y gastric bypass surgery, as many as 75% of patients exhibit iron deficiency anemia if iron is not supplemented and the condition not treated.

Gastric bypass leads to iron deficiency anemia in large part because the bypassing of the acid-producing portion of the stomach prevents the reduction of iron to the absorbable ferrous iron. If you are experiencing symptoms such as fatigue or discomfort or enlargement of the tongue, these could be signs of significant iron deficiency anemia. Sometimes people with iron deficiency also feel cold even when the room temperature is normal. The problem is detected with a routine blood test, hemoglobin and serum iron studies (iron level, TIBC, ferritin, transferrin)

Iron deficiency is common enough that iron supplementation is recommended for every patient undergoing weight loss surgery. We generally use ferrous sulfate, 325 mg p.o. daily or this can be increased to twice a day. For more severe cases, intravenous iron infusion may be required.

Vitamin B12

B12 (cyanocobalamin) deficiency is common following bariatric surgery, especially Roux-en-Y gastric bypass surgery. The decreased exposure to stomach acid and the less overall secretion of stomach acid leads to less release and absorbtion of vitamin B12 from foods. Oftentimes, patients consume less B12 because foods such as beef and chicken are consumed less frequently.

Sometimes people who are deficient in B12 may also experience tingling or numbness in their hands and feet, or unsteady walking. Sometimes people experience an enlarged tongue, weakness or depression. Because B12 deficiency would occur commonly after gastric bypass surgery, it is a standard recommended supplement postoperatively. This is given either as an intramuscular injection monthly with 1000 to 3000 mcg per injection. Intramuscular injections are available locally at iMetabolic, at 971 W. Moana at Lakeside. More recently, good absorption of B12 occurs with sublingual preparation and nasal sprays. Our standard practice is for every patient to take sublingual B12 daily for a lifetime. Sublingual B12, and all of the vitamins we recommend, are available at our website and soon at the WBI Arlington office itself, after the renovations are done!

Thiamine

Thiamine is otherwise known as vitamin B1. Thiamine is found in foods such as beef and pork and to a lesser extent in some legumes, dried beans, peas and in certain grains. Mild thiamine deficiency is fairly common among seriously overweight individuals prior to surgery and can worsen after surgery or any prolonged illness with vomiting. The symptoms of thiamine deficiency can be vague and include fatigue, poor memory, appetite suppression, abdominal discomfort, difficulties with balance or unsteady walking, even confusion or neurologic changes. It is supplemented in the bariatric multivitamins an can be further supplemented if necessary in rare cases.

Vitamin B6 (pyridoxine)

Vitamin B6 is present in meats, beans, whole grains and certain nuts. Many people are deficient in B6 if it is tested rigorously. The incidence is probably increased after gastric bypass and bariatric surgery. It appears to be well absorbed and effective if given in a standard multivitamin dose. There are symptoms such as those of thiamine and B12.

Folic acid

Folic acid is important for red blood cell production. It is present in green leafy vegetables, as well as beans. Folate is another B complex vitamin that is absorbed less after gastric bypass surgery or any procedures that decreases the stomach acids’ contact with the meal. Confusion, weakness, anemia, enlarged tongue and neuropathy are all symptoms of thiamine(?) deficiency. It is treated with thiamine replacement and is generally bioavailable in the multivitamin. It can also be given as an intravenous supplementation.

Calcium and vitamin D

Mineral calcium and vitamin D are interrelated as they work together in maintaining the serum calcium levels. Vitamin D is found in milk, eggs, fish and liver. Calcium is present in dairy products. Calcium deficiency may result after gastric bypass and Vitamin D deficiency may result from any type of intestinal bypass procedure that leads to decreased absorption of fat-soluble vitamins. Fat-soluble vitamins (A, D, E and K) tend to be reduced most in biliopancreatic diversion, duodenal switch, and jejunoileal bypass. The fat-soluble vitamins can also become deficient in patients taking Alli or Xenical, the fat-blocking weight loss drug. The active form of vitamin D requires sun exposure to the skin.

Deficiencies of calcium and vitamin D lead to increased breakdown of bone deposits to liberate calcium for the bloodstream. Symptoms of vitamin D and calcium deficiency are muscle aches, fatigue, joint pain. Progression to osteoporosis increases risk of bone fracture.

Calcium and vitamin D should both be supplemented with1200 mg of calcium and 8 mcg of vitamin D or more. Some bone loss appears to occur with significant weight reduction independent of calcium and vitamin D deficiency.

Vitamin A

Vitamin A is a fat-soluble vitamin present in an array of foods including dairy products, pumpkins, cantaloupe and liver. Deficiencies of vitamin A can lead to night blindness and ocular symptoms. Deficiencies of vitamin A generally occur as a result of the deficiencies that involve the fat-soluble vitamins. This generally results from an intestinal bypass procedure such as jejunoileal bypass (no longer performed) or biliopancreatic diversion/duodenal switch procedures. In these procedures, fat absorption is markedly impaired. There is the potential for vitamin A deficiency with use of Xenical or Alli weight loss medications.

Treatment can be given with oral or intramuscular vitamin A. Specific oral vitamin A routine supplementation is not generally felt to be necessary after Lap Band or gastric bypass, but is necessary after duodenal switch or biliopancreatic diversion.

Vitamin K

Vitamin K is a fat-soluble vitamin present in green leafy vegetables. Deficiencies can lead to impairment of the blood clotting system and therefore lead to bruising and bleeding of the gums. Vitamin K deficiency is possible after procedures that result in significant fat malabsorption such as biliopancreatic diversion or duodenal switch and jejunoileal bypass. It appears to be less common and reported and is not routinely supplemented or tested.

Vitamin E

Vitamin E is found in green leafy vegetables, nuts, seeds and vegetable oils. Vitamin E deficiency appears rare and is associated with neurologic symptoms. It is not routinely tested or supplemented.

Protein deficiency and muscle wasting

Protein is increasingly recognized as import for maintaining muscles and for helping with weight loss. Bariatric centers generally recommend a person consume between 60 and 100 grams of protein daily.

Protein deficiency is often detected by serum protein measures including total protein, albumin and prealbumin. Protein deficiency can occur in patients who have complications following bariatric surgery or if they experience excessive food intolerance and diminished protein intake. Usually this problem is resolved once the person has begun eating more foods.

For patients with routine postoperative courses, emphasis on protein supplementation with meal replacements, shakes, bars and carefully selected foods are important to emphasize. A wide variety of protein-based shakes and snacks and other delicacies are now produced by high quality labs and manufacturers. We have made many of these available online at our website and at iMetabolic. Let us know online which ones you like or what others you would like to see carried!

It is also important to emphasize muscular activity to stimulate synthesis of muscle mass and preservation of lean body mass during rapid and profound weight loss.

Zinc

Zinc is a mineral found in meat, fish, eggs, grains and nuts. Zinc deficiency may be present in 5 to 10% of patients prior to surgery and zinc deficiencies result from procedures involving malabsorption, including gastric bypass surgery. Zinc deficiency is associated with hair loss, skin rashes and impaired wound healing. It is recommended to routinely supplement postoperatively with zinc in the form of a multivitamin that contains zinc. For specific identified deficiencies, increased dose of zinc sulfate may be warranted and may arrest hair loss following gastric bypass surgery.

Selenium

Selenium is a mineral that is an antioxidant like vitamin E. Selenium deficiency has been reported in a small percentage, perhaps 5%, of obese patients prior to bariatric surgery. After bariatric surgery, selenium deficiency increases although it is not clear what symptoms may arise as a result of impaired antioxidant function. Selenium supplementation is recommended as part of a multivitamin.

Conclusion

So enjoy the holidays, work hard to avoid the carbohydrates in all the holiday treats. Remember your weight loss and health goals. At Holiday events, try to enjoy the people more, and the food less! It sometimes takes hard work to achieve your potential, but you can do it.

And don’t forget your vitamins!

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Dr. Kent Sasse, Medical Director | 75 Pringle Way Suite 804 Reno, NV 89502 | Phone: 775-829-7999

Dr. Kent Sasse serves the entire city of Reno and all the surrounding areas. Dr. Sasse is one of the nation's foremost medical weight loss and bariatric surgical experts.
Dr. Sasse has educated patients about food nutrition and weight loss for many years.

Copyright © 2007-2010 Kent Sasse, M.D. All Rights Reserved.

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