| Vitamins and Minerals |
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Vitamin and mineral problems can occur after weight loss surgery,
but in general this issue is overestimated by the average patient. Patients
who have precipitous weight loss after gastric bypass surgery, are down
to or below their ideal body weight, or who have had mechanical
complications related to the surgeries that could have resulted in
malnutrition are far more likely to suffer vitamin and mineral
deficiencies than average patients. Since the LapBand operation does not change the intestinal anatomy the absorption of vitamins and minerals are not much affected. Vitamin and mineral deficiencies are rare. We recommend LapBand patients only take a multivitamin such as VITABAND. Gastric Bypass patients can develop deficiencies as a result of the change in the anatomy. These problems occur in a minority of patients. However, it is absolutely essential that patients be screened for these problems by routine blood tests periodically. We do this before each appointment, starting 1 month after surgery. The standard laboratory blood tests we check on the patients are…. Blood count (CBC) Electrolytes (SMA-7) Ionized Calcium Parathyroid Hormone Level (PTH) Albumin Prealbumin Total Protein Iron Total Iron Binding Capacity (TIBC) Ferritin Vitamin B12 Vitamin B1 Folate Deficiencies Iron Deficiency – this is the most common deficiency seen in our patients after gastric bypass surgery. Conversely, it is the most common deficiency seen in our patients before the operation. Gastric Bypass reroutes the food away from the distal stomach and the first portion of the small intestine – the duodenum. The duodenum is where most elemental iron is picked up in the intestinal tract. Because of this, gastric bypass results in worse iron absorption. We screen all patients for iron deficiency pre-operatively: if they are low, we give supplemental iron and see if iron level rise in the blood to normal levels. If iron remains low then it can be assumed the patient has poor iron absorption. We do not recommend gastric bypass in these patients. For those whose iron levels rise to normal we would continue with gastric bypass if they choose that surgery. In patients who develop iron deficiency after operation we will treat the deficiency with a ferrous fumarate formulation (REPLIVA) for 2 months. If they return to normal we would recommend a maintenance iron formulation to be taken from then on. Occasionally, iron deficiency can be profound after gastric bypass surgery necessitating iron infusion therapy intravenously. Vitamin B12 – For vitamin B12 to be effectively absorbed from the intestine it needs to be bound to a substance produced in the stomach called “intrinsic factor.” After gastric bypass the B12 in the patients’ diet is less effectively bound to intrinsic factor and therefore may not be picked up as well. Vitamin B12 deficiencies are not common, but can occur slowly, several years after surgery. Profound deficiency - < 250pg/dl – is treated by either injection or application of a spray to the nasal lining (NASCOBAL) for several months. Patients in the low normal range 250-400 pg/dl should take a vitamin formulation specifically for B12 deficiency (). After the deficiency has been corrected the patient should take a supplemental B complex vitamin formulation from then on. Vitamin B1 (Thiamine) – B1 deficiency is rare after weight loss surgery, however, it can become important with generalized malnutrition or other medical problems (e.g. alcohol abuse). Deficiency leads to a number of problems with mental status changes, ending in hallucinations and problems with movement being the most commonly cited. Treatment would require IV thiamine if severe, followed by maintenance B complex vitamins for life. Folic Acid – This is the least common of the recognized vitamin deficiencies after gastric bypass surgery. It occurs in fewer than 1% of the patients. It should be treated for several months with an oral replacement therapy. We suggest that the standard multivitamin taken after gastric bypass be one that contains folic acid. Folic acid is a main ingredient of any vitamin formulation that is considered “prenatal.” Calcium – Low calcium levels can occur after gastric bypass. Since most calcium in the blood stream is bound to protein, anyone who has protein deficiency after gastric bypass is likely to have a low total calcium level on standard blood tests. This does not mean necessarily mean that the functional level of calcium in the blood is low. The test should be repeated to check the ionized calcium level – this is the true marker of calcium deficiency. A complete assessment of calcium status also includes the parathyroid hormone level(PTH). This hormone becomes elevated when the blood concentration of calcium starts to drop. An elevated PTH associated with a normal or low-normal ionized calcium is an indicator of calcium deficiency. If the ionized calcium level is low the patient should be take an oral preparation of calcium such as (Tums 500mg tabs, 4 tablets a day). Of course, it is often a recommendation that women over 40 add supplemental calcium to their diet to prevent eventual osteoporosis. Supplemental calcium despite a normal ionized calcium in this group would be reasonable, as long as too high a level of calcium – hypercalcemia – does not occur. |
