Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation

Bottom line?

A study just published in the May issue of the American Journal of Clinical Nutrition shows that the majority of gastric bypass patients cannot maintain their nutritional health on a basic multivitamin supplement. The study followed 137 gastric bypass patients for two years.

By the end of year one, 59% of the participants required additional supplements and by the end of year two, this number had increased to 98%.

The most common additional supplements needed were B12, folic acid, calcium, iron and vitamin D. Much less commonly, they identified deficiency of thiamine, zinc, magnesium and B6. The authors concluded that basic multivitamins are not effective at preventing deficiency in gastric bypass, and typical supplementation to keep a gastric bypass patient health averages about $420.00/year when additional nutrients are accounted for.

They also encouraged further study and the use of routine post-operative labs to assess nutritional status.

Source:  American Journal of Clinical Nutrition, Vol. 87, No. 5, 1128-1133, May 2008
© 2008 American Society for Nutrition

Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation^1,2

Christoph Gasteyger¹, Michel Suter¹, Rolf C Gaillard¹ and Vittorio Giusti¹

¹ From the Division of Endocrinology, Diabetology, and Metabolism (CG, RCG, and VG) and the Department of Visceral Surgery (MS), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland

Background: Despite the increasing use of Roux-en-Y gastric bypass (RYGBP) in the treatment of morbid obesity, data about postoperative nutritional deficiencies and their treatment remain scarce. 

Objective: The aim of this study was to evaluate the efficacy of a standard multivitamin preparation in the prevention and treatment of nutritional deficiencies in obese patients after RYGBP. 

Design: This was a retrospective study of 2 y of follow-up of obese patients after RYGBP surgery. Between the first and the sixth postoperative months, a standardized multivitamin preparation was prescribed for all patients. Specific requirements for additional substitutive treatments were systematically assessed by a biologic workup at 3, 6, 9, 12, 18, and 24 mo. 

Results: A total of 137 morbidly obese patients (110 women and 27 men) were included. The mean (±SD) age at the time of surgery was 39.9 ± 10.0 y, and the body mass index (in kg/m²) was 46.7 ± 6.5. Three months after RYGBP, 34% of these patients required at least one specific supplement in addition to the multivitamin preparation. At 6 and 24 mo, this proportion increased to 59% and 98%, respectively. Two years after RYGBP, a mean amount of 2.9 ± 1.4 specific supplements had been prescribed for each patient, including vitamin B-12, iron, calcium + vitamin D, and folic acid. At that time, the mean monthly cost of the substitutive treatment was $34.83. 

Conclusion: Nutritional deficiencies are very common after RYGBP and occur despite supplementation with the standard multivitamin preparation. Therefore, careful postoperative follow-up is indicated to detect and treat those deficiencies.

Comments

[Tom - winelover215]

This should be common knowledge just based on the experiences of other post op patients if people stay up on things. If they follow up and have blood work done most need extra of something. Whatever doctor started telling people taking a few Flintstones chewable vitamins must have been on crack!

[Meghan]

That makes sense... I guess that's why I started out with instructions to take a multi as well as iron, B12, and calcium w/ D.

[teresa]

Back when I was working in hospitals, it was standard procedure to give detoxing alcoholics a thiamine shot immediately to keep them from having seizures (evidently the alcohol washes it out of them due to it's diuretic effect). My point is to say - is it possible your seizures are brought on by a low thiamine level? Or maybe a combination of low glucose and low thiamine? I really wish there was something I could do to help you MM. I can see you are trying very hard to help yourself and it's got to be tremendously difficult being the Mom in the midst of all this.
Take care, Teresa

[MM]

Teresa,

Imagine if you just diagnosed me.

You'd be like Dr. House.

:)

What does Thiamine look like on a Lab Sheet?

[MM]

Wait - is that B-12?

[teresa]

Thiamine is B1. B12 is cyanocobalamin - lack of that one can contribute to/cause anemia.
I'm not sure who Dr. House is since I'm a farm dwellin' non- TV watchin' freak of nature, but I sure am hoping for a simple cause to your problem. Simple is good.

[MM]

I'm looking at labs now - these are the last draws I have:

Vitamin B12

365

Ferritin

4

Folate

15.74

Vit B1 was empty in that column

[teresa]

You know, something just jumped out at me from this drug book I looked up the B
vits in( cuz I couldn't remember if thiamine was B12 ;))
It says that thiamine combines with adenosine triphosphate to form a coenzyme needed for carbohydrate metabolism. So, if you were low on thiamine, and you tended to also run low glucoses, you might be getting a double whammy because the low thiamine would impair your body's ability to metabolize carbs to raise your glucose on it's own. Does that make sense?

[teresa]

Low B6 can also cause seizures. Many of the B vits become low in people who have malabsorption issues (which is essentially what RNY causes). Off the top of my head, I think the B vits are absorbed somewhere in the proximal small intestine, which, depending on how aggressive your surgeon was, may not be intact/present/functioning properly.
I'm going to say something here that may or may not be relevant to you. If this is indeed the root of your problem - someone other than me should have thought of it first. Someone with an MD behind their name. If your thiamine level has not been checked in light of the seizures you've been having with the history of a RNY, that's very poor medical practice and maybe even malpractice! Big ifs, but you have some things to consider/act on.

[MM]

Odd, that ... I have no B levels on my hospital lab sheets then? Other than B-12?

[teresa]

I would assume that when you were at the hospital they were focused on your anemia which is why they would check your B12.
You should find a primary care doctor who has a focus on nutrition/ holistic medicine. The problem with only going to specialists is that they do not look at the body as a whole and tend to focus only on their specialty area, i.e. a neurologist may tend to focus only on neurological answers to a specific set of symptoms without considering things like malabsorption as a cause. Especially if they see a history of psych diagnosis they tend to brush you off.
I would definitely explore every other avenue I could before having a part of my pancreas removed. This will likely require you being a very aggressive advocate for yourself.

[MM]

But of course. They've already labeled me a psych patient with no psych hx. I've never really considered myself a psych case. Well, aside from some attention issues, but I've been that way since BIRTH. I function well on stimulants, ie. Ritalin.

[Fiona]

I had WLS just over a year ago. I have had slow weight loss, but I have other health issues in addition to the fact that I was over 300lbs. I am down to 209lbs. I have the following blood tests done every 3 months and ask for a copy of them for my records. As a result, I am able to talk to my GP about the results, and identify if something might need looking into. I was able to identify an iron deficiency long before it became full blown anemia and get treatment for it. I know that in the US many of you have to pay for your tests, so every 3 months may be overkill, but it is about you taking control of your post WLS health. I hope this helps.
Hematology
hemoglobin
hematocrit
WBC count
RBC count
MCV
MCH
MCHC
RDW
Platelet count
Absolute
Neutros
Lymph
Mono
EOS
BASO
Coagulation - INR
Ferritin
Chemistry
Iron
UIBC
TIBC
Iron Saturation
Glucose fasting ser
Magnesium Ser
creatinine
eGFR
Urate
Sodium
Potassium
Chloride
Albumin
Calcium
Total Bilirubin
Alk Phos
AST
ALT
Gamma GT
A1C
Urine Chemistry
Microalbumin
creatinine
microalb/creat
Cholesterol
Total Cholesterol
Triglycerides
HDL
LDL
Chol/HDL Ratio
TSH
Ferritin
B12
RBC Folate
FSH Serum
DHEA Sulphate
PTH
Vit D 25 Hydr
Vit D 1-25DIHY
Zinc
Vit A
B6
Vit E

[Fiona]

Ferritin of 4 is dangerously low. Get your blood work done immediately! Include Iron, Ferritin, Iron Sats, Trans Ferrin. While not a doc, I suspect definite anemia issues here!

[mm]

I've been anemic since 1 year post op Fiona. I get infusions, but... they keep me at baseline levels. My ferritin is still >4. (It's July what, 19, 2008 today?) So... this is going to be a battle.

[Fiona]

Minimum levels are not enough for WLS patients. We are supposed to be kept at mid to high levels of the acceptable ranges.

How long since you started? and How often do you get infusions? Once started it does take a while to raise levels, and you may have to keep doing them for awhile until your body learns how to absorb iron again.

What kind is it? Most commonly used is Iron Dextrose, but a better one is Venofer. You might try that.

Deficiencies in other vitamins will also impact how you absorb the iron infusion. If you are low in these, then it does not matter how much iron they pour into you. I know that B12, calcium, and vit C are directly related.

The other thing to watch for is kidney function. WLS patients eat high protein diets which are hard on the kidneys. You should be doing 24 hour urine tests for oxalate as well. I have a friend who was not monitoring, and as a result her kidneys failed and she is on dialysis and waiting for a transplant. Now she had many pre-existing health conditions, but this still should have been watched as it could have been provented.

Family GP's do not always know what is right for WLS patients, so we have to take ownership and help to educate them to take care of us.

If not seeing one already, you might ask for a referral to a Haematologist (sp)for this.

My surgeon stressed pre-surgery education and we had to fill out test type things before we were even approved for surgery. I live in Canada and had to go to the US for my surgery.

Unfortunately, not all surgeons do this, and there are many patients out there that do not know the diet restrictions (like no pop or coffee or tea) or post surgical follow ups that are required. Many surgeons feel their job is over when the incisions are healed. This is why it is so important for patients to learn and keep learning through sites like this and others as new things are being found out every day!

Fiona

Fiona