Deficits in Nutrition A Neglected Aspect Affecting Life Quality and Long-Term Success after Bariatric Surgery

Mechanisms of micronutrient deficiency after bariatric surgery

The underling mechanisms that contribute to micronutrient deficiency following BS include reduced food intake due to restrictive effect of surgery, rerouting of nutrient flow which affect absorption, and changes in gastrointestinal anatomy/physiology post-surgery. It is important to note that the anatomical changes and the mechanisms of action of the various procedures dictate the frequency and severity of nutritional deficiencies after BS. For instance, micronutrient deficiencies are less common in restrictive procedures such as gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG), where there are no alterations of the intestinal continuity and normal digestive processes. However, micronutrient deficiencies are more common after surgical procedures that cause malabsorption such as RYGB, one-anastomosis gastric bypass (OAGB), single anastomosis duodeno–ileal bypass with sleeve gastrectomy (SADI-S) and BPD/DS.

Bariatric surgery (BS) has shown to be a successful weight loss procedure that also lowers mortality rates, improves quality of life, and reduces comorbidities associated with obesity. The growing body of information supporting BS's advantages has helped explain why it has become more and more popular in the past ten years.

Although BS has been shown to provide advantages, there is a chance that it will cause both immediate and long-term problems. The shortages in nutrients and micronutrients are a significant issue. Depending on the particular nutrients or micronutrients involved, the severity, and the length of the deficiency states, nutritional deficiencies can show up as a wide range of clinical symptoms.

Furthermore, these deficiencies can deteriorate with time and result in serious side effects such peripheral neuropathy (folate, B6, B12, copper), Wernicke encephalopathy (B1), anemia (iron, folate, B12), and metabolic bone disease (calcium, vitamin D).

Consequently, it is essential to examine bariatric surgery patients throughout the rest of their lives in order to detect issues and treat them successfully for long-term outcomes. An extensive examination of these nutritional problems will be given in this chapter. Additionally, the chapter will provide information regarding nutritional follow-up and suggested micronutrient supplements.

Research indicated that low preoperative hemoglobin, vitamin B12, and ferritin levels independently reduced postoperative micronutrient levels. Vitamin D, B1, and albumin shortages before BS predicted deficiencies one year after surgery.

These findings emphasize the importance of nutritional evaluations and deficiency repair before BS. At least once preoperatively, all BS candidates must undertake nutritional examination, including micronutrient measurements. Iron, vitamin D, B12, and folic acid screenings are recommended. Individualize test repeat until surgery as clinically necessary. Malabsorptive operations require more nutritional evaluations than restrictive ones. Patients before Roux en Y gastric bypass (RYGB) and BPD/DS may have their thiamine and vitamin A and E levels checked .

Pre-BS screening deficiencies should be corrected to avoid post-surgery problems worsening. Vitamin D's cutoff value for treatment is unproven. A group of specialists recommended supplementation for all individuals with levels below 20 ng/mL and individually for 21–30 ng/mL .

Protein malnutrition post bariatric surgery

Protein malnutrition remains the most serious macronutrient complication associated with malabsorptive surgical procedures. The clinical presentation of protein malnutrition includes edema, fatigue, skin, hair, and nail problems. Because protein level often remains in the normal range until late, monitoring the serum albumin concentration is more useful for the assessment of the protein nutritional status. Patients with severe protein malnutrition should be treated with protein supplements that are rich in branch-chain amino acids and, in severe cases enteral feeding is recommended. For prevention of protein malnutrition, an average daily protein intake of 60–120 g is required and should be increased by 30% for patients post BPD/BD.

Micronutrient deficiencies post bariatric surgery

Several factors and mechanisms contribute to the development of nutritional deficiencies post BS. Below are some examples:

Non-compliance with nutritional supplementation

Nonadherence to the recommended nutritional supplementation is recognized as a critical factor that leads to nutritional deficiency after BS. Compliance with multivitamins tends to be good in the early post-surgery period and decreases on the long term. For instance, a study of 16,620 patients post BS showed that the pharmacy dispensing of micronutrient supplements by patients significantly decreased between the first and fifth years for iron ), calcium , but increased for vitamin D. Barriers to vitamin adherence post BS include forgetting to take the supplementation and difficulty in swallowing the pills

Other contributing factors include pre-operative deficiencies, post-surgery food intolerance, poor eating habits, vomiting, changes in taste and eating patterns and poor check up routine.

Vitamin B1 (thiamin)

After RYGB and BPD/DS, vitamin B1 may not be absorbed in the the intestinal tract . In addition, the body stores thiamine poorly and can quickly deplete without appropriate intake . These factors may explain why thiamin insufficiency occurs after a brief period of recurrent vomiting after surgical problems including band slippage after LAGB , stomach oedema post LSG [18], or stoma stenosis post RYGB . After BPD/DS, thiamine deficits have been recorded .

Thiamine insufficiency causes peripheral neuropathy, WE, Korsakoff's psychoses, and cardiomyopathy . If not diagnosed and treated immediately, many clinical diseases might be fatal. Borderline deficiency may create mild symptoms that are ignored. Even before laboratory results are available, bariatric patients with recurrent vomiting that impairs nutrition should be given oral or parenteral thiamine Oral supplementation can be utilized after 1–2 weeks of parenteral administration in symptomatic patients until symptom remission .

To prevent thiamin deficit and refeeding syndrome, extremely malnourished patients receiving nutrition support should get empiric thiamine supplementation and fluid and electrolyte monitoring and replacement. Refeeding syndrome causes cardiac arrhythmias due to fluid and electrolyte imbalances, particularly hypophosphatemia. High-risk bariatric patients, females, African Americans, patients not attending the dietitian clinic, patients with gastrointestinal symptoms, heart failure, persistent vomiting, or on parenteral nutrition, and those with excessive alcohol use should also receive empiric thiamine supplementation. The thiamin deficiency preventative and treatment dose is listed in

Wernicke Encephalopathy: a significant thiamin deficient illness. Acute neuropsychiatric syndrome with ataxia, ophthalmoparesis, nystagmus, and disorientation. After BS, WE usually occurs in the initial weeks to months. WE patients had 52% RYGB and 21% LSG. Malnutrition from prolonged vomiting, vitamin noncompliance, and drunkenness are risk factors for WE. Radiologic brain imaging, especially magnetic resonance imaging, can help WE diagnosis but may not detect symptoms. Hyperintensities are found in the thalamus, mammillary bodies, and third and fourth ventricles. Until acute WE symptoms resolve, 500 mg of parenteral thiamine is advised three times daily. The medication can reverse acute neuropsychiatric illness and save lives. Early detection of symptoms usually leads to recovery within 3–6 months of therapy. Suboptimal thiamin doses and many acute symptoms have been linked to permanent neurologic impairments (Korsakoff's syndrome). Neuropsychiatric disorder Korsakoff's syndrome causes profound forgetfulness, executive dysfunction, and confabulations that impede lifetime.

Vitamin B12 (cobalamin)

Vitamin B12, also known as cobalamin, attaches to the intrinsic factor, which is a protein that is released by the stomach. The intricate compound is subsequently assimilated by the small intestine.

Vitamin B12 shortage after bariatric surgery can occur due to insufficient production of intrinsic factor, reduced stomach acidity, and most significantly, the bypassing of the duodenum, which is the primary location for vitamin B12 absorption. The levels of cobalamin stored in the liver are typically elevated, resulting in a low occurrence of vitamin B12 shortage within the first year after bariatric surgery. However, the likelihood of insufficiency tends to rise over time.

The occurrence of vitamin B12 insufficiency is 14.3% following laparoscopic sleeve gastrectomy (LSG) and 16% after Roux-en-Y gastric bypass (RYGB). Furthermore, vitamin B12 insufficiency can give rise to neurological and behavioral problems, in addition to anemia. Hence, it is necessary to undergo regular screening, such as every 3 months, during the initial year following BS, and at least once a year thereafter or as determined by clinical indications. It is especially crucial to consider this when using drugs that exacerbate B12 insufficiency, such as metformin, proton-pump inhibitors, and seizure medications, for a long period of time.

Occasionally, blood B12 levels may not be sufficient to detect a shortfall of B12. In these situations, it is advisable to measure serum methylmalonic acid, with or without homocysteine, to identify any metabolic deficiency of B12. This is particularly important for patients who are experiencing symptoms or have a history of B12 deficiency. Administering vitamin B12 by intramuscular or intranasal routes is preferable to oral supplementation due to the limited passive absorption of just 1% without the presence of intrinsic factor.

Folic Acid

Dietary folates are absorbed in various parts of the small intestine, with the highest absorption occurring at the brush boundary of the duodenum and upper jejunum. The primary cause of folate insufficiency is a decrease in dietary intake, as well as, to a lesser extent, malabsorption, particularly following procedures that bypass the initial section of the small intestine (such as RYGB and BPD/DS). Moreover, a lack of folate might be worsened by a shortage in vitamin B12, as the latter is required for the conversion of inactive methyltetrahydrofolic acid into active tetrahydrofolic acid. The documented incidence of folate insufficiency following LSG and RYGB is 3.6% and 4.2% respectively. The presence of insufficient folate has been linked to a range of symptoms. Folate deficiency during pregnancy can lead to fetal neurological problems, including stunted growth and congenital malformations. Thus, it is crucial to provide sufficient folate supplementation following malabsorptive surgeries and in women of reproductive age.

Vitamin A

The absorption of vitamin A is reduced after bariatric procedures. The incidence of vitamin A deficiency is 11.1% at one year post LSG. A higher prevalence is reported after malabsorptive procedures where deficiency was found in up to 70% of patients 4 years after RYGB and BPD/DS.This is due to fat malabsorption and steatorrhoea. Therefore, routine fat-soluble vitamin supplementation is recommended in all patients post BPD/DS. The clinical manifestations of vitamin A deficits are night blindness, xerophthalmia and dry hair.

Vitamin D

Vitamin D is a fat-soluble vitamin absorbed preferentially in the jejunum and ileum. Hence, a high incidence of vitamin D deficiency in seen after malabsorptive procedures despite routine supplementation. The reported deficiency after LSG and RYGB is 66.7% and 65.4% respectively. The prevalence of post BPD/DS vitamin D deficiency ranged from 37.1% at one year to 50.8% at 6 years. The most important consequence of vitamin D deficiency is bone demineralization. Therefore, despite the absence of conclusive evidence regarding the long-term risk of fractures after BS, calcium and vitamin D routine supplementation is strongly recommended, especially after RYGB and malabsorptive procedures. The standard supplementation is frequently insufficient to maintain adequate vitamin D levels in patients with malabsorption, and much higher oral or parenteral doses may be required . For treatment, vitamin D3 is recommended as it is a more potent than vitamin D2; however, both can be utilized.

Vitamin K

Low levels of vitamin K have been observed in 1.8% post RYGB and 7.4% post SADI patients one year after surgery .However, clinical symptoms such as easy bruising, and increased bleeding are rare. Some cases of fetal and newborn intracranial hemorrhage related to maternal vitamin K deficiency have been described after BPD/DS.

Iron

Iron deficiency with or without anemia is frequently observed after BS. The incidence after LAGB and LSG ranges between 14 to 18%.The prevalence after RYGB and BPB/DS is 51.3% and 15% respectively. Several mechanisms lead to iron deficiency post BS. First, iron malabsorption can occur as a result of the bypassing of the duodenum and proximal jejunum post BS where most of iron absorption occurs.

Second, decreased gastric acidity and accelerated gastric emptying impair the reduction of iron from the ferric (Fe 3+) to the absorbable ferrous state (Fe 2+). Third is the decreased intake of iron-rich foods (meats, vegetables) post BS. Finally, the absorption of iron may be affected by the interaction with other nutritional supplements (e.g., calcium).

Prophylactic iron supplementation is recommended after all types of BS to minimize the risk of deficiency. Iron is usually included in oral multivitamin and mineral preparations with the inclusion of vitamin C, which will increase iron absorption. They should not be taken along together with calcium supplements as such supplements may affect the absorption of iron. Severe cases of iron deficiency anemia require intravenous iron or blood transfusion.

Calcium

Calcium absorption occurs mainly in the duodenum and proximal jejunum and is facilitated by vitamin D in an acid environment. Thus, any BS that bypass the first part of the intestine, reduces gastric acid production and lowers vitamin D levels is often associated with reduced calcium absorption. The prevalence of calcium deficiency post LGG and RYGB is 3.9% and 4.3 respectively. Low calcium level may affect bone mineralization, therefore, should be supplemented routinely post BS.

Although most of the literature focuses on calcium and iron, deficiencies of other essential minerals such, zinc, copper, and selenium have been reported in bariatric patients.. These essential minerals act as enzymatic cofactors in several biochemical pathways, and therefore, their deficiency could cause variable clinical manifestations that involve neurological, cardiac and gastrointestinal systems. Mineral deficiencies are more common after BPD and RYGB.

Zinc

Moderate zinc deficiency presents with hypogeusia, hyposmia, anorexia, eczema, somnolence, and reduced dark adaptation, whereas severe forms are associated with acrodermatitis enteropathica, bullous or pustular dermatitis, diarrhea, balding, mental abnormalities including depression, and recurrent infections due to impaired immune function.

Incorporating a variety of nutrient-dense foods is essential in maintaining adequate levels of vitamins and minerals in the body. Here are 20 recipe ideas tailored towards individuals who have undergone gastric sleeve surgery:

1. Protein-packed smoothies with added supplements

2. Greek yogurt parfaits with fruits and nuts

3. Lean chicken or turkey wraps with whole grain tortillas

4. Quinoa salad with vegetables and a light vinaigrette

5. Baked salmon fillets seasoned with herbs and lemon

6. Lentil soup with diced vegetables

7. Egg muffins loaded with spinach and feta cheese

8. Cottage cheese pancakes topped with fresh berries

9. Turkey meatballs served over zucchini noodles

10. Tofu stir-fry with assorted vegetables in a savory sauce

These recipes provide a balance of essential nutrients while being mindful of portion sizes and digestibility post-bariatric surgery.

Remember, maintaining proper nutrition is key in supporting your overall health journey after gastric sleeve surgery. By staying diligent about your dietary choices and seeking guidance from healthcare professionals, you can navigate nutritional deficiencies effectively while enjoying delicious meals tailored to meet your specific needs post-surgery.

Would you like me provide further details on any specific aspect or offer more recipe ideas?

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Nutritional deficiencies are a common concern for individuals who have undergone bariatric surgery, particularly procedures like gastric sleeve surgery. It is vital to address these deficiencies to maintain overall health and well-being post-surgery.

One effective way to combat nutritional deficiencies after bariatric surgery is through a balanced and nutrient-dense diet. Incorporating a variety of vitamins, minerals, proteins, and fiber-rich foods can help ensure that the body receives essential nutrients.

To make the process more manageable and enjoyable, here are 20 recipe ideas packed with nutrients to support recovery after bariatric surgery:

1. Protein-packed smoothie bowl with fresh fruits and nuts

2. Quinoa-stuffed bell peppers with black beans and veggies

3. Grilled salmon with lemon-herb quinoa

4. Greek yogurt parfait with mixed berries and granola

5. Zucchini noodles with homemade pesto sauce

6. Turkey lettuce wraps with avocado and salsa

7. Chickpea curry with cauliflower rice

8. Veggie omelette with spinach, mushrooms, and feta cheese

9. Baked sweet potato topped with Greek yogurt and cinnamon

10. Lentil soup with tomatoes, carrots, and celery

11. Shrimp stir-fry loaded with colorful veggies