ASMBS ER Care Poster, part 2

On August 26, 2011, in Uncategorized, by Andrea

The ASMBS has pulled their link to the ER Care sheet. I don’t know why.

I don’t like that.

Thus, I’ve stolen it and put it on my site.

Here.

 

Adult Gummy Vitamins

On January 10, 2011, in Fat Solubles, Minerals, Reviews, Vitamins, Water Solubles, by Andrea

For all the vitamins that are out on the market, the newest “craze” are the gummy “vitamins.”

First came the gummies for kids to help get kids to take them.  I get the reasoning.

But then they made adult vitamins using a gummy formulation.

And post-ops who thought Flintstones were good enough?  Now thought gummies were a great option.

And just like Flintstones.. they aren’t.

Continue reading »

ASMBS ER Sheet

On January 8, 2011, in Uncategorized, by Andrea

There are few things I tell people they MUST do.

You MUST get your own labs and put your own eyes on them to track trends.

You MUST learn how to stand up for your health.

Now?  You MUST go and print off a copy of the ASMBS Clinical Pearls for Emergency Care of the Bariatric Surgery Patient.

Yes.  I mean it.  Go. Do it now.  And put it with your list of medications and supplements and last labs for any emergencies that might pop up.

You never know when you might need it.

It could even save your life.

ASMBS suggested supplementation

On November 16, 2009, in General Nutrition, Vitamins, by Andrea

The American Society of Metabolic and Bariatric Surgeons has made a series of suggestions for postoperative vitamin supplementation prior to labs dictating otherwise.

Multivitamin
- Adjustable Gastric Band/VSG: 100% of daily value
- RNY: 200% of daily value
- BPD/DS: 200% of daily value

  • Choose a multivitamin that is a high-potency vitamin containing 100% of daily value for at least 100% of daily value of 2/3 of nutrients
  • Begin with chewable or liquid
  • Progress to whole tablet/capsule as tolerated
  • Avoid time-released supplements
  • Avoid enteric coating
  • Choose a complete formula containing at least 18 mg iron, 400mcg folic acid, as well as selenium, and zinc in each serving
  • Avoid children’s formulas that are incomplete
  • May improve gastrointestinal tolerance when taken close to food intake
  • May separate dosage
  • Do not mix multivitamin containing iron with calcium supplement, take at least 2 hours apart
  • Individual brands should be reviewed for absorption rate and bioavailability
  • Specialized bariatric formulations are available

Additional cobalamin (B12)
- AGB/VSG: Not Applicable
- RNY: 350-500mcg if taken orally, 1000mcg / mo intramuscular injection
- BPD/DS: NA

Additional elemental calcium
- AGB/VSG: 1500mg /day
- RNY: 1500-2000mg
- BPD/DS: 1800-2400mg

  • Choose a brand that contains calcium citrate and vitamin D3
  • Begin with chewable or liquid
  • Progress to whole tablet / capsule as tolerated
  • Split into 500-600 mg doses; be mindful of serving size on supplement label
  • Space doses evenly throughout day
  • Suggest a brand that contains magnesium, especially for BPD/DS
  • Do not combine calcium with iron containing supplements
  • Wait 2 or more hours after taking multivite or iron supplement to take
  • Wait 2 or more hours between doses
  • Promote intake of dairy beverages and/or foods that are significant sources of dietary calcium in addition to recommended supplements
  • Combined dietary and supplemental calcium intake greater than 1700 mg/day might be required to prevent bone loss during rapid weight loss

Additional elemental iron
- AGB / VSG: NA
- RNY: Minimum 18-27mg / day elemental
- BPD/DS: Minimum 18-27mg / day elemental

  • Recommended for menstruating women and those at risk of anemia
  • Begin with chewable or liquid
  • Progress to tablet as tolerated
  • Dosage may need to be adjusted based on biochemical markers
  • No enteric coating
  • Do not mix iron and calcium supplements, take at least 2 hours apart
  • Avoid excessive intake of tea due to tannin interaction
  • Encourage foods rich in heme iron
  • Vitamin C may enhance absorption of non-heme iron sources

Fat-soluble vitamins
- AGB / VSG: NA
- RNY: NA
- BPD/DS: 10,000 IU of vitamin A, 2000 IU of vitamin D, 300 mcg of vitamin K

  • With all procedures, higher maintenance doses may be required for those with a history of deficieincy
  • Water-soluble preparations of fat-soluble vitamins are available
  • Retinol sources of vitamin A should be used to calculate dosage
  • Most supplements contain a high percentage of beta carotene which does not contribute to vitamin A toxicity
  • Intake of 2000 IU vitamin D3 may be achieved with careful selection of multivitamin and calcium supplements
  • No toxic effect known for Vitamin K1, phytonadione (phyloquinone)
  • Vitamin K requirement varies with dietary sources and colonic production
  • Caution with vitamin K supplementation should be used for patients receiving coagulation therapy
  • Vitamin E deficiency is not prevalent in published studies

Optional B complex
- AGB / VSG: 1 per day
- RNY: 1 per day
- BPD/DS: 1 per day

  • B-50 dosage
  • Liquid form is available
  • Avoid time released tablets
  • No known risk of toxicity
  • May provide additional prophylaxis against B-vitamin deficiencies, including thiamin, especially for BPD/DS procedures as water-soluble vitamins are absorbed in the proximal jejunum
  • Note >1000mg of supplemental folic acid provided in combination with multivitamins could mask B12 deficiency

Flintstones and Tums aren’t enough postop.

Some of us know this already — but heya! there’s a study that gives some credence to what some of us have been saying.  There was an article published in The American Journal of Clinical Nutrition, the Official Journal of the American Society for Clinical Nutrition, Inc.

Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation, by Christoph Gasteyger, Michel Suter, Rolf C Gaillard, and Vittorio Giusti.  (Article can be read here.)

Before you ask, the numbers are based off of an unknown, regular multivitamin.  The studies are not based off of a bariatric multivitamin, or using ASMBS recommendations.  However, this just proves why we should heed those recommendations.  Lots of numbers ahead – scary numbers, actually.


The study, in the end, included 137 morbidly obese patients (110 women and 27 men) — these were the ones who maintained the lab requirements, the supplementation requirements, the doctor visits, etc.  Initially, there were 348 patients in the study, but only about 33% complied with the postoperative care requirements, which, in of itself, is a sobering statistic.

Lab testing was done at 3, 6, 12, 18, and 24 months postoperatively.

This, folks, is where it gets really scary.

  • 3 months postop, 34% required at least one additional supplement to the multivite
  • 6 months postop, 59% required at least one additional supplement
  • 12 months postop, 86% required at least one additional supplement
  • 18 months postop, 93% required at least one additional supplement
  • 24 months postop, 98% required at least one additional supplement to the multivite
  • After 2 years, 2.2% took 0 additional supplements
  • 18.3% took 1 additional supplement
  • 19.7% took 2 additional supplements
  • 22.6% took 3 additional supplements
  • 27.7% took 4 additional supplements to the multivite
  • 6.6% took 5 additional supplements
  • 2.9% took 6 additional supplements
  • B12 was the most often supplemented — 10% were taking it at 3 months and 80% were taking it at 2 years
  • Iron was next — 15% at 3 months, and 60% at 2 years
  • Calcium +D — 17% at 3 months, 60% at 2 years
  • Folic Acid — 7% at 3 months, 45% at 2 years
  • B1 — 1% at 3 months, 4% at 2 years
  • B6 — 1% at 3 months, 13% at 2 years
  • Magnesium — 1% at 3 months, 13% at 2 years
  • Zinc — 1% at 3 months, 12% at 2 years

So what does all of this tell us?  Quite a bit.  First off..  33% of the people included in this study were able to pop a single pill, keep up with doctor appointments, get blood draws, add supplements as needed?  Only 33% could comply for a measly two years?  They got their insides sliced and diced, knowing this was going to be for life, knowing they would need vitamins for life, and they couldn’t maintain a simple protocol for a measly two years?  This frightens the heck out of me more than the numbers above do.  I mean.. what happens at year three?  Or, if they are still kicking, year ten?

But while we’re looking at the numbers, and let’s keep in mind that these are only for two years — and let’s not think about those of us kicking around the five year mark — that 98% of those in the study were at least on one additional supplement to a multivite.  That tells us that we need much, much more than the average bear.  So maybe, perhaps, the ASMBS has it right with their recommendations for doubling the multivite, adding some calcium, some iron, some b12, etc.?  That Flintstones and Tums aren’t going to cut it for long.

Yes, sobering statistics to be certain.