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

CNN gives the DS a shoutout

On November 16, 2009, in Uncategorized, by Andrea

Finally.

In a quick Q&A, a CNN.com doc answers a question about resolution of diabetes with weight loss surgery:

Does roux-en-Y gastric bypass cure diabetes?

Asked by Rick Shetron, Troy, New York

“60 Minutes” had a story several months ago about a type of weight-loss surgery that seemed to also cure type 2 diabetes in many people. Has more research been done on this? Do you need the full bypass of about one-third of the small intestine or just the duodenum and jejunum? My weight problem came about with/after diabetes, not before.

Expert answer

Hi, Rick. I’m not a surgeon, so to answer your question more thoroughly, I consulted with a very well-respected bariatric surgeon in San Francisco, John Rabkin, M.D. He explained that the roux-en-Y gastric bypass (RGB) improves type 2 diabetes via at least three different mechanisms:

1. The surgery decreases caloric intake immediately after the procedure because food intake is restricted by the small volume of the created stomach pouch, which holds only 1 ounce. The decrease in food intake, particularly refined carbohydrates, which are not well-tolerated after this procedure, can help stabilize blood sugar levels and immediately improves control of diabetes.

2. The significant amount of weight loss that results from the surgery improves insulin resistance over time.

3. There are changes in hormones and caloric processing because the food ingested bypasses the segment of the small intestine closest to where it attaches to the stomach (the duodenum and proximal jejunum), but not quite as much as you mentioned (not one-third of the small intestine). Because of the anatomical changes resulting from the surgery, it appears that these hormonal changes are greater than would be seen with weight loss via diet and exercise, but no research has yet to compare the two directly and evaluate hormonal changes.

The overall outcome is complete resolution of type 2 diabetes in greater than 70 percent of patients with diabetes before the procedure.

Unfortunately, as many RGB patients regain weight over time, the durability of the cure isn’t as high as with a newer procedure called the duodenal switch.

In this procedure, there is a much larger pouch created (4 to 5 ounces), and the complete stomach anatomy is preserved, which helps preserve more normal stomach function. In this procedure, the rearrangement of the intestines leads not only to some restriction of food, but also causes your body to absorb significantly fewer calories, which has a more lasting effect.

Rabkin, a leader in this procedure, reports that he has had a 96 percent cure of type 2 diabetes at one year after surgery, which has persisted for five and 10 years post -op and seems to be similarly durable out past 15 years post-op.

Hope this helps. I strongly recommend spending a considerable amount of time with your surgeon if you are considering either of these procedures, as both have important lifestyle-related issues that should be discussed to determine the best procedure for you for the long term.

Answered by Dr. Melina Jampolis Physician Nutrition Specialist

Bout time this is really hitting the mainstream.  I would take some exception with the assumption that all RNY’ers regain their weight, but many do.  I get that.  I only wish they had qualified this a bit better, but glad the DS got some mainstream attention.

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