Transcript Folie 1

Micronutrient status after bariatric
surgery
Kurt Widhalm
Emeritus Professor for Clinical Nutrition and
Pediatrics
Paracelsus Medical University, Salzburg
Austrian Academic Institute for Clinical Nutrition,
Vienna
Oliver Helk
Austrian Academic Institute for Clinical Nutrition,
Vienna
The importance of long term
follow-up
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While bariatric surgery can generally be considered
a safe procedure there is little to no data on
possible micronutr. deficiencies after bar. Surg. in
adolescents.
A recent study1) has reported for the first time that
adherence to vitamin supplementation is very poor
in adolescent patients  high risk for deficiency!
Special attention should be put on possible
deficiencies in patients who have not yet reached
full maturity at the time of surgery
1) Modi AC, Zeller MH, Xanthakos SA, Jenkins TM, Inge TH.
Obesity (Silver Spring). 2013 Mar;21(3):E190-5. doi: 10.1002/oby.20031.
Adherence to vitamin supplementation following adolescent
bariatric surgery.
What do we know from literature?
Currently no reports from trials on
micronutrient deficiencies following bariatric
surgery in adolescents available!
 There are however case reports of
adolescent patients with severe comorbidities resulting from micronutrient
deficiency!
E.g.: Wernicke encephalopathy2), Myelopathy

3)
2) Stenerson M, Renaud D, Dufendach K et al.,
Recurrent Wernicke encephalopathy in an adolescent female following laparoscopic
gastric bypass surgery.
Clin Pediatr (Phila). 2013 Nov;52(11):1067-9.
3) Plantone D, Primiano G, Renna R et al
Copper deficiency myelopathy: A report of two cases.
J Spinal Cord Med. 2014 Oct 24.
Deficienices: Results from
Adults
Vitamin B1: reported rates of up to 49%
following gastric bypass! Cave: Wernicke
encephalopathy! 1)
 Vitamin B9: special importance in female
patients, increased rate of pregnancies
after bar. Surg. Generally deficiencies are
rare2), however there are reports of up to
39%!3)

1) Aasheim ET, Bjorkman S, Sovik TT, Engstrom M, Hanvold SE, Mala T et al (2009) Vit
185after bariatric surgery: a randomized study of gastric bypass an duodenal switch. A
Nutr 90:15–22
2) Decker GA, Swain JM, Crowell MD, Scolapio JS (2007) Gastrointestinal and nutrition
cations after bariatric surgery. Am J Gastroenterol 102:2571–2580
3) Halverson JD (1986) Micronutrient deficiencies after gastric bypass for morbid obesi
52:594–598
Results from adults
Vitamin B12: needs to be administered
perenterally, studies show low incidence
and prevalence; but: what happens in
patients lost to follow-up? 4)
 Vitamin C: Only two trials reporting
deficiencies, however def. rate was 35% in
one of them5)

4) Kwon Y, Kim HJ, Lo Menzo E et al, Anemia, iron and vitamin B12 deficiencies
after sleeve gastrectomy compared to Roux-en-Y gastric bypass: a metaanalysis.
Surg Obes Relat Dis. 2014 Jul-Aug;10(4):589-97
5) Clements RH, Katasani VG et al (2006) Incidence of
206vitamin deficiency after laparoscopic Roux-en-Y gastric bypass in a university
hospital setting.
Am Surg 72:1196–1204
Results from adults
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Vitamin A: Reports range up to 69%6), however
oral Multivitamin supplementation appears to
prevent this successfully7)
Vitamin D: High importance in adolescents for
skeletal health! Underprovision rates are high in
pre-surgical patients and are often worsened by
bariatric procedures. 8) Best results for the
prevention of deficiencies were achieved by
5.000IU/day9)
6) Slater GH, Ren CJ, Siegel N, Williams T, Barr D, Wolfe B et al (2004) Serum fat-soluble
vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery.
J Gastrointest Surg 8:48–55
7)Clements RH, Katasani VG, Palepu R, Leeth RR, Leath TD, Roy BP et al (2006) Incidence of
vitamin deficiency after laparoscopic Roux-en-Y gastric bypass in a university hospital setting.
Am Surg 72:1196–1204
8) Gemmel K1, Santry HP, Prachand VN, Alverdy JC. Vitamin D deficiency in preoperative bariatric surgery pat
Surg Obes Relat Dis. 2009 Jan-Feb;5(1):54-9.
9) Goldner WS, Stoner JA, Lyden E, Thompson J, Taylor K, Larson L et al (2009) Finding the
optimal dose of vitamin D following Roux-en-Y gastric bypass: a prospective, randomized
pilot clinical trial. Obes Surg 2006(243):701–704
Results from adults

Other: While Selenium, Copper and Zinc
deficiencies are reported very rarely in
studies, there are reports of severe
morbidity resulting from deficiency in
patients who were lost to follow-up and
did not adhere to their supplementation
regimen! Possible symptoms involve
psychiatric disorders, haematological
disorders, neurological symptoms and
symptoms of the GI tract. 10)
10) Prodan CI, Bottomley SS, Vincent AS, Cowan LD, Meerveld BG, Holland
NR et al (2009) Copper
deficiency after gastric surgery: a reason for caution. Am J Med Sci 337:256–
258
Own experiences
From our outpatient clinic: 185 patients
with a BMI exceeding the 99.5th percentile:
An example: Christoph
17y, 166kg, BMI=48BMI
 Body fat >45%
 Striae distensae
 Steatosis hepatitis (NASH)
 Hypertension
 Gynaecomastia
 increased CRP
 Insulin-resistance
 Dyslipoproteinemia
  Calorie intake >3000 kcal/d
 Physical activity
 Depression
 Many multidisciplinary treatments
without success
THE PATH TO SURGERY
Surgical approaches of obesity-therapy in
adolescents can be considered if...
1.
2.
3.
4.
5.
6.
7.
BMI>40 (or >99.5 percentile)
...treatments in a specialised center were unsuccessful for at least 6-12
...patient shows adequate bone maturation and overall maturity.
...the patient is capable of parcipating in an extensive medical- and psychological
evaluation pre- and post surgery.
...the patient has agreed to participate in a multidisciplinary treatment program after
...the patient suffers from genetic syndromes (e.g. Prader-Willi) a surgical procedure
can be considered at an earlier stage.
...if surgery is performed at a surgical department with experience on bariatric
surgery and specially trained pediatric. A thourough quality management and a
european patient register are desirable.
Fried et al. Widhalm K. 2007. Int J Obes;31(4):569-77.
Fried et al.Widhalm K. 2007. Obes. Surg. 17 (2)
Morbid (extreme) Obesity in Children and Adolescents
Definition:
>95th percentile of skinfolds
>99th perc. BMI
>99.5 perc. BMI
Characteristics: at least 2 risk factors
(99th Perc.)
(Gortmaker 1987)
(Inge 2007)
(AGA 2008)
(Freedman 2006)
all of those children remained obese into adulthood
with an average adult BMI of 43
(Freedman 2006)
Morbidly obese men and women have a multivariate
rel. risk of death which is really fourfold that of their
normal weight counterparts
(Adam 2006)
Treatment :
(Behavioral Treatment etc.)
Rarely sustainable effects
(Janevski 2003, Epstein 1990, Kirk 2005)
Weight (kg) after Gastric Banding in 8 adolescent patients
180
170
Secondary procedure:
Gastric Bypass
160
150
140
130
120
110
100
0 months
Pre surgery:
155.1±7.7
6 months
12 months
24 months
48 months
72 months
48 months after surgery:
139.6±19.2
Helk O, Widhalm K: Vitamin Deficiencies After Bariatric Surgery?
In: Widhalm K, Prager G: Morbid Obesity in Adolescents, Springer 2015
Weight (kg) after Gastric Bypass in 17 adolescent patients
170
160
150
140
130
120
110
0 months
Pre surgery:
153.9±9.4
6 months
12 months
24 months
36 months
24 months after surgery:
129.3±7.2
Helk O, Widhalm K: Vitamin Deficiencies After Bariatric Surgery?
In: Widhalm K, Prager G: Morbid Obesity in Adolescents, Springer 2015
 Follow-up
program
Visits with pediatrician
and dietitian
Monthly visits in the first year post
surgery, every 6 months thereafter
Blood sampling
In 1st, 6th and 12th month post
surgery, every 3 months thereafter
IMT measurement and
echohepatography
In 1st, 6th and 12th month post
surgery, every 6 months thereafter
DXA- and bone density
measurement (often
impossible: patient
exceeding weight limit
etc.)
In 1st, 6th and 12th month post
surgery, every 6 months thereafter
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(Follow-up on:
Vitamin A,B9,B12,C,D,E
Magnesium, Iron, Phosphorus,
Zink, Calcium,…
Hs-CRP, Lp(a), LDL, HDL, CHOL
Insulin, PTH)
 Vitamin
substitution
Daily:
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Monthly:
• 1000µg Vitamin B12 i.m.
Vitamin A 3333 I.E.
Thiamin (Vitamin B1) 4,013 mg
Riboflavin (Vitamin B2) 5,1 mg
Pyridoxinhydrochlorid (Vitamin B6) 6,0 mg
Cyanocobalamin (Vitamin B12) 6,0 μg
Ascorbinacid (Vitamin C) 180,0 mg
Colecalciferol (Vitamin D3) 200 I.E.
DL-α-Tocopherolacetat (Vitamin E) 14,9 mg
Biotin (Vitamin H) 0,3 mg
Folicacid (Vitamin B9) 0,2 mg
Nicotinamid 57,0 mg
Iron 3,6 mg
Supplementation was regularly
Calcium 50,0 mg
adjusted during the regular
Magnesium 40,0 mg
visits in our outpatient clinic
Phosphorus 50,0 mg
based on individual needs!
Mangan 0,5 mg
Zink 3,0 mg
Vitamin A levels (serum, μmol/l) after Gastric Bypass in
17 adolescent patients
2.5
2
1.5
1
Deficiency!
0.5
0
0 months
Pre surgery:
1.78±0.33
6 months
12 months
24 months
36 months
24 months after surgery:
1.71±0.31
Helk O, Widhalm K: Vitamin Deficiencies After Bariatric Surgery?
In: Widhalm K, Prager G: Morbid Obesity in Adolescents, Springer 2015
Iron (serum, μg/dl) after Gastric Bypass
in 17 adolescent patients
120
100
80
60
40
Deficiency!
20
0
0 months
Pre surgery:
63±19.3
6 months
12 months
24 months
36 months
24 months after surgery
54.2±19.3
Helk O, Widhalm K: Vitamin Deficiencies After Bariatric Surgery?
In: Widhalm K, Prager G: Morbid Obesity in Adolescents, Springer 2015
Vitamin B12 (serum, ρmol/l) after Gastric Bypass in
17 adolescent patients
700
600
500
400
300
200
Deficiency!
100
0
0 months
Pre surgery:
371±133
6 months
12 months
24 months
36 months
24 months after surgery:
307±110
Helk O, Widhalm K: Vitamin Deficiencies After Bariatric Surgery?
In: Widhalm K, Prager G: Morbid Obesity in Adolescents, Springer 2015
Vitamin D (25-OH, serum, nmol/l) after Gastric Bypass in
17 adolescent patients
90
80
Insufficiency
70
60
50
Deficiency
40
30
Severe Deficiency
20
10
0
0 months
Pre surgery:
64.1±12.1
6 months
12 months
24 months
48 months
72 months
48 months after surgery:
54.4±4.6
Helk O, Widhalm K: Vitamin Deficiencies After Bariatric Surgery?
In: Widhalm K, Prager G: Morbid Obesity in Adolescents, Springer 2015
Vitamin D deficiency in healthy adolescents
10
9
8
7
6
5
pre surgery
4
post surgery
3
2
1
0
Sufficient
Insufficient
Deficient
Severely
Deficient
HELENA-study
Gonzales-Gross M. et al.:Vitamin D status among
adolescents in Europe
British Journal of Nutrition 2011 Aug 17:1-10
Conclusion
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Bariatric surgery should be the „ultima ratio“ after unsuccessful
conservative multidisciplinary treatment regimes in a certified
pediatric center with close cooperations with a specialised surgical
center
At this point, no valid alternatives are avaiable
An accurate selection of patients and a consequent follow-up
program (substitution) are neccessary
A similar follow-up program is essential also for
conservative weight-reducing regimens in order to generate
comparative data
Prevention of morbid obesity is of utmost importance
More long-term trials on Vitamin deficiencies and other side
effects from bariatric surgery in adolescents are urgently
needed
Conclusion 2
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
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Special efforts must be made to convince patients to adhere to
follow-up visits for the detection and prevention of deficiencies.
Vitamin D deficiency appears to be the most prevalent.
Patients lost to follow-up are at high risk for vitamin
deficiencies and severe complications!!!
One major criteria in regard to judgement of complance for followup care is the clear readiness for cooperation not only from the
patient, but also from his/her family.
Thank you!
Maria Fritsch MD, Elsie Aldover-Macasaet MTA, Christoph Binder MD, Anna
Kellersmann MD,Alexandra Kreissl MSc, Marika Miklautsch MSc, Maytree Pandey
MD, Kathrin Schöggl MSC, Gabrielle Skacel, Maria Hochgerner, Bimba (the dog)
Morbid Obesity
Definition and Health Consequences of Morbid Obesity
Ernst J. Drenick, Surg. Clin. N. Amer. 59,6:963(1979)
„100 pound excess over desirable weight„
„twice the ideal weight or more„
For younger and middle-aged groups:
„a decisive 60% excess mortality becomes evident when the
relative overweight is 60% above normal or greater „
Study:Build and Blood pressure by the Society of Actuaries a
mortality ratio of 168% of expected was calculated for insured
males weighing >115kg.
In the Veterans Administration study: 200 morbidly obese
men,
(23-70 yrs), mean weight 143.5kg
→12 fold increase of mortality :25-34 yrs.
→ 6fold : 35-44 yrs.
1959
NAFLD IN OBESE CHILDREN / ADOLESCENTS
Wiegand S,Widhalm K. et al. Int J Obesity (2010) 1-7
SUCCESS RATE OF 129 TREATMENT PROGRAMS FOR OBESE CHILDREN
Reinehr T, Widhalm K et al. Obesity 2009(12)6:1196-1199