ARTICLES 

Nutrient Deficiencies and Health Consequences

Part I: Gastric Restrictive Surgeries

Cynthia Buffington, Ph.D.

Beyond Change, July 2002

Nutrient deficiencies following bariatric surgical procedures can lead to serious health consequences if left unattended. The provision of knowledge to bariatric surgical candidates of the nutrient deficiencies associated with their particular surgical procedure and the steps necessary to avoid their occurrence is the responsibility of the bariatric surgeon and his/her staff. Taking those steps, however, is solely the responsibility of the patient.

Do you take your vitamin/mineral supplements on a daily basis and in the amounts recommended?  Is your body losing bone because you can’t remember to take your calcium?  Does your body feel tired and run down because you refuse to take iron?  Is your hair falling out and muscles diminishing in size because you eat too little protein or refuse to use protein supplements?

Do you realize that hair loss, reduced muscle and bone are only a few of the many health consequences of long-term nutrient deficiencies? that anemia is likely to develop with deficits in iron, B12, and folate intake or absorption? And, did you know that without sufficient levels of zinc, defects in immune function may occur? 

Are you aware that low intake or absorption of B-vitamins can lead to neurological defects and damage, some which are irreversible (untreatable)? Do you know that low anti-oxidant vitamin and minerals may increase the risk for cancer, heart disease, diabetes, hypertension, cataracts, other diseases, as well as promote aging?

What are the possible nutrient deficiencies that may occur with the particular surgical procedure you selected for weight loss and how can such deficiencies be prevented or treated?  

This month’s column discusses nutrient deficiencies that have been reported and the management of such deficiencies following bariatric surgeries that reduce the size of the stomach, i.e. vertical banded gastroplasty and adjustable gastric band. Next month’s column will examine nutritional consequences of surgeries that not only reduce the size of the stomach but also induce malabsorption via bypass of a portion of the gut, i.e. gastric bypass and biliopancreatic diversion with and without the duodenal switch. 

Nutrient management of the Bariatric patient actually needs to begin prior to surgery. Why? The morbidly obese have numerous metabolic aberrations and hormonal defects that may negatively influence nutrient status.  In addition, many morbidly obese patients have eating abnormalities, such a high carbohydrate craving, binge eating, and bulimia, that may cause nutrient deficits.

A number of studies found that obesity, among  adults as well as children, is associated with low intake, as well as low blood and tissue levels, of anti-oxidants, including vitamin E, beta-carotene, vitamin C, zinc, selenium, copper, manganese, molybdenum and others.  Several studies also reported low blood levels of
B-complex vitamins, particularly folate, in morbidly obese surgical candidates. And, other investigators found that the morbidly obese, prior to obesity surgery, have low vitamin D. 

Since obesity surgery, secondary to calorie restriction or surgical technique, may cause nutritional deficits, it is of utmost importance that any pre-existing nutritional problem(s) be corrected prior to surgery. Such pre-existing deficiencies can usually be corrected by dietary supplements of vitamins and minerals at levels close to
the RDI taken daily for a period of no less than 2 and preferably 6 weeks prior
to surgery. 

The management of nutrient deficiencies following surgery depends upon the type of surgical procedure, whether it is purely gastric restrictive (reduces the size of the stomach only), such as gastric banding or gastroplasty (stomach stapling), or also contains a malabsorptive component (bypasses part of the gut) as does the gastric bypass, biliopancreatic diversion, or duodenal switch.

Gastric restrictive surgeries (gastric banding, gastroplasty) reduce the size of the stomach and the rate at which food leaves the stomach, all of which induce weight loss by reducing food consumption. Reports of calorie intake below 1000 per day are not unusual in the first few post-operative months following gastric restrictive surgeries. Such low energy intake may cause nutrient deficiencies, including vitamins and minerals deficits and protein malnutrition.

Nutrient deficiencies may also occur within the first few months following gastric restrictive surgery because most patients at this time are consuming soft foods and liquids instead of solids. Furthermore, during the early post-operative period, patients may frequently vomit until they have learned how to eat small food portions and chew their food well.

Frequent regurgitation can lead to serious nutrient deficiencies and eating abnormalities. Many patients, particularly those who have had a vertical banded gastroplasty with restrictive ring may become so fearful of vomiting that they drink their calories or eat processed or high-sugar containing foods rather than meat, fruits, and vegetables. Such behaviors may lead to long-term eating abnormalities and nutrient deficiencies.

Studies have reported that, within the early post-operative months following gastric restrictive surgeries, protein deficits occur, as do reduced intakes of a variety of vitamin and minerals, i.e. potassium, iron, zinc, phosphate, calcium, B-complex vitamins, and vitamins E, D, and A. 

Such deficiencies can be corrected by taking a daily oral supplement (chewable form in the early post-op period) with vitamin and mineral levels at, or close to, the RDI. Protein supplements or intake of foods high in protein (eggs, cheese, fish, other meats) may, in addition, help to prevent muscle or hair loss resulting from protein and nutrient deficiencies.

Some nutrient deficiencies may have serious health consequences, particularly in the early months following surgery. There have been multiple reports of neurological (nervous system) defects following gastric restrictive surgery, particularly for individuals who vomit frequently. Such neurological defects are attributable to vitamin B1 (thiamine) deficiency and often characterized by double vision, mental confusion or mild memory impairment, disorientation, severe weakness of the legs and other symptoms. Correction of such problems generally requires IV infusion of vitamin B1 and close follow-up medical supervision.

Studies have found that, 12 to 24 months following gastric restrictive procedures, nutrient intake improves in association with changes in the pouch, gastric emptying rates and the intake of solid foods. At this time, protein, vitamin and mineral deficiencies become far less common.

There are reports of long-term nutrient deficiencies, such as for calcium, following vertical banded gastroplasty in individuals not on dietary supplements. And, there are other reports of nutrient deficiencies in post-surgical patients whose diets are high in processed foods and sugar (crackers, bread, chips, cookies, cakes, etc.) and low in meat, fruits and vegetables.

The individual who has had gastric restrictive surgeries needs to alter their diets to include more protein and to reduce considerably their intake of carbohydrates high in sugar and processed grains. Such dietary changes will not only improve nutritional status but promote greater weight loss success, as well. In addition to changes in diet, it is recommended that the gastric restrictive bariatric surgical patient continue their daily intake of vitamin and mineral supplements long-term.

In summary, gastric restrictive surgeries can lead to nutrient deficiencies, i.e. vitamins, minerals, and protein malnutrition. Such deficiencies, if left unattended, can result in significant muscle loss, anemia, hair loss, extreme fatigue and even neurological disorders. The greatest risk for nutrient deficiencies occurs in the first few months following surgery and generally becomes less prevalent as solids are reintroduced into the diet.