A new outpatient Bariatric Surgery Clinic recently opened at Bellevue Hospital Center. This clinic offers laparoscopic adjustable gastric banding to patients 18 years of age or older who meet specific BMI and medical criteria. This life-altering surgery is now covered by Medicaid and those who are uninsured can work with financial counselors to obtain funding through special HHC programs. While the surgeons diligently educate their patients on their dietary transitions and requirements after surgery, primary care physicians, amongst other issues after bariatric surgery, should be aware of the risk of nutritional deficiencies that these patients face.
After roughly one month postoperatively, patients begin their transition diet from liquid to a soft, solid diet as they learn to tolerate larger, richer food boluses. A significant focus is placed on chewing quality and pattern at this time. Eating habits of patients who undergo bariatric surgery vary somewhat based on whether they undergo gastric bypass or banding. Those who undergo gastric banding quickly learn to monitor their portion sizes and some may experience food aversions secondary to extensive vomiting. For patients who undergo gastric banding, the transition is more subtle. The initial band that is placed is actually deflated at first and then gradually tightened in 4-6 week intervals during the first 1- 2 years after surgery.
Patient’s who undergo any type of bariatric surgery are at increased risk of nutritional deficiencies as a result of drastic changes in food intake, altered digestive anatomy, and possible persistent vomiting. Common deficiencies include those of fat soluble vitamins, folic acid, and thiamine. Patients that undergo gastric bypass surgery are at a much higher risk of these deficiencies when compared to those that undergo gastric banding due to the varying operative procedures. For example, since food does not pass through the calcium transporter-rich duodenum in these patients, a calcium deficiency may occur. If combined with insufficient Vitamin D intake, secondary hyperparathyroidism can result. Patients who undergo gastric bypass also suffer more deficiencies of iron, Vitamin B12, and fat soluble vitamins. Though recommendations are somewhat limited, in general, vitamin supplementation in patients undergoing bariatric surgery (more specifically gastric bypass), should include a daily multivitamin (vitamins C, vitamin K, vitamin A, 800 IU vitamin D , E, B vitamins) in either pill or liquid form, monthly injections of vitamin B12 or sublingual B12 1000-2000 mcg daily, daily calcium supplements, iron (if at risk or a deficiency is present), and daily thiamine (if suffering from persistent vomiting).
In short, as bariatric surgery becomes available to more of our patients, primary care physicians should be aware of dietary issues and the potential for nutritional deficiencies in this demographic, especially those undergoing gastric bypass (which is not currently available at Bellevue). Physicians caring for these patients must assure that the appropriate labs are periodically checked to evaluate for any such deficiencies and vitamin supplementation should follow if necessary.
1. Bariatric surgery clinic opens at Bellevue Hospital @ med.nyu.edu, posted 4/3/08, accessed 5/5/08.
2. Boan, J., Mun, E. Management of patients after bariatric surgery @ uptodate.com, accessed 5/5/08.
3. Schweitzer, D., Posthuma, E. Prevention of vitamin and mineral deficiencie after bariatric surgery: evidence and algorithms. Obesity Surgery, 2008.