A patient’s intake and absorption of micronutrients should be monitored in the years following weight loss surgery. Perhaps as a combination of pre-existing nutrient issues, reduced consumption leading up to and following weight loss surgery, as well as surgery-related absorption changes, patients may be deficient in a variety of vitamins, including vitamin D, vitamin B12 and iron. Such deficiencies can lead to fatigue, irritability, anemia, the loss of bone mass and neuropathy, among others.
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Assessing these deficiencies and bone health prior to surgery is very important. However, studies indicate that following bariatric surgery, patients benefit from an extended period of nutritional support.
“We know that nutritional management is a critical component for diabetes patients going into bariatric surgery,” states Sangeeta Kashyap, MD. “And it’s is just as important after surgery.”
Patients may feel asymptomatic
After patients lose weight and begin to see improvements in symptoms from comorbidities, they often feel good. “This is when patients start to see their weight loss efforts payoff: they may feel more confident and happier with their appearance, sleep better, have more energy and perhaps feel less pain in their joints.” According to Dr. Kashyap, “Patients may think that their vitamin levels are adequate because they don’t feel symptomatic. They may not realize that after surgery, they might not be able to absorb and process vitamins like they did before.”
And these changes aren’t as transient as one might think. An ancillary investigation of STAMPEDE trial data indicated patients with type-2 diabetes who underwent weight loss surgery had chronically elevated bone turnover markers at the five-year mark compared to patients who were randomized to medical interventions alone. Although surgical patients did achieve significant improvements in weight loss, glycemic control, triglyceride and HDL cholesterol levels, the metabolic changes were still present five years later, putting them at higher risks for fractures.
“While this may be a drawback, we have to weigh the risk of potential fractures against the benefits of improved glycemic control achieved by these surgeries,” notes Dr. Kashyap.
Most patients report difficulty adhering to supplement regimen
Most patients receive education and counseling about diet, including the lifelong need for micronutrient supplements, prior to weight loss surgery. New research indicates that more than half of patients who had Roux-en-Y gastric bypass or sleeve gastrectomy found it difficult to adhere to a prescribed supplement regimen. Patients reported several barriers to adherence, including difficulty remembering, too many pills, side effects, not receiving a prescription from their primary care providers, bad taste, and feeling as though they didn’t need supplements.
Dr. Kashyap has a few recommendations for physicians involved in the care of patients in the years following weight loss surgery:
- Reduce the “ask.” Try compounded vitamins to cut down on the number of pills.
- Consider prescribing an app. Nutrition tracking apps made specifically for bariatric patients sometimes have the ability to send vitamin reminders throughout the day. While you might not want your patient to rely solely on technology for compliance, automatic reminders may help.
- Involve exercise and nutrition specialists. Between monitoring comorbidities and managing a patient’s weight, physicians may not have enough time to address specific nutritional or exercise needs.
“Patients get the surgery to make themselves healthier, but if they do not follow the nutrition guidelines, they could be doing themselves a real disservice. Patients should really see a nutritionist twice a year, and adhere to a structured exercise program,” Dr. Kashyap says. “That is the bottom line.”