Transcript vitamin B 12

Dr : Reem Murad
“Bariatric surgery should be considered for adults with BMI ≥ 35
kg/m2 and type 2 diabetes, especially if the diabetes is difficult to
control with lifestyle and pharmacologic therapy.”
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– American Diabetes Association (2009)
“When indicated, surgical intervention leads to significant
improvements in decreasing excess weight and co-morbidities
that can be maintained over time.”
– American Heart Association (2011)
“Bariatric surgery is an appropriate treatment for people with type
2 diabetes and obesity not achieving recommended treatment
targets with medical therapies”
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– International Diabetes Federation (2011)
“The beneficial effect of surgery on reversal of existing DM and
prevention of its development has been confirmed in a number of
studies”
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– American Association of Clinical Endocrinologists (2011)
Sources: American Diabetes Association. Standards of medical care in diabetes – 2009. Diabetes Care 2009; 32(S1):S13-S61,
Poirier P, Cornier M-A, Mazzone T et al. Bariatric surgery and cardiovascular risk factors: A scientific statement from the American Heart Association. Circulation 2011; 123:00-00.
International Diabetes Federation. Bariatric surgical and procedural interventions in the treatment of obese patients with type 2 diabetes. 2011.
Handelsman Y, Mechanick JI, Blone L et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for developing a diabetes mellitus comprehensive plan. Endocr Prac 2011; 17(Suppl 2).
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Roux-en-Y Gastric Bypass
LAP-BAND
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Type 2 diabetes mellitus
Hypertension
Hyperlipidemia
Degenerative joint disease
Sleep apnea
GERD
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5% to 10% weight reduction is associated with
significant decrease in risk
Weight loss from surgery reduces or eliminates
medications
Improves severity or resolves co-morbid disease
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Protein
Carbohydrates
Fat
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Iron
Calcium and Vitamin D
Vitamin B12
Folic acid
Thiamin
Zinc
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Stomach
 Water, ethyl alcohol, copper, iodide, fluoride,
molybdemum, intrinsic factor
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Duodenum
 Calcium, iron, phosphorus, magnesium, copper,
selenium, thiamin, riboflavin, niacin, biotin,
folate, vitamins A, D, E, K
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Jejunum
 Thiamin, riboflavin, niacin, pantothenate, biotin,
folate, vit B6, vit C, vit A, D, E, K, dipeptides,
tripeptides, calcium, phosphorus, magnesium,
iron, zinc, chromium, manganese, molybdenum,
amino acids
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Ileum
 Vit C, folate, vit B12, vit D, vit K, magnesium, bile
salts/acids
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Gastric Bypass:
 Most common: Iron, Vitamin B-12,
Folic acid, Fat soluble Vitamins A, D, & E
 Thiamin (seen in patients with frequent vomiting)
 Calcium
 Protein malnutrition
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Gastric Banding:
 Except for folate, nutrition deficiencies are less commonly seen post
gastric banding
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Sleeve Gastrectomy
 Possible B-12
Common following RYGB
As high as 49% of patients
Multifactorial cause
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Low gastric acid levels prohibit iron cleavage from food
Absorption inhibited because no nutrient exposure to
duodenum or proximal jejunum
Decrease in iron-rich food consumption due to intolerance
Treat with oral supplementation of ferrous sulfate or
ferrous gluconate
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Patients with persistent iron loss should be
evaluated for blood loss through the
gastrointestinal tract.
Ulcers at the margin of the.
All NSAIDs, including aspirin have the
potential to cause ulcers
Absorption of thiamin occurs primarily in the
proximal small intestine
 Thiamin deficiency after RYGB surgery can occur
in up to 49% of patients
 Thiamin deficiency mainly affects the central
nervous system, potentially leading to beriberi
and Wernicke encephalopathy which can
develop into Wernicke-Korsakoff syndrome
(WKS).
 The classic triad of symptoms of WE involves
ocular abnormalities, gait ataxia, and mental
status changes
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Niacin/Vitamin B 3 Niacin deficiency after
bariatric surgery is rare
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Folate absorption occurs in the proximal
portion of the small intestine, Complete
absorption requires B12
Absorption dependent on HCl and upper 1/3
stomach
postoperative deficiency up to 40% patients
It is recommended that patients consume
200% of the daily value (800 mcg) of folic acid
daily
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Up to 70% of patients
Lack of hydrochloric acid and pepsin in
stomach
Manifestation of vitamin B 12 deficiency is
more likely to develop years after surgery due
to the body’s B 12 reserve capacity.
Oral supplementation usually adequate,
otherwise, IM injections used
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Recommended treatment for maintenance
levels is 1000 mcg/d.
Several treatment options exist(daily, weekly,
monthly) and method of intake (oral,
intramuscular, nasal)
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Roen-en-Y gastric bypass: protein and fat
malabsorption. .
Fat malabsorption manifests its presence by
fat-soluble vitamins A, D, and K
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Vitamin D absorption occurs primarily in the
distal small intestine.
a suggested dose is 50,000 international units
of ergocalciferol taken orally, once weekly,
for 8–12 weeks
recommended supplementing 3000
international units of vitamin D 3 daily
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Calcium absorption occurs mainly in the
duodenum and proximal jejunum and is
dependent on vitamin D levels
To support optimal bone health throughout
weight loss, calcium supplementation should
be given at 1200–1500 mg/d along with
regular consumption of calcium-rich foods.
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Vitamin D deficiency is common among obese people
Calcium absorption decreased because duodenum is
bypassed
Intolerance to dairy, foods high in calcium
Vitamin D is required for Ca++ absorption
Prolonged deficiencies lead to
 Bone resorption, osteomalacia, osteoporosis
Vitamin A :risk for vitamin A deficiency those with
BPD and DS due to the limited available absorptive
area and changes with fat absorption after surgery
 recommended that 50,000–100,000 international
units of vitamin A be given intramuscularly for 3 days
followed by 50,000 international units per day
intramuscularly for 2 weeks
 Treatment for vitamin A deficiency without corneal
changes is 10,000– 25,000 international units per day
orally until clinical improvement is seen.
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Calcium: bone pain
Iron: fatigue
Zinc: brittle nails
Vitamin A: inability to see in the dark
Vitamin E: poor wound healing
Vitamin K: easy bruising
Vitamin B1 (Thiamin): numbness and tingling
in the hands and feet
Vitamin B12 (Methylcobalamin): fatigue
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” Due to fat malabsorption, severe vitamin D
deficiency will develop along with an already
reduced ability to absorb calcium
fractured bones
a bone density study “severe bone loss”
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or telogen effluvium, is seen frequently 3–6
months after surgery.
Lasting as long as 6–12 months
it can be terribly distressing to the patient.
Although there is no known treatment, it
usually reverses without intervention
Thiamin (vitaminB1) :Goal Female, 30–160
mcg/dL Male, 30–300 mcg/dL
 Treatment: Confirm patient taking 2 MVIs daily
(1 MVI LAGB) each containing 100% RDA
thiamin. •
 Parenteral supplementation 100 mg/d for 7.14 d,
then 50 mg/d until levels are normal or
symptoms resolve
 500 mg/d IV thiamine should be given for severe
deficiency, followed by 250 mg/d for 3.6 d or
until symptoms resolve
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Cobalamin (vitamin B 12 ) :200–1000 pg/mL
Confirm patient taking 2 MVIs (1 MVI LAGB).
Confirm patient (except LAGB) is taking
vitamin B 12 : up to 1000 mcg/d orally or 500
mcg/wk intranasally, or 1000 mcg/mo IM.
œ If <200 pg/mL -IM injections or supplement
with 350.1000 mcg/d orally. •
Vitamin D, 25-hydroxyvitamin D :>30 ng/mL
(insufficiency = 25–30 ng/dL) If <20 mg/mL,
• start ergocalciferol or cholecalciferol 50,000
units/wk orally •~ 8 wk.
• maintenance dose of vitamin D3, 3000
international units daily if level is persistently
low
• Supplementation for vitamin maintenance is
recommended a 1000.2000 i u per day
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Calcium and intact PTH Serum :
Ca: 9–10.5 mg/dL Ionized Ca: 4.5–5.6 mg/dL
iPTH <65 pg/mL
Confirm patient taking calcium citrate
1200.1500 mg/d.
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Folic acid RBC folate: 280–791 ng/ mL Serum
folate: 11–57 mmol/L, 5.3–99 ng/mL
Confirm patient taking 2 MVIs (1 MVI LAGB)
daily with 400 mcg of folic acid. œ
Supplement with 1000 mcg/d orally if serum
levels are low, up to 5 mg/d possibly needed
with severe malabsorption. (RBC folate is a
more sensitive marker than serum folate,
which reflects dietary intake).
Encourage consumption of folate-rich foods.
Iron Serum :iron: 37–170 mcg/ dL
Confirm patient taking 2 MVIs each containing at least
18 mg of iron.
 Menstruating women and those at risk of anemia may
require additional supplementation. •
 If oral iron therapy has failed to improve laboratory
values, then refer to hematology for IV iron
replacement.
 After iron infusions, patients should be encouraged to
continue with goal iron intake of 50.100 mg/d to
prolong period between infusions
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Vitamin K : PT: 10–13 Seconds
Confirm patient taking 2 MVIs daily.
1 mg/d vitamin K supplementation
recommended when INR values are >1.4. •
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Vitamin A Plasma retinol: 20–80 mcg/dL
Without corneal changes: 10,000. 25,000
international units of vitamin A per day orally
until clinical improvement.
With corneal changes: 50,000.100,000
international units of vitamin A IM for 3 d
followed by 50,000 international units per day
IM for 2 wk.
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Zinc 0.66–1.1 mcg/ mL
Confirm patient taking 2 MVIs containing
zinc.
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Copper : 0.75–1.45 mcg/ mL
Confirm patient taking 2 MVIs that provide
at least 2 mg/d copper.
Patients should be referred to dietitian.
Ensure 1 mg copper for every 8.15 mg of oral
zinc intake.
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Patients require lifelong vitamin and mineral
supplementation
regimens following bariatric surgery.
Routine biochemical monitoring for nutrition
status
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Multivitamin with iron
Calcium (citrate) with vitamin D (1200-1500
mg calcium with 800-1000 IU vitamin D)
Oral vitamin B12 (500-1000 mcg)
Iron (65 mg/day in elemental form)
 Vitamin C (to increase absorption of Iron)
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Thiamin (10 mg/day)