Notes on Nutritional Deficits

From the 52nd Annual Postgraduate Symposium Family Medicine Update: 2009, presented by theSan Diego Academy of Family Physicians

Educational Objectives

The goals of this program are to improve management of patients after gastric bypass surgery and those with anorexia or bulimia. After hearing and assimilating this program, the clinician will be better able to:

1.   Describe differences among surgical weight loss procedures.

2.   List symptoms of nutritional deficiencies common after gastric bypass surgery.

3.   Select appropriate forms of supplementation for patients with iron deficiency and osteoporosis.

4.   Monitor patients with eating disorders to prevent morbidity and mortality.

5.   Counsel patients and family members about therapy for anorexia and bulimia.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and the planning committee re­ported nothing to disclose.

Acknowledgements

Drs. Fujioka and Maletz were recorded in San Diego, CA, at 52nd Annual Postgraduate Symposium Family Medicine Update: 2009, presented June 26-28, 2009, by the San Diego Academy of Family Physicians. The Audio-Digest Foundation thanks the speakers and the San Diego Academy of Family Physicians for their cooperation in the produc­tion of this program.

Common Nutritional Deficiencies After Gastric Bypass

Kenneth Fujioka, MD, Director of Nutrition and Metabolic Research, and Director, Center for Weight Man­agement, Scripps Clinic Medical Group, San Diego, CA

Why gastric bypass surgery works: small pouch restricts amount of food eaten; »20 ft of small intestine acts as common limb with bile acid (does not cause malabsorption); negative aversion  —  eg, when candy bar (»1000 os­mol/L) eaten, it does not pass through pylorus (candy bar goes directly to small intestine where osmolarity 280-290 osmol/L); fluid rushes into small intestine and causes expansion; vagal reaction causes patients to feel unwell; “they don’t eat candy anymore”

Brain and weight control: brain programmed to eat continuously; body weight controlled by, eg, hormonal or vagal messages that shut off eating for »2 hr; within 2 hr, drive to forage for food returns; after reaching higher weight, body defends that weight; hormones  —  ghrelin from stomach stimulates appetite; peptide YY (PYY) and glucagon-like peptide 1 (GLP-1) turn off hunger

Procedures: gastric bypass  —  causes 37% to 38% weight loss, but weight gradually regained due to lowered metabo­lism (eg, if 10% of body weight lost, metabolism lowers by 25%); results in »25% weight loss; gastric banding  —  band placed at top of stomach; does not alter hormones, so amount of weight loss »50% less than that of other pro­cedures; restricts eating; slippage  —  occurs after band placement; causes vomiting of fluids; one side of band breaks loose from sutures, slips, and rotates around one side and results in obstruction and herniation; surgical emergency; gastric pouch  —  part of stomach removed and stapled; tubularized stomach restricts eating; pylorus in­tact; lowers ghrelin and increases GLP-1; weight loss results better than with banding (almost as good as gastric by­pass)

Adjustment of medications for type 2 diabetic with gastric bypass surgery: serum glucose likely to drop and nor­malize due to reduced eating and increased GLP-1; speaker recommends discontinuing agents that reduce serum glucose below normal (eg, glipizide [Glucotrol] and insulin)

Thiamine deficiency: case  —  6 wk after gastric bypass and 50-lb weight loss, patient presents with vomiting, vision problems, and symptoms of ataxia; often missed; restore thiamine urgently; worsens with carbohydrate intake

Pain after gastric bypass: case  —  1 yr after surgery and 100-lb weight loss, patient presents with epigastric pain of 3-wk duration; no nausea or vomiting; normal stools; ask about use of over-the-counter (OTC) drugs; when drug (eg, aspirin) taken, it bypasses stomach, goes directly to small intestine, and causes pain

Osteoporosis after gastric bypass: case  —  woman 52 yr of age presents 7 yr after surgery; lost 90 lb, but regained 25 lb; menopausal for »4 yr; dual energy x-ray absorptiometry (DEXA) shows moderate osteoporosis; work-up  —  check parathyroid hormone (PTH) and 25-hydroxyvitamin D levels; chemistry panel; hyperparathyroidism sec­ondary to vitamin D deficiency  —  consider if PTH elevated and vitamin D low; patients cannot absorb vitamin D or calcium; replace calcium and vitamin D (start with ergocalciferol, 50,000 U/wk; recheck level in 2 wk); give intra­venous (IV) bisphosphonates; patients cannot acidify calcium bicarbonate (give calcium citrate, 1000-1500 mg/day); seen in up to 30% of patients; usually occurs 7 to 10 yr after surgery

Iron deficiency: common (60%-90% of patients; especially in menstruating women); presents as pica (eg, chewing ice or dirt); since patients in slow metabolic state, inflammatory markers drop (ferritin accurate for measuring iron; total iron-binding capacity and serum iron acceptable); due to inability to absorb iron, patients may need IV iron, eg, iron sucrose, 200 mg (reaction [eg, fever, joint aches] rate, 1%-2%)

Vitamin B₁₂ deficiency: treat with sublingual form (effective 80% of time); must be taken regularly; monitor regu­larly; some patients require monthly vitamin B₁₂ injection

Supplements: multivitamin with iron for all patients; calcium citrate; potassium and magnesium early on; zinc and copper  —  enter through same transport system; as zinc replaced, copper malabsorbed; necessary to stop one, then start other (“it’s a game, but you have to hang in there with it”); check levels regularly

Conclusions: bariatric surgery beneficial (especially to seriously overweight patients with type 2 diabetes); be pre­pared to withdraw diabetic medications; follow nutritional problems; check hemoglobin A_1C yearly; diabetes recurs in some patients as they regain weight; 15% of patients who undergo gastric bypass fail (ie, do not lose >20 lb, and regain weight)

Questions and Answers

Major cause of weight regain: metabolic slowdown; body lowers metabolic rate more than needed; weight gain seen in patients who consume 1500 to 1700 calories/day

Absorption of medications: thyroid replacement therapy  —follow thyroid-stimulating hormone levels after gastric bypass every 6 mo to 1 yr; 20% to 25% of patients may need increased doses (from, eg, 125 μg/day to 200-300 μg/day); oral contraceptives (OCs)  —  after surgery, estrogen levels drop as body fat drops, resulting in heavy men­strual periods; maintain patients on standard dosage; celecoxib (Celebrex)  —  not studied in gastric bypass patients; cannot guarantee use will not result in ulcer

b-Carotene deficiency: common; good general nutritional marker for fat-soluble vitamins; check levels 18 mo after surgery; can be replaced with OTC b-carotene; difficult to absorb from fruits and vegetables; recommend B com­plex vitamin

Vitamin D monitoring: patients require vitamin D supplementation for life; PTH levels change after »6 wk of vita­min D supplementation; check every 6 to 8 wk

Thiamine deficiency: rarely seen later than 6 mo after surgery; usually occurs within 2 to 3 mo

Iron deficiency: cannot be treated with interferon; treat with iron dextrose, iron sucrose, or iron gluconate

Criteria for gastric bypass: morbid obesity (2 times normal weight); body mass index (BMI) cutoff, 40 (35 if pa­tient has diabetes or hypertension)

Update for Primary Care: Anorexia and Bulimia

Louis Maletz, MD, Volunteer Clinical Faculty, Department of Family Medicine, University of California, School of Medicine, San Diego, and Medical Director, Mandometer Clinic for Eating Disorders, San Diego, CA

Introduction: »40% of anorexics develop bulimic symptoms; patients with BMI <20 to 25 at as high risk for health issues as patients with BMI of 40 to 55; 90% of patients with anorexia or bulimia women; survey found 7% of white, 7% of Hispanic, and 4% of black students said they took laxatives or vomited to lose weight or to avoid gain­ing weight; normal weight for woman 5'4”  —  125 lb, BMI 21.5; BMI calculator available online

Constitutional thinness vs anorexia: BMI similar, but percentage of body fat differs; leptin related to amount of body fat; leptin responds more acutely when body fat reduced due to anorexia, compared to constitutional thinness; anorexic patients amenorrheic (>16% to 17% of body fat required for menstruation); constitutionally thin women menstruate; check estradiol levels (should be ³30 pg/mL) to verify

Cachexia vs starvation: cachexia  —  inflammatory process destroys body protein; starvation  —  resting energy expen­diture decreases as body tries to protect protein for survival

Prevalence: anorexia affects 0.9% of girls and women (bulimia, 1.5%-3.0%); binge eating disorder increasing; indi­viduals with bulimia or binge eating disorder do not commonly seek treatment; most patients hospitalized for an­orexia 16 to 18 yr of age (18-21 yr of age for bulimia); see patients regularly to reduce health service utilization

Treatment: expensive; inpatient criteria  —  medical reason requiring admission; risk for suicide; failed outpatient treatment; clinic facilities  —  often distant from patient's residence; patients usually referred by insurance company or primary care physician; traditional model of treatment  —psychotherapy; fluoxetine (60 mg) for bulimia; no med­ications available for treatment of anorexia, but 60% placed on antidepressant despite lack of efficacy; utilization review to help patients stay in treatment (drop-out rate high; encourage patients to stay in treatment)

Mortality and anorexia: significant; has highest mortality of any psychiatric condition (including depression); 1981 data from prison in Northern Ireland found average number of days for young healthy men 20 to 30 yr of age to sur­vive before dying of starvation, 66 days;  Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria  —  15% weight loss below ideal BMI (BMI usually <17.5); weight phobia; distorted body per­ception; amenorrhea; anorexic patient who also purges difficult to manage; mortality of bulimia lower than that of anorexia; treat complications of bulimia with electrolytes and fluids; if BMI <14, consider hospitalization

Recovery and complications: remission  — »1 yr without symptoms; recovery  —  >1 yr without symptoms; study found 46% of patients do well; relapse common; complications  —  patients usually present with many medications (eg, psychiatric medications) on board; medications used to keep patient comfortable; treatment of osteoporosis and osteopenia not as effective as in patients without eating disorder; irregular heart rhythm (eg, bradycardia); low blood pressure; constipation; amenorrhea; osteoporosis; depression; sudden death (monitor for risk); anemia; os­teopenia

Initial management: weigh patient; evaluate behavior; record medication history; drug or alcohol use important; bu­limics tend to engage more in risky behavior and stealing; assess  risk for suicide; perform physical examination, laboratory studies (including drug screen), and electrocardiography (ECG); indications for hospitalization include risk for suicide and lack of progress

Prevention of refeeding syndrome: check phosphorus level; decrease in phosphorus can trigger refeeding syn­drome; refeed patients at low levels

Effects of bulimia: amylase elevation common; check electrolytes; vomiting reduces potassium, increases bicarbon­ate, and reduces chloride; <10% present with low potassium levels (rate nearly double with laxative abuse); 46% to 48% of anorexics with bulimia have low potassium

Psychiatric therapy: cognitive behavioral therapy (CBT) useful for treatment of bulimia; patients have difficulty ex­pressing emotion and may appear uninterested in getting well; behavior modification  —  eg, device used to measure food; try to increase eating rates in patients with anorexia, and decrease eating rates in those with bulimia; allows patients to focus on normalizing hunger and satiety; body image dysfunction usually last to resolve

Conclusion: treat patients urgently; assure patients they will not become overweight with treatment; perform thor­ough physical examination; use medications sparingly; focus on behavior, not on weight; focus on reaching weight for menstruation to resume; educate family and inform them it may take 1 to 2 yr for patient to go into remission

Questions and Answers

Risk for refeeding syndrome: low; check phosphorus levels

Teenage girl with extremely restricted eating habits: check for normal weight; assess whether girl has fear of fat or becoming fat; monitor such patients closely

Treatment outcomes at specialty clinics: Mandometer program saw 75% remission rate vs 50% in other programs; results may be poorer in academic centers because patients treated have more severe disease; Mandometer  —  device used to measure food; goal for patient to eat 350 g per meal in <15 min

Associated history of sexual abuse or molestation: literature indicates higher incidence in patients with eating dis­orders (not seen in speaker’s clinic); other associated issues include interpersonal dynamics with parents or spouses

Studies of treatment with naltrexone: most studies conducted in bulimic anorexics; bulimia may be similar to ad­diction; interruption of binging and purging cycle results in withdrawal symptoms (eg, irritability, insomnia); no drug therapy with demonstrated efficacy

Albumin as marker for long-term mortality: not useful (albumin can be lowered by inflammation)

Causes of sudden death: not always due to low potassium; U waves seen on ECG in patients with low potassium, but there may be other causes of prolonged QT intervals

Suggested Reading

Becker AE et al: Clarifying criteria for cognitive signs and symptoms for eating disorders in DSM-V. Int J Eat Dis­ord Jul 31, 2009 [Epub ahead of print]; Frankenburg FR: Case 20-2008: Abdominal pain and weakness after gastric bypass surgery. N Engl J Med 359:1852, 2008; Gray P: Mandometer treatment of Australian patients with eating dis­orders. Med J Aust 189:184, 2008; Hartmann A et al: Interpersonal problems in eating disorders. Int J Eat Disord Aug 28, 2009; [Epub ahead of print]; Ioakimidis I et al: A method for the control of eating rate: a potential interven­tion in eating disorders. Behav Res Methods 41:755, 2009; Jin J et al: Utilization of preoperative patient factors to predict postoperative vitamin D deficiency for patients undergoing gastric bypass. J Gastrointest Surg 13:1052, 2009; Keidar A et al: Band slippage after laparoscopic adjustable gastric banding: etiology and treatment. Surg Endosc 19:262, 2005; Matrana MR et al: Vitamin deficiency after gastric bypass surgery: a review. South Med J Sep 4, 2009 [Epub ahead of print]; Meguid MM et al: Weight regain after Roux-en-Y: a significant 20% complication related to PYY. Nutrition 24:832, 2008; Health implications of obesity. National Institutes of Health Consensus Development Conference Statement. Ann Intern Med 103:1073, 1985; Pournaras DJ et al: The gut hormone response following Roux-en-Y gastric bypass: cross-sectional and prospective Study. Obes Surg Oct 14, 2009 [Epub ahead of print]; Serpa Neto A et al: Effect of weight loss after Roux-en-Y gastric bypass, on renal function and blood pressure in morbidly obese patients. J Nephrol 22:637, 2009; Steinhausen HC: The outcome of anorexia nervosa in the 20th century. Am J Psychiatry 159(8):1284, 2002; Zandian M et al: Cause and treatment of anorexia nervosa. Physiol Be­hav 92:283, 2007.