COMPARISON OF NUTRITIONAL DEFICIENCIES AND COMPLICATIONS FOLLOWING VERTICAL SLEEVE GASTRECTOMY, ROUX-EN-Y GASTRIC BYPASS, AND BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH Kinsy Miller A Thesis Submitted to the graduate college of Bowling Green State University in partial fulfillment of the requirements for the degree of MASTER OF FAMILY CONSUMER SCIENCE August 2009 Committee: Martha Sue Houston, Advisor Rebecca Pobocik Priscilla Coleman ii ABSTRACT Martha Sue Houston, Advisor Background: The prevalence of morbid obesity continues to increase and bariatric surgery remains the superior way to treat morbid obesity and related disorders. Although bariatric surgery can produce significant weight loss and alleviate comorbidities, it can also impact nutritional status in ways that have not been adequately studied. Objective: The objective of the present study was to compare the incidence of nutritional deficiencies, significant complications, and amount of weight loss in patients undergoing three different bariatric surgery procedures: Vertical Sleeve Gastrectomy (VSG); Roux-en-y Gastric Bypass (RNY-GB); and Biliopancreatic Diversion with Duodenal Switch (BPD-DS). In addition, the role of the registered dietitian (RD) in the outcome of bariatric patients was explored. Design: A review of all patients undergoing bariatric surgery between April 2006 and December 2007 (n = 119) was conducted from prospectively maintained medical records of a single bariatric surgery practice. Laboratory data related to specific nutrients, hyperlipidemia, and anemia, concerns about compliance with nutrient supplement intake and dietary protein intake, and complication and post-surgery hospitalization rates were compared among patients undergoing the three surgical procedures, VSG, RNY-GB, and BPD-DS. Patients were followed for a minimum of 6 months and a maximum of 18 months after surgery. Results: Vitamin B12 and calcium deficiency were uncommon after surgery at 1.2% and 2.6%, respectively, among recipients of all surgery types (p = 0.506, and p = 0.092, respectively). The overall rate of folate deficiency was 7.2% and the rate of BPD-DS patients developing folate deficiency after surgery was 37.5% (p = 0.002). The overall rate of anemia was 33.8% and the iii rate of RNY-GB patients developing anemia following surgery was 50% (p = 0.010). Vitamin D deficiency was markedly high at 66.7% of all patients. All of the BPD-DS patients developed deficiency, which was significantly higher than the other groups (p = 0.003). Protein and vitamin A deficiency were present in 38% and 34.8% of all patients, respectively, but there were no significant differences among surgery types (p = 0.216, and p = 0.141, respectively). Patients who were documented as non-compliant with multivitamin/mineral intake were more likely to develop anemia (p = 0.015) and those who were documented as non-compliant with calcium supplements were more likely to develop vitamin D deficiency (p = 0.022). Weight loss over time among all surgery types was significantly different (p < 0.0001). At 12 months after surgery average percent excess body weight loss (EBWL) was 70.9% for BPD-DS, 59.7% for RNY-GB and 40.2% for VSG. There were no significant differences across groups in the risk of developing complications after surgery relative to weight loss (p = 0.079). Lower albumin levels following surgery were correlated with more complications (r = - 0.31, p = 0.008). RD visits were positively correlated with higher minimum albumin levels (r = 0.24, p=0.025) and greater %EBWL (r = 0.30, p = 0.002). Conclusions: Nutritional deficiencies and anemia occurred as a result of all bariatic surgery procedures, both restrictive (VSG) and malabsorptive procedures (RNY-GB and BPD-DS) in the 18 months post-surgery. The incidence of vitamin D deficiency (66.7%) was particularly concerning. Patient intake of recommended levels of nutrient supplements and dietary protein was poor and was related to some of the nutrient deficiencies and anemia. RD visits were beneficial as more RD visits were related to greater weight loss and higher albumin levels following surgery. Increased RD visits and monitoring of nutritional status, nutrient supplement intake and dietary intake of patients pre and post-bariatric surgery is warranted. iv ACKNOWLEDGMENTS I would like to acknowledge my advisor, Dr. Sue Houston, for all of the hours and work put in to this project. In addition, I would like to acknowledge my thesis committee members Dr. Rebecca Pobocik and Dr. Priscilla Coleman for their time and efforts in putting this thesis together. Finally, a thank you to the Bowling Green State University Statistical Lab for all of their hours devoted to analyzing the data presented in this study. v TABLE OF CONTENTS Page CHAPTER I. INTRODUCTION TO OBESITY ............................................................... 1 CHAPTER II. LITERATURE REVIEW........................................................................... 4 Introduction to Bariatric Surgeries......................................................................... 4 Normal Digestion and Absorption ......................................................................... 7 Nutritional Deficiencies......................................................................................... 8 Comparison of Nutritional Deficiencies Following Bariatric Surgeries .................. 11 STATEMENT OF THE PROBLEM................................................................................. 13 RESEARCH QUESTIONS............................................................................................... 14 CHAPTER III. METHODS.............................................................................................. 15 Nutritional Counseling .......................................................................................... 16 Indicators of Nutritional Status.............................................................................. 20 STATISTCAL METHODS............................................................................................... 23 CHAPTER IV. RESULTS ................................................................................................ 24 CHAPTER V. DISCUSSION ........................................................................................... 51 REFERENCES ......... ....................................................................................................... 58 vi LIST OF FIGURES/TABLES Figure/Table Page 1 Anatomy of roux-en-y........................................................................................ 4 2 Anatomy of biliopancreatic diversion with duodenal switch .................................. 5 3 Anatomy of vertical sleeve gastrectomy ................................................................ 6 1 Summary of protein, iron, vitamin B12, calcium, and vitamin D deficiency (% of subjects) following various bariatric surgeries.............................................. 10 2 Number of patients undergoing medically supervised weight loss for 3 or 6 months per type of surgery performed .................................................................... 16 3 Foods included in full and clear liquid diet prior to surgery .................................... 17 4 Vitamin, mineral, and protein recommendations per type of bariatric surgery at 0-1 months and 3 + months post-operatively.......................................................... 17 5 Protein requirements following bariaric surgery per diet phase .............................. 18 6 Optisource™ chewable vitamin and mineral supplement ........................................ 18 7 Nutrition parameters studied and laboratory data available during the study perioda ……………… ........................................................................................... 20 8 Pre-operative characteristics of subjects by surgery typea....................................... 24 9 Evidence of nutritional deficiencies pre and post-surgery ...................................... 26 10 Evidence of iron-related nutritional deficiencies pre-and post-surgery ................... 33 11 Evidence of cholesterol related abnormalities pre-and post-surgery a,b .................... 36 12 Documented concerns regarding adequacy of patient intake of multi-vitamin mineral supplements, calcium supplements, vitamin A & D supplements, and protein dietary intake after bariatric surgery........................................................... 37 vii LIST OF FIGURES/TABLES, CONT. Figure/Table Page 13 Difference in nutritional deficiencies among patients categorized by documented concerns regarding multivitamin mineral supplement and protein intake following bariatric surgery ..................................................................................................... 38 14 Differences in nutritional deficiencies related to compliance with calcium supplementation .................................................................................................... 41 15 Comparison study of weight loss ........................................................................... 43 4 Differences in pounds lost over time among the 3 different surgery types.............. 44 5 Differences in Percent Excess Body Weight Loss (%EBWL) over time among the 3 different surgery types........................................................................................ 45 16 Complications following bariatric surgery a ........................................................... 46 1 CHAPTER