Management of morbid obesity - The Journal of Family Practice

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Management of morbid obesity: The role of bariatric surgery TABLE 5 Nutrient supplementation after gastric bypass surgery Recommended dosage Comments Iron 40-65 mg/day • 2 chewable multiple vitamin (with iron) tablets daily for the first month, then • 1 prenatal multiple vitamin or 2 regular multiple vitamin (with iron) tablets daily Vitamin B 12 350 mcg/day • An additional 1,000 mcg IM every 1-3 sublingually months, if necessary Folate 800-1,000 • Most multiple vitamin tablets contain mcg/day recommended dosage Calcium + Calcium: 1,200- • Calcium citrate preferred over calcium Vitamin D 1,500 mg/day carbonate, which is malabsorbed after Vitamin D: gastric bypass 1,600 IU/day lowed by runny nose, excessive salivation, nausea, tachycardia, syncope or presyncope, vomiting, and diarrhea. 17 The small bowel gradually adapts to the anatomic changes of surgery, and dumping syndrome usually resolves in 6 to 12 months. Although uncomfortable, the syndrome provides valuable negative reinforcement for patients to avoid concentrated sweets and carbohydrates. Psychologic follow-up After surgery, patients need early and frequent contact with a psychologist or psychiatrist to address such issues as adjustment to behavioral and dietary changes, depression, marital/family discord, poor selfimage/esteem, and impaired coping mechanisms). Continued participation in support groups is beneficial and recommended. Many online support groups and chat rooms have appeared recently. Visiting such sites (eg, Association for Morbid Obesity Support at www.obesityhelp.com/morbid obesity/index.html) may help to reinforce goals of the bariatric program. Medical management Patients who have undergone a malabsorptive procedure require lifelong supplementation with vitamins and 24 Supplement to The Journal of Family Practice March 2005 minerals, iron, vitamin B 12, and calcium with vitamin D (TABLE 5). 18 Gastric bypass patients should receive 40 to 65 mg/day of iron, which can be obtained from most prescription prenatal vitamin supplements. Additional iron may be warranted, especially in menstruating women. Folate deficiency is rare after malabsorptive procedures. The recommended 800 to 1,000 mcg/day of folate is generally contained in over-the-counter multiple vitamins. Vitamin B 12 deficiency occurs in about one-third of patients after malabsorptive surgery. An average dose of 350 mcg/day of sublingual B 12 is recommended. Intramuscular injections of 1,000 mcg of B 12 every 1 to 3 months may be warranted in some patients. Calcium with vitamin D is an important supplement that is often overlooked in gastric bypass patients. Calcium absorption, which occurs in the duodenum, is bypassed by the procedure, placing these patients at increased risk for osteoporosis. Calcium citrate (1,200-1,500 mg/day along with 1,600 IU of vitamin D) is preferred over calcium carbonate. The pouch of gastric bypass patients contains fewer than the normal number of parietal cells, resulting in decreased acid secretion and accelerated absorption of calcium carbonate. Deficiencies of these essential nutrients can cause significant neurologic and metabolic disorders; therefore, annual serologic testing and measurement of bone mineral density is recommended. In patients with significant steatohepatitis or fibrosis at the time of surgery, a liver biopsy performed 12 to 24 months postoperatively will help assess progression or regression of disease. Similarly, follow-up polysomnogram should be considered to ensure resolution of obstructive sleep apnea. The ramifications of altered gut absorption for drug dosing extend well beyond the early postopera-
tive period. Adequate absorption of medication should be held in question at least until the jejunum has fully adapted surgical alterations. Measurement of blood drug levels may be necessary, particularly in patients receiving antiseizure, thyroid replacement, or antipsychotic medications, and dosages adjusted to achieve required therapeutic levels. In some cases, placement of a G-tube at the time of surgery is warranted to ensure adequate drug levels. Pregnancy should be avoided for 12 to 18 months after surgery. The altered absorption of essential nutrients and rapid weight loss confer an increased risk for neural tube defects and other perinatal complications. 19,20 As with all medications, therapeutic blood levels of oral birth control pills cannot be assumed and additional birth control (eg, barrier methods, patches, or intramuscular injection) is necessary. Realistic expectations Weight loss after bariatric surgery ranges from 30% to 90% of excess body-weight loss depending on the procedure performed. Even more important is amelioration of obesity-related comorbidities. A comprehensive meta-analysis by Buchwald et al showed that HbA 1c reverted to normal in 77% of patients with preoperative diabetes, blood pressure decreased to normal in 62% of patients, and obstructive sleep apnea resolved in 86%. 21 A more detailed discussion of this study can be found on page 15. In a survey of 100 gastric bypass patients, some of whom had been followed for 20 years, Cook and Edwards found that patients with the most successful outcomes adhered to a strict regimen. The regimen included eating 5 small meals a day to avoid hunger, avoiding fluids for the first hour after eating, a daily intake of 60 oz of noncarbonated calorie-free beverages supplemented with calcium and vitamin B 12, sleeping an average of 7 hours a night, exercising 2.5 hours a week, and weighing themselves at least once a week. 22 Summary Bariatric surgery can be a major effective component of comprehensive team management of morbid obesity, pro- THE JOURNAL OF FAMILY PRACTICE vided that the family physician gives serious consideration to both the bariatric program and surgical procedure. The family physician can be an integral member of the bariatric team who initiates patient selection, makes a referral to a program that includes medical, nutritional, psychologic, and surgical interventions, and participates in pre- and postoperative management. ■ REFERENCES 1. Steinbrook R. Surgery for severe obesity. N Engl J Med. 2004;350:1075- 1079. 2. NIH Consensus Development Conference Panel. Gastrointestinal surgery for severe obesity. Ann Intern Med. 1991;115:956-961. 3. Mun EC, Blackburn GL, Matthews JB. Current status of medical and surgical therapy for obesity. Gastroenterology. 2001;120:669-681. 4. Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics. 2004;114:217-223. 5. Kushner RF. Roadmaps for clinical practice: Case Studies in Disease Prevention and Health Promotion. Assessment and Management of Adult Obesity: A Primer for Physicians (Booklet 7: Surgical Management). Chicago, Ill: American Medical Association; 2003. 6. Papaioannou A, Michaloudis D, Fraidakis O, et al. Effects of weight loss on QTc interval in morbidly obese patients. Obes Surg. 2003;13:869-873. 7. Ferrell A, Byrne T, Robison J. Placement of inferior vena cava filters in bariatric surgical patients: possible indications and technical considerations. Obes Surg. 2004;14:738-743. 8. White RH, Zhou H, Kim J, Romano PS. A population-based study of the effectiveness in inferior vena cava filter use among patients with venous thromboembolism. Arch Intern Med. 2000;160:2033-2041. 9. Christou N, Sampalis J, Liberman M, et al. Surgery decreases long term mortality, and health care in morbidly obese patients. Ann Surg. 2004;240:416-424. 10. Torgerson JS, Sjöström L. The Swedish Obese Subjects (SOS) study—rationale and results. Int J Obes Relat Metab Disord. 2001;25(suppl 1):S2-S4. 11. Fernandez AZ Jr, De Maria EJ, Tichansky DS et al. Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors relalted to leak and resultant mortality. Surg Endosc. 2004;18: 193-197. 12. Schauer PR, Ikramuddin S, Hamad G, et al. The learning curve for laparoscopic Roux-en-Y gastric bypass in 100 cases. Surg Endosc. 2003;17: 212-215. 13. Nguyen N, Rivers R, Wolfe B. Factors associated with operative outcomes in laparoscopic gastric bypass. J Am Coll Surg. 2003;197:548-557. 14. Hamilton EC, Sims TL, Hamilton TT, Mullican MA, Jones DB, Provost DA. Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc. 2003;17:679-684. 15. Miller MT, Rovito PF. An approach to venous thromboembolism prophylaxis in laparoscopic Roux-en-Y gastric bypass surgery. Obes Surg. 2004;14:731-737. 16. Nguyen N, Rivers R, Wolf B. Early gastrointestinal hemorrhage after laparoscopic gastric bypass surgery. Obes Surg. 2003;13:62-65. 17. Kellum J, Kuemmerle J, O'Dorisio T, et al. Gastrointestinal hormone responses to meals before and after gastric bypass and vertical banded gastroplasty. Ann Surg. 1990;211:763-770. 18. Elliot K. Nutritional considerations after bariatric surgery. Crit Care Nurs Q. 2003;26:133-138. 19. Wittgrove A, Jester L, Wittgrove P, et al. Pregnancy following gastric bypass for morbid obesity. Obes Surg. 1998;8:461-466. 20. Moore KA, Ouyang DW, Whang EE. Maternal and fetal deaths after gastric bypass surgery for obesity. N Engl J Med. 2004;351:721-722. 21. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-1737. 22. Cook C, Edwards C. Successful habits of long-term gastric bypass patients. Obes Surg. 1999;9:80-82. 23. McTigue KM, Harris R, Hemphill B, et al. Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2003;139:933-949. March 2005 Supplement to The Journal of Family Practice 25
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