In medical school, we were taught that our bodies store enough B12 to last a couple of years—turns out that isn’t quite the case. Those who have a Roux-en-Y gastric bypass can become deficient in B12 withinfour months. Iron levels can also decrease quickly, so we recommend a CBC at three months and again at six months. Order other tests based on those results. B12 levels can be checked at six months. Some patient just love getting B12 shots—although the sublingual from is equally effective. Therapy should be based on B12 levels and response, and not just a set schedule.
Pre-menstrual women should get Chromagen Forte, or some type of iron. Be sure it is not mixed with calcium. Iron supplementation is not needed for all patients and some forms of iron will cause the stomach to be quite upset, so if they take some iron and vomit, switch to a type of iron they can tolerate. Some people will even require iron given intravenously or intramuscularly, as that is the only way they will absorb the iron.
Anemia is not “normal” for weight loss surgery patients…
…and demands a work-up. Don’t assume that their procedure is the cause of iron or B12 deficiency. Do a work-up to rule out bone marrow suppression, ongoing blood loss from the GI tract, as well as premature destruction of red blood cells.
Distal bypass patients frequently need to have vitamin K levels monitored as a protime (although clearly other things can effect protime). If they are getting bruised a bit, it may be vitamin K related.
Alkaline phosphatase rises not because of the liver enzymes component, but because bone is being used as a source of calcium. Calcium replacement is needed in almost everyone who has had weight loss surgery, but especially in those who have had a distal Part of your job is to teach about good food—and that fish is good for thembypass. Often up to 2000 grams per day in divided doses is needed to get the alkaline phosphatase or the parathyroid hormone to normal levels.
Don’t be alarmed if gastric bypass patient’s total cholesterol is low, the HDL levels are also low, while VLDL is high. There is no evidence this is a problem. However, with either an increase in fish consumption, flaxseed oil, or the pill form of omega 3 fatty acids, the HDL level can rise. Part of your job is to teach about good food—and that fish is good for them.
Vitamin B levels can fall to low levels, especially in those who have a lot of vomiting. This is easy to correct, but worthwhile remembering when admitting a patient for dehydration. Some cases of Weneicke-Korsakoff encephalopathy have been reported—so adding multivitamins to the IV solution for patients who are dehydrated is useful, as is giving thiamin.
Labs drawn at six months post procedure
- B12 levels
- Complete Metabolic Panel
- Hepatic function panel
All liver enzymes rise in response to protein starvation during the time patients are getting most of their calories from carbohydrates. NASH (Non-alcoholic Steatohepatitis) is common among obese people, and can lead to cirrhosis. Prompt treatment with protein is helpful. If a patient has severe protein-calorie malnutrition, they can develop an elevation of liver enzymes. Some bariatric surgeons routinely biopsy all livers for NASH—while this makes for interesting articles, it is not needed. If your patient develops elevated liver enzymes, have your gastroenterologist intervene.
Other symptoms of mild protein malnutrition include lightheadedness. This is often cured by having patients supplement their diet with protein shakes. While food is the best source, protein shakes are good. Those made of egg whites or whey are better than those of soy products. Some protein-deficient patients willdevelop leg edema, become listless, and have nausea. Occasionally these people need pancreatic enzymes added to their meals, and sometimes they need to have TPN or a feeding tube to get them through.
Bariatric patients are some of the most pleasurable patients to have. You will see dramatic weight loss and improvement in co-morbidities (sleep apnea, hypertension, diabetes, and joint problems). If you have several weight loss patients in your practice, and are getting more, I would encourage you to form a support group for them. You will enjoy watching them go through the weight loss process and members of the group will be a great help and encouragement to each other.
Physicians referring people to a weight loss surgeon are often asked to prescribe for the patient six months of a physician supervised diet. The insurance companies will ask for your chart notes. This template is an example of the information the chart notes should contain. Please be certain to see your patient at least two times per month during this period.