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Kurt Widhalm Emeritus Professor for Clinical Nutrition and Pediatrics Paracelsus Medical University, Salzburg Austrian Academic Institute for Clinical.

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Presentation on theme: "Kurt Widhalm Emeritus Professor for Clinical Nutrition and Pediatrics Paracelsus Medical University, Salzburg Austrian Academic Institute for Clinical."— Presentation transcript:

1 Kurt Widhalm Emeritus Professor for Clinical Nutrition and Pediatrics Paracelsus Medical University, Salzburg Austrian Academic Institute for Clinical Nutrition, Vienna Oliver Helk Austrian Academic Institute for Clinical Nutrition, Vienna Micronutrient status after bariatric surgery

2 The importance of long term follow-up While bariatric surgery can generally be considered a safe procedure there is little to no data on possible micronutr. deficiencies after bar. Surg. in adolescents. While bariatric surgery can generally be considered a safe procedure there is little to no data on possible micronutr. deficiencies after bar. Surg. in adolescents. A recent study 1) has reported for the first time that adherence to vitamin supplementation is very poor in adolescent patients  high risk for deficiency! A recent study 1) has reported for the first time that adherence to vitamin supplementation is very poor in adolescent patients  high risk for deficiency! Special attention should be put on possible deficiencies in patients who have not yet reached full maturity at the time of surgery Special attention should be put on possible deficiencies in patients who have not yet reached full maturity at the time of surgery 1) Modi AC1) Modi AC, Zeller MH, Xanthakos SA, Jenkins TM, Inge TH.Zeller MHXanthakos SAJenkins TMInge TH Obesity (Silver Spring).Obesity (Silver Spring) Mar;21(3):E doi: /oby Adherence to vitamin supplementation following adolescent bariatric surgery.

3 What do we know from literature?  Currently no reports from trials on micronutrient deficiencies following bariatric surgery in adolescents available!  There are however case reports of adolescent patients with severe co- morbidities resulting from micronutrient deficiency! E.g.: Wernicke encephalopathy 2), Myelopathy 3) 2) 2) Stenerson M, Renaud D, Dufendach K et al., Recurrent Wernicke encephalopathy in an adolescent female following laparoscopic gastric bypass surgery. Clin Pediatr (Phila) Nov;52(11): ) Plantone D3) Plantone D, Primiano G, Renna R et alPrimiano GRenna R Copper deficiency myelopathy: A report of two cases. J Spinal Cord Med.J Spinal Cord Med Oct 24.

4 Deficienices: Results from Adults  Vitamin B1: reported rates of up to 49% following gastric bypass! Cave: Wernicke encephalopathy! 1)  Vitamin B9: special importance in female patients, increased rate of pregnancies after bar. Surg. Generally deficiencies are rare 2), however there are reports of up to 39%! 3) 1) Aasheim ET, Bjorkman S, Sovik TT, Engstrom M, Hanvold SE, Mala T et al (2009) Vitamin status 185after bariatric surgery: a randomized study of gastric bypass an duodenal switch. Am J Clin Nutr 90:15–22 2) Decker GA, Swain JM, Crowell MD, Scolapio JS (2007) Gastrointestinal and nutritional compli- cations after bariatric surgery. Am J Gastroenterol 102:2571–2580 3) Halverson JD (1986) Micronutrient deficiencies after gastric bypass for morbid obesity. Am Surg 52:594–598

5 Results from adults  Vitamin B12: needs to be administered perenterally, studies show low incidence and prevalence; but: what happens in patients lost to follow-up? 4)  Vitamin C: Only two trials reporting deficiencies, however def. rate was 35% in one of them 5) 4) Kwon Y, Kim HJ, Lo Menzo E et al, Anemia, iron and vitamin B12 deficiencies after sleeve gastrectomy compared to Roux-en-Y gastric bypass: a meta- analysis. Surg Obes Relat Dis Jul-Aug;10(4): ) Clements RH, Katasani VG et al (2006) Incidence of 206vitamin deficiency after laparoscopic Roux-en-Y gastric bypass in a university hospital setting. Am Surg 72:1196–1204.

6 Results from adults  Vitamin A: Reports range up to 69% 6), however oral Multivitamin supplementation appears to prevent this successfully 7)  Vitamin D: High importance in adolescents for skeletal health! Underprovision rates are high in pre-surgical patients and are often worsened by bariatric procedures. 8) Best results for the prevention of deficiencies were achieved by 5.000IU/day 9) 6) Slater GH, Ren CJ, Siegel N, Williams T, Barr D, Wolfe B et al (2004) Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg 8:48–55 7)Clements RH, Katasani VG, Palepu R, Leeth RR, Leath TD, Roy BP et al (2006) Incidence of vitamin deficiency after laparoscopic Roux-en-Y gastric bypass in a university hospital setting. Am Surg 72:1196–1204 8) Gemmel K 1, Santry HP, Prachand VN, Alverdy JC. Vitamin D deficiency in preoperative bariatric surgery patients Surg Obes Relat Dis Jan-Feb;5(1): ) Goldner WS, Stoner JA, Lyden E, Thompson J, Taylor K, Larson L et al (2009) Finding the optimal dose of vitamin D following Roux-en-Y gastric bypass: a prospective, randomized pilot clinical trial. Obes Surg 2006(243):701–704

7 Results from adults  Other: While Selenium, Copper and Zinc deficiencies are reported very rarely in studies, there are reports of severe morbidity resulting from deficiency in patients who were lost to follow-up and did not adhere to their supplementation regimen! Possible symptoms involve psychiatric disorders, haematological disorders, neurological symptoms and symptoms of the GI tract. 10) 10) Prodan CI, Bottomley SS, Vincent AS, Cowan LD, Meerveld BG, Holland NR et al (2009) Copper deficiency after gastric surgery: a reason for caution. Am J Med Sci 337:256– 258

8 From our outpatient clinic: 185 patients with a BMI exceeding the 99.5 th percentile: An example: Christoph 17y, 166kg, BMI=48BMI  Body fat >45%  Striae distensae  Steatosis hepatitis (NASH)  Hypertension  Gynaecomastia  increased CRP  Insulin-resistance  Dyslipoproteinemia   Calorie intake >3000 kcal/d  Physical activity   Depression  Many multidisciplinary treatments without success Own experiences

9 Surgical approaches of obesity-therapy in adolescents can be considered if BMI>40 (or >99.5 percentile) 2....treatments in a specialised center were unsuccessful for at least patient shows adequate bone maturation and overall maturity the patient is capable of parcipating in an extensive medical- and psychological evaluation pre- and post surgery the patient has agreed to participate in a multidisciplinary treatment program after 6....the patient suffers from genetic syndromes (e.g. Prader-Willi) a surgical procedure can be considered at an earlier stage if surgery is performed at a surgical department with experience on bariatric surgery and specially trained pediatric. A thourough quality management and a european patient register are desirable. Fried et al. Widhalm K Int J Obes;31(4): Fried et al.Widhalm K Obes. Surg. 17 (2) THE PATH TO SURGERY

10 Morbid (extreme) Obesity in Children and Adolescents Definition: >95th percentile of skinfolds (Gortmaker 1987) >99th perc. BMI (Inge 2007) >99.5 perc. BMI (AGA 2008) Characteristics: at least 2 risk factors (Freedman 2006) (99th Perc.) all of those children remained obese into adulthood with an average adult BMI of 43 (Freedman 2006) Morbidly obese men and women have a multivariate rel. risk of death which is really fourfold that of their normal weight counterparts (Adam 2006) Treatment : (Behavioral Treatment etc.)Rarely sustainable effects (Janevski 2003, Epstein 1990, Kirk 2005)

11 48 months after surgery: 139.6±19.2 Pre surgery: 155.1±7.7 Helk O, Widhalm K: Vitamin Deficiencies After Bariatric Surgery? In: Widhalm K, Prager G: Morbid Obesity in Adolescents, Springer 2015

12 Pre surgery: 153.9± months after surgery: 129.3±7.2 Helk O, Widhalm K: Vitamin Deficiencies After Bariatric Surgery? In: Widhalm K, Prager G: Morbid Obesity in Adolescents, Springer 2015

13  Follow-up program  Visits with pediatrician and dietitian Monthly visits in the first year post surgery, every 6 months thereafter Blood sampling (Follow-up on: Vitamin A,B9,B12,C,D,E Magnesium, Iron, Phosphorus, Zink, Calcium,… Hs-CRP, Lp(a), LDL, HDL, CHOL Insulin, PTH) In 1 st, 6 th and 12 th month post surgery, every 3 months thereafter IMT measurement and echohepatography In 1 st, 6 th and 12 th month post surgery, every 6 months thereafter DXA- and bone density measurement (often impossible: patient exceeding weight limit etc.) In 1 st, 6 th and 12 th month post surgery, every 6 months thereafter

14  Vitamin substitution Daily:   Vitamin A 3333 I.E.   Thiamin (Vitamin B1) 4,013 mg   Riboflavin (Vitamin B2) 5,1 mg   Pyridoxinhydrochlorid (Vitamin B6) 6,0 mg   Cyanocobalamin (Vitamin B12) 6,0 μg   Ascorbinacid (Vitamin C) 180,0 mg   Colecalciferol (Vitamin D3) 200 I.E.   DL-α-Tocopherolacetat (Vitamin E) 14,9 mg   Biotin (Vitamin H) 0,3 mg   Folicacid (Vitamin B9) 0,2 mg   Nicotinamid 57,0 mg   Iron 3,6 mg   Calcium 50,0 mg   Magnesium 40,0 mg   Phosphorus 50,0 mg   Mangan 0,5 mg   Zink 3,0 mg Monthly: 1000µg Vitamin B12 i.m. Supplementation was regularly adjusted during the regular visits in our outpatient clinic based on individual needs!

15 Pre surgery: 1.78± months after surgery: 1.71±0.31 Helk O, Widhalm K: Vitamin Deficiencies After Bariatric Surgery? In: Widhalm K, Prager G: Morbid Obesity in Adolescents, Springer 2015

16 Pre surgery: 63± months after surgery 54.2±19.3 Helk O, Widhalm K: Vitamin Deficiencies After Bariatric Surgery? In: Widhalm K, Prager G: Morbid Obesity in Adolescents, Springer 2015

17 Pre surgery: 371± months after surgery: 307±110 Helk O, Widhalm K: Vitamin Deficiencies After Bariatric Surgery? In: Widhalm K, Prager G: Morbid Obesity in Adolescents, Springer 2015

18 Pre surgery: 64.1± months after surgery: 54.4±4.6 Helk O, Widhalm K: Vitamin Deficiencies After Bariatric Surgery? In: Widhalm K, Prager G: Morbid Obesity in Adolescents, Springer 2015

19 Vitamin D deficiency in healthy adolescents HELENA-study Gonzales-Gross M. et al.:Vitamin D status among adolescents in Europe British Journal of Nutrition 2011 Aug 17:1-10

20 Conclusion  Bariatric surgery should be the „ultima ratio“ after unsuccessful conservative multidisciplinary treatment regimes in a certified pediatric center with close cooperations with a specialised surgical center  At this point, no valid alternatives are avaiable  An accurate selection of patients and a consequent follow-up program (substitution) are neccessary  A similar follow-up program is essential also for conservative weight-reducing regimens in order to generate comparative data  Prevention of morbid obesity is of utmost importance  More long-term trials on Vitamin deficiencies and other side effects from bariatric surgery in adolescents are urgently needed K.W. Sept. 2011

21 Conclusion 2  Special efforts must be made to convince patients to adhere to follow-up visits for the detection and prevention of deficiencies.  Vitamin D deficiency appears to be the most prevalent.  Patients lost to follow-up are at high risk for vitamin deficiencies and severe complications!!!  One major criteria in regard to judgement of complance for follow- up care is the clear readiness for cooperation not only from the patient, but also from his/her family.

22 Thank you! Maria Fritsch MD, Elsie Aldover-Macasaet MTA, Christoph Binder MD, Anna Kellersmann MD,Alexandra Kreissl MSc, Marika Miklautsch MSc, Maytree Pandey MD, Kathrin Schöggl MSC, Gabrielle Skacel, Maria Hochgerner, Bimba (the dog)

23 Morbid Obesity Definition and Health Consequences of Morbid Obesity Ernst J. Drenick, Surg. Clin. N. Amer. 59,6:963(1979) „100 pound excess over desirable weight„ „twice the ideal weight or more„ For younger and middle-aged groups: „a decisive 60% excess mortality becomes evident when the relative overweight is 60% above normal or greater „ Study:Build and Blood pressure by the Society of Actuaries a mortality ratio of 168% of expected was calculated for insured males weighing >115kg. In the Veterans Administration study: 200 morbidly obese men, (23-70 yrs), mean weight 143.5kg → 12 fold increase of mortality :25-34 yrs. → 12 fold increase of mortality :25-34 yrs. → 6fold : yrs. 1959

24 Wiegand S,Widhalm K. et al. Int J Obesity (2010) 1-7 NAFLD IN OBESE CHILDREN / ADOLESCENTS

25 Reinehr T, Widhalm K et al. Obesity 2009(12)6: SUCCESS RATE OF 129 TREATMENT PROGRAMS FOR OBESE CHILDREN


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