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OBES SURG (2008) 18:187–191DOI 10.1007/s11695-007-9384-8 Need for Multivitamin Use in the Postoperative Periodof Gastric Bypass Fernanda G. Colossi & Daniela S. Casagrande &Raquel Chatkin & Myriam Moretto &Anália S. Barhouch & Giuseppe Repetto &Alexandre V. Padoin & Cláudio C. Mottin Received: 23 November 2007 / Accepted: 28 November 2007 / Published online: 28 December 2007 # Springer Science + Business Media B.V. 2007 RYGBP. Thus, the routine use of multivitamins is deemed Background Based on the reduced gastric volume and the necessary after the first month postoperatively, with its malabsorption produced by Roux-en-Y gastric bypass maintenance preferably for the rest of the patient’s life, (RYGBP) and diet therapy, it is essential in the postoper- without abandoning periodic clinical and laboratory ative period to obtain and maintain an adequate nutritional state, with the aim of preventing malnutrition and seeking ahealthy life. It is observed that patients have difficulty in Keywords Bariatric surgery . Morbid obesity .
understanding the new food choices that must considered, as they have eating habits that are very divergent fromthose currently proposed. There is often the need forvitamin and mineral replacement after laboratory tests.
Methods This study calculated and evaluated the 24-heating records of 210 patients, collected in the course of The preoccupation of healthcare professionals with morbid nutritional visits in follow-ups of the first, third, sixth, ninth, obesity has grown proportionally with its prevalence in the 12th, 18th, and 24th months postoperative.
population worldwide. When clinical methods are shown to Results It was possible to observe an increase in the be ineffective in the treatment of morbid obesity, surgical consumption of nutrients in the course of the study period, treatment is considered, which is growing in demand and but it was not regular and significant for all the nutrients.
which constitutes the major control of this disease Also, it is noted that the minimal requirements for vitamin For the surgery to produce satisfactory results, it is A, vitamin C, calcium, iron and B-complex vitamins essential to have solid and continuous clinical-nutritional (except for cyanocobalamin and riboflavin) were not follow-up. This requires the involvement of the patient who attained. The nutrients in which satisfactory results were should adhere to the treatment and follow the guidance obtained were total proteins of high biological value: rendered []. Currently, the most variable degrees of medium- and long-term nutritional deficiencies are ob- Conclusion This study demonstrated the concern for served in these patients. This is the greatest concern of the nutrient supplementation in the postoperative period of healthcare professionals involved in this treatment ].
The nutritional and medical evaluation and follow-up in F. G. Colossi D. S. Casagrande R. Chatkin M. Moretto the pre- and postoperative period are essential for monitor- A. S. Barhouch G. Repetto A. V. Padoin C. C. Mottin ing these deficiencies , Nutritional deficiencies and Centro da Obesidade Mórbida, Hospital São Lucas da PUCRS, alterations most often determined by laboratory tests during the first year after surgery are: hypoalbuminemia, deficien- cies in iron, folic acid, and vitamin B12, and anemia Centro Clínico, Hospital São Lucas da PUCRS, AV Ipiranga 6690/302, CEP 90610-000 Porto Alegre, Because of the decreased caloric intake of the diet, RS, Brazile-mail: claudiomottin@terra.com.br vitamin/mineral supplementation is indispensable because the patients do not achieve an adequate amount of nutrients Analysis of variance (ANOVA) for repeated measures based on that recommended by the Dietary References was utilized to compare the percentage of nutrient intake Intake (DRI) [This situation is aggravated by malab- over the 2 years of evaluation. Some variables did not show sorption, which leads to a low bioavailability when a normal distribution, but were homoscedastic (equal compared to normal individuals [–, , , , , variances), which validated the model, as homoscedasticity is a more important criterion for the utilization parametric The routine replacement of nutrients in the postoperative models. ANOVA for repeated measures was complemented period of bariatric surgery diverges from one team to the by the application of the Bonferroni test.
other []. The aim of this study was to determine It was also determined if there was a linear relationship the need for multivitamin use after the first 30 days after of the percentage of nutrient intake over the course of the Roux-en-Y gastric bypass (RYGBP), at treatment centers 2-year study based on the linear tendency test, which is for obesity surgery, for the purpose of preventing nutritional obtained by ANOVA for repeated measures. Significance deficiencies in the most in-depth manner.
was set at the 5% level, where differences were consideredstatistically significant for values of p≤0.05.
An observational study was conducted with the collectionof data from patients seen at the nutrition outpatient clinic The sample we have to this study were of 210 patients of the Center for Morbid Obesity of Hospital São Lucas da postoperative and of this 70% were women. The age groups Pontificia Universidade Catolica of Rio Grande do Sul. An with more occurrences are until 40 years old and the body analysis was made of the medical charts of 210 patients, mass index (BMI) more frequently are between 40 to selected randomly, in the postoperative period of RYGBP.
44 kg/m2 or more than 50 kg/m2 (Table ).
The nutritional value was calculated from the food intake The study shows an increase in the consumption of for 24 h recorded at nutrition consults, which were part of nutrients in the course of the period, but it was not regular.
the postoperative protocol at the first, third, sixth, ninth, Also, it is noted that the minimal requirements for vitamin 12th, 18th, and 24th month. Of these patients, we were able A, vitamin C, calcium, iron and B-complex vitamins to obtain complete data for the first month in 189 inquiries, (except for cyanocobalamin and riboflavin) were not the third month 182, the sixth month 158, the ninth month attained. The nutrients in which satisfactory results were 187, the 12th month 147, the 18th month 164, and the 24th obtained were total proteins of high biological value, The food intake records, mentioned above, were ana- The analysis of linear relationship of the percentage of lyzed by the nutrition software Dietwin® Professional 2.0 nutrient intake over the course of the 2-year study based on of Brubins e Dataweb Tecnologia, Brazil Thissoftware carries out, besides other tasks, the nutritionalanalysis of diets. In analyzing the eating records of thepatients, a calculation was made of the percentage of adequate intake of the nutrients studied in relation to the Dietary Reference Intake (DRI) for healthy adults. The DRIutilized corresponds to the age group and sex of each individual studied. The nutrients evaluated in this study were protein, calcium, iron, vitamin A, vitamin C, and B complex vitamins: thiamin—B1; riboflavin—B2; niacin— B3; pantothenic acid—B5; pyridoxine—B6; folic acid— After calculating the percentage of adequate intake for each nutrient for each period in relation to the DRI of each of the individuals, a statistical analysis was performed using SPSS (Statistical Package for the Social Sciences) version 10.0. The quantitative variables were expressed as means a Age varied from 12 to 67 years with mean of 36.8 years (SD=10.9).
and standard deviation, and the categorical variables as b BMI varied from 35 to 87.3 kg/m2 with a mean of 46.9 kg/m2 Table 2 Percentage of nutrient intake according to DRI during the 2-year period following bariatric surgery Consumption of nutrients post-bariatric surgery (%) *Value obtained by Wilk's lambda test of analysis of variance (ANOVA) for repeated measures.
a,b,c,d,e,f: The same letters indicate no significant difference by the Bonferroni test .
the linear tendency test with a IC (Confiance Index) of 95% was shown in all nutrients observed p<0.001, except incalcium (Linear Relation Intake =8.62%; p=0.004) and It is estimated that only 57% of the protein ingested is ab- vitamin A (Linear Relation Intake = 5.04%; p = 0.026) sorbed during the postoperative period by the extent of the intestinal bypass performed in the RYGBP , , According to the data obtained in this study, there was anadequate protein intake by the patients in relation to the Table 3 Analysis of linear relationship of the percentage of nutrient DRI, but the deficiencies encountered in clinical practice intake over the course of the 2-year study based on the linear tendency show evidence of an absorptive deficit.
Studies have demonstrated that patients in the postoper- ative period of bariatric surgery show abnormalities in bone mass, showing hypocalcemia in as many as 15% to 48% ofpatients []. Moreover, the deficient absorption of lipid-soluble vitamins (vitamins A, E, D, and K) aggravate The malabsorption of vitamin D interferes in the absorption of calcium and stimulates hyperparathyroidism, which in the long term leads to the occurrence of osteoporosis , , ]. In this study, calcium deficiency was observed in the diet, and in clinical practice, the above Deficient iron intake, demonstrated in this study, explains the frequent treatment of anemia in the postoper- ative period [, , , , This also occurs by Linear tendency test was obtained by ANOVA for repeated measures.
the difficulty patients have in eating beef ].
Vitamin C improves cellular immunity and enhances limitation of food intake and alterations in absorption, iron absorption, besides being essential for the synthesis of which justifies the utilization of nutritional supplements, collagen, adrenal hormones, amines, and carnitine. This mainly the use of vitamin and mineral complex, so that a vitamin is important, especially for the bariatric patient better allowance of these is attained [–, , , ]. Unfortunately, in this study, the daily recommen- ded allowance for vitamin C was not achieved.
The nutrients that reached the recommended levels Thiamin (vitamin B1) deficiency as a consequence of according to DRI standards in the food eaten by the reduced absorption in the duodenum is caused by the patients studied, curiously, are those reported frequently in following: decrease in gastric juice production, losing its scientific studies as a result of malabsorption caused by the activity at pH>7; restriction in food intake; and frequency surgery [, , –Besides, this study points of vomiting. Patients who drink alcoholic beverages out the concern for metabolic conditions that ensue when frequently show blocked absorption of this vitamin.
recommended daily intake amounts of nutrients are not met Replacement of this nutrient becomes necessary not only and also when these nutrients absorbed at insufficient rates, because the recommended amount by DRI is not reached, which is rarely determined adequately.
but also because of the above factors [, , , ].
An efficient consumption was demonstrated for ribofla- vin (vitamin B2), but this vitamin is sensitive to light, ultraviolet rays, the presence of zinc, iron, copper, caffeine,theophyllin, nicotinamide, sodium, tryptophan, urea, and This study provides further evidence of the necessity of ascorbic acid , ]. As it is a vitamin with many routine supplementation of vitamins and minerals using interactions among nutrients, its malabsorption in the multivitamins, starting by the 30th day after bariatric postoperative period makes a deficiency plausible.
surgery and persisting for the rest of the patient’s life.
Niacin (vitamin B3) is involved in supplying cellular Certainly, this routine does not eliminate the need for energy through its part in the metabolism of macronutrients.
complementary supply of some specific nutrients based on There is a tendency toward a deficiency in bariatric surgery periodic clinical and laboratory evaluation, but probably reduces the potential occurrence of deficiencies and also of Pantothenic acid (vitamin B5) is sensitive to light, alkaline pH, and its deficiency occurs together with otherB complex vitamins. Besides not being ingested in thenecessary quantities, in this study, it would still be exposedto the conditions related above , ].
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