【医脉通】2016+ASMBS减重手术患者综合健康营养指南：微量元素（英文更新版）.pdf

Surgery for Obesity and Related Diseases (2017)0000Review articleAmerican Society for Metabolic and Bariatric Surgery Integrated HealthNutritional Guidelines for the Surgical Weight Loss Patient 2016Update:MicronutrientsJulie Parrott,M.S.,R.D.N.a,*,Laura Frank,Ph.D.,M.P.H.,R.D.N.,C.D.b,Rebecca Rabena,R.D.N.,L.D.N.c,Lillian Craggs-Dino,D.H.A.,R.D.N.,L.D.N.d,Kellene A.Isom,M.S.,R.D.N.,L.D.N.e,Laura Greiman,M.P.H.,R.D.N.faFormulas for Fitness,Morganville,New JerseybMultiCare Health System(MHS),Tacoma,WashingtoncEXOS Performance Dietitian,Philadelphia,PennsylvaniadCleveland Clinic Florida,Weston,FloridaeCenter for Metabolic and Bariatric Surgery,Brigham and Womens Hospital,Boston,MassachusettsfSurgical Weight Loss Program,Sharp Memorial Hospital,San Diego,CaliforniaReceived December 20,2016;accepted December 20,2016AbstractBackground:Optimizing postoperative patient outcomes and nutritional status begins pre-operatively.Patients should be educated before and after weight loss surgery(WLS)on the expectednutrient deficiencies associated with alterations in physiology.Although surgery can exacerbatepreexisting nutrient deficiencies,preoperative screening for vitamin deficiencies has not been thenorm in the majority of WLS practices.Screening is important because it is common for patientswho present for WLS to have at least 1 vitamin or mineral deficiency preoperatively.Objectives:The focus of this paper is to update the 2008 American Society for Metabolic andBariatric Surgery Nutrition in Bariatric Surgery Guidelines with key micronutrient research inlaparoscopic adjustable gastric banding,Roux-en-Y gastric bypass,laparoscopic sleeve gastrectomy,biliopancreatic diversion,and biliopancreatic diversion/duodenal switch.Methods:Four questions regarding recommendations for preoperative and postoperative screeningof nutrient deficiencies,preventative supplementation,and repletion of nutrient deficiencies in pre-WLS patients have been applied to specific micronutrients(vitamins B1 and B12;folate;iron;vitamins A,E,and K;calcium;vitamin D;copper;and zinc).Results:Out of the 554 articles identified as meeting preliminary search criteria,402 were reviewedin detail.There are 92 recommendations in this update,79 new recommendations and an additional13 that have not changed since 2008.Each recommendation has a corresponding graded level ofevidence,from grade A through D.Conclusions:Data continue to suggest that the prevalence of micronutrient deficiencies is increasing,while monitoring of patients at follow-up is decreasing.This document should be viewed as a guideline fora reasonable approach to patient nutritional care based on the most recent research,scientific evidence,resources,and information available.It is the responsibility of the registered dietitian nutritionist and WLSprogram to determine individual variations as they relate to patient nutritional care.(Surg Obes Relat Dis2017;:0000.)r2017 American Society for Metabolic and Bariatric Surgery.All rights reserved.The role of the registered dietitian nutritionist(RDN)continues to be a vital component of the weight loss surgery(WLS)process.Recent guidelines recommend that allhttp:/dx.doi.org/10.1016/j.soard.2016.12.0181550-7289/r2017 American Society for Metabolic and Bariatric Surgery.All rights reserved.*Corresponding author:Julie Parrott,Clinical Director,Formulas forFitness,51 Sandburg Drive,Morganville,NJ 07751.E-mail: Table 1Pre-WLS Nutrient Screening RecommendationsMicronutrientPre-WLS Nutrient Screening RecommendationRationaleOther ConsiderationsThiamin?Routine pre-WLS screening*is recommended forall patients.(Grade C,BEL 3)*?Prevalence of thiamin deficiency pre-WLS isreported to be as high as 29%.?Thiamin diphosphate,the biologically active formof thiamin,is not found in measurableconcentrations in plasma,and is best determined inwhole blood specimens.Plasma thiaminconcentration reflects recent intake rather than bodystores.Thiamin carried by albumin will bedecreased with concomitant hypoalbuminemia.Vitamin B12(cobalamin)?Routine pre-WLS screening of B12 isrecommended for all patients.(Grade B,BEL 2)?Serum MMA is the recommended assay for B12evaluation for symptomatic or asymptomaticpatients and in those with history of B12 deficiencyor preexisting neuropathy.(Grade B,BEL 2)?Prevalence of B12 deficiency is reported to be218%in patients with obesity and 630%inpatients taking proton pump inhibitors.?Serum B12 levels alone may not be adequate toidentify B12 deficiency.?Elevated MMA levels(values 40.4 mmol/L)maybe a more reliable indicator of B12 status because itindicates a metabolic change that is highly specificto B12 deficiency.Folate(Folic Acid)?Routine pre-WLS screening is recommended for allpatients.(Grade B,BEL 2)?Prevalence of folate deficiency is reported to be ashigh as 54%in patients with obesity.?RBC folate andserum homocysteine andnormal MMA levels indicate folate deficiency.Iron?Routine pre-WLS screening is recommended for allpatients.(Grade B,BEL 2)?Screening patients for iron status,but not for thepurpose of diagnosing iron deficiency,may includethe use of ferritin levels.(Grade B,BEL 2)?A combination of tests(serum iron with serumtransferrin saturation and total iron-bindingcapacity)is recommended for diagnosing irondeficiency.(Grade B,BEL 2)?Screening for iron deficiency should includeassessment of clinical signs and symptomscommon to this condition(e.g.,feeling tired andweak,decreased work performance,decreasedimmune function,and glossitis).(Grade B,BEL 2)?Prevalence of iron deficiency is reported to be ashigh as 45%in patients with obesity.?Ferritin levels should not be used to diagnosedeficiency because iron is an acute-phase reactantand may fluctuate with age,inflammation,andinfection.?Lab tests indicate iron deficiency if iron o50 g/dL,ferritin o20 g/dL,TIBC 4450 g/dL.Vitamin D and Calcium?Routine pre-WLS screening is recommended for allpatients.(Grade A,BEL 1)?Routine pre-WLS screening of calcium status,vitamin D deficiency and insufficiency isparticularly important for pre-and postmenopausalwomen.(Grade D,BEL 4)?Prevalence of vitamin D deficiency is reported tobe as high as 90%in patients with obesity.?Elevated values of carboxy-terminal telopeptidehave been reported in 66.7%of patients under50 years of age.?Use a combination of laboratory tests:vitamin D,25-OH,serum alkaline phosphatase,PTH,and24-hr urinary calcium in relationship to dietaryintake.?Peri-and postmenopausal women may be screenedfor increased bone resorption by using urinary and/or serum type I collagen N-telopeptide levels,which are higher in patients with decreasingestrogen production.J.Parrott et al./Surgery for Obesity and Related Diseases (2017)00002 Fat-soluble vitamins(A,E,K)?Routine pre-WLS screening is recommended for allpatients.(Grade C,BEL 3)?Prevalence of deficiencies pre-WLS is reported tobe vitamin A 14%,vitamin E 2.2%.?There are no data on vitamin K deficiencies in pre-WLS patients.?Use physical signs and symptoms and labs(Table 5)for:oVit A deficiency:Retinol binding protein andplasma retinolo Vit E deficiency:plasma-tocopherolo Vit K deficiency:DCPZinc?Routine pre-WLS screening of zinc status isrecommended for patients before RYGB or BPD/DS.(Grade D,BEL 3)?Zinc assays in pre-WLS patients should beinterpreted in light of the fact that patients withobesity have lower serum zinc levels and lowerconcentrations of zinc in plasma and erythrocytesthan leaner patients.Thus,repletion of zinc isindicated when signs and symptoms are evidentand zinc assays are severely low.(Grade C,BEL 3)?Prevalence of zinc deficiency is reported to be 2428%in WLS samples overall,?and 74%of patients seeking BPD/DS.?Use physical signs and symptoms and labs(Table 5):o serum or urinary zinc or RBC zincCopper?Routine pre-WLS screening of copper using serumcopper and ceruloplasmin is recommended forpatients before RYGB or BPD/DS,but results mustbe interpreted with caution.(Grade D,BEL 4)?Erythrocyte superoxide dismutase is the preferredassay for determining copper status in patients whohave undergone WLS.It is a more precisebiomarker for screening of copper deficiency whenit is available and affordable.(Grade D,BEL 4)?Prevalence of copper deficiency is reported to be ashigh as 70%in pre-BPD women.?Serum copper and ceruloplasmin are recommendedfor screening indices,but are acute-phase reactantsand thus affected by inflammation,age,anemia,and medications.WLS weight loss surgery;BEL best evidence level;MMA methyl malonic acid;RBC red blood cell;TIBC total iron-binding capacity;PTH parathyroid hormone;DCP des-gamma-carboxy prothrombin;RYGB Roux-en-Y gastric bypass;BPD/DS biliopancreatic diversion/duodenal switch.Recommendations were formulated for each question within each micronutrient with reference to the previous guidelines.Once this was completed,grades A through D(strongest to weakest)were assignedto the recommendations by following the AACE protocol(see Appendices BE).*“Routine pre-WLS screening”refers to acquiring a nutrient baseline before WLS.New recommendation since 2008 1 is noted by,otherwise there is no change in the current recommendation.ASMBS Guidelines 2016 Update/Surgery for Obesity and Related Diseases (2017)00003 Table 2Post-WLS Nutrient Screening RecommendationsMicronutrient Post-WLS Nutrient Screening RecommendationRationaleOther ConsiderationsThiamin?Routine post-WLS screening*is recommended for high-riskWLS groups(Grade B,BEL 2):o Patients with risk factors for TD(Grade B,BEL 2)o Females(Grade B,BEL 2)o Blacks(Grade B,BEL 2)o Patients not attending a nutritional clinic after surgery(Grade B,BEL 2)o Patients with GI symptoms(intractable nausea andvomiting,jejunal dilation,mega-colon,or constipation)(Grade B,BEL 2)o Patients with concomitant medical conditions such ascardiac failure(especially those receiving furosemide)o Patients with SBBO(Grade C,BEL 3)?If signs and symptoms or risk factors are present in post-WLSpatients,thiamin status should be assessed at least during thefirst 6 mo,then every 36 mo until symptoms resolve.(Grade B,BEL 2)?Prevalence of TD post-WLS ranges from o1%to 49%andvaries by type of WLS and post-WLS time frame.?Risk of TD in WLS patients increases with otherrisk factors:o malnutrition,excessive and/or rapid weightloss,and excessive alcohol use.Vitamin B12?Routine post-WLS screening of vitamin B12 status isrecommended for patients who have undergone RYGB,SG,orBPD/DS.(Grade B,BEL 2)?More frequent screening(e.g.,every 3 mo)is recommended inthe first post-WLS year,and then at least annually or asclinically indicated for patients who chronically usemedications that exacerbate risk of B12 deficiency:nitrousoxide,neomycin,metformin,colchicine,proton pumpinhibitors,and seizure medications.(Grade B,BEL 2)?Serum B12 may not be adequate to identify B12 deficiency.It is recommended to include serum MMA with or withouthomocysteine to identify metabolic deficiency of B12 insymptomatic and asymptomatic patients and in patients withhistory of B12 deficiency or preexisting neuropathy.(Grade B,BEL 2)?Prevalence of B12 deficiency post-WLS at 25 yr is o20%inRYGB and 420%in SG.?Vitamin B12 deficiency can occur due to foodintolerances or restricted intake of protein andvitamin B12containing foods.Folate?Routine post-WLS screening of folate status is recommendedfor all patients.(Grade B,BEL 2)?Particular attention should be given to female patients ofchildbearing age.(Grade B,BEL 2)?Prevalence of folate deficiency is reported in up to 65%patients post-WLS.?Poor dietary intake of folate-rich foods andsuspected nonadherence with multivitamin maycontribute to folate deficiency.Iron?Routine post-WLS screening of iron status is recommendedwithin 3 mo after surgery,then every 36 mo until 12 mo,andannually for all patients.(Grade B,BEL 2)?Iron status in post-WLS patients should be monitored at regularintervals using an iron panel,complete blood count,total iron-binding capacity,ferritin,and soluble transferrin receptor(ifavailable),along with clinical signs and symptoms.(Grade C,BEL 3)?Prevalence of iron deficiency is reported to occur in post-WLSpatients from 3 mo to 10 yr:AGB 14%,SG o18%,RYGB 2055%BPD 1362%DS 850%?Post-WLS iron deficiency can occur after anyWLS procedure,despite routine supplementation.J.Parrott et al./Surgery for Obesity and Related Diseases (2017)00004?Additional iron screening in post-WLS patients should beconducted as warranted by clinical signs or symptoms and/orlaboratory findings,or in other instances in which a deficiencyis suspected.(Grade B,BEL 2)Vitamin DandCalcium?Routine post-WLS screening of vitamin D status isrecommended for all patients.(Grade B,BEL 2)?More research is needed to establish a recommendationregarding the use of vitamin D binding protein assays as anadditional tool for determining vitamin D status in post-WLSpatients.(Grade C,BEL 3)?Prevalence of vitamin D deficiency is reported to occur in upto 100%of post-WLS patients.?25(OH)D is the preferred biochemical assay ofvitamin D?Elevated PTH levels?Increased bone formation/resorption markersVitamins A,E,K?Post-WLS patients should be screened for vitamin A deficiencywithin the first postoperative year,particularly those who haveundergone BPD/DS,regardless of symptoms.(Grade B,BEL 2)?Vitamin A should be measured in patients who have undergoneRYGB and BPD/DS,particularly in those with evidence ofprotein-calorie malnutrition.(Grade B,BEL 2)?While vitamin E and K deficiencies are uncommon after WLS,patients who are symptomatic should be screened.(Grade B,BEL 2)?Prevalence of vitamin A deficiency is reported to occur in upto 70%of patients with RYGB and BPD/DS within 4 yearspost-WLS.Deficiencies of vitamins E and K are uncommonafter WLS.Zinc?Post-RYGB and post-BPD/DS patients should be screened atleast annually for zinc deficiency.(Grade C,BEL 3)?Serum and plasma zinc are the most appropriate biomarkers forzinc screening of post-WLS patients.(Grade C,BEL 3)?Zinc should be evaluated in all post-WLS patients when thepatient is symptomatic for iron deficiency anemia but screeningresults for iron deficiency anemia is negative.(Grade C,BEL 3)?Post-WLS patients who have chronic diarrhea should beevaluated for zinc deficiency.(Grade D,BEL 4)?Prevalence of zinc deficiency occurs in:up to 70%post-BPD/DS;40%post-RYGB;19%post-SG;34%post-AGB?Deficiency of zinc is possible,even if taking zincsupplements and especially if primary sites ofabsorption(duodenum and proximal jejunum)arebypassed.Copper?Routine post-WLS screening of copper status is recommendedat least annually after BPD/DS and RYGB,even in the absenceof clinical signs or symptoms of deficiency.(Grade C,BEL 4)?In post-WLS patients,serum copper and ceruloplasmin are therecommended biomarkers for determining copper statusbecause they are closely correlated with physical symptoms ofcopper deficiency.(Grade C,BEL 4)?Prevalence of copper deficiency is reported to be as high as90%of patients post-BPD/DS and 1020%post-RYGB.?Only 1 case report noted for