A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
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11 Clinical Nursing Education Bariatric Times • February 2017 INTRODUCTION Metabolic and bariatric surgery is the most effective treatment strategy for severe obesity, shown to improve or resolve many comorbid conditions as well as produce sustained significant weight loss and weight maintenance. 1 Critical to the long-term health of a patient who undergoes metabolic and bariatric surgery is their adherence to numerous lifelong behaviors, including daily micronutrient supplementation. 2 Adherence rates across multiple areas of interest following metabolic and bariatric surgeries are varied. Patients exhibit greater adherence to directions from their healthcare providers prior to surgery and immediately postoperatively. The rate of adherence and follow up visits decreases as patients progress further out from surgery. 3 The improved health outcomes of metabolic and bariatric surgery are undeniable, however, the high frequency of micronutrient deficiencies, especially those that are under-recognized and left untreated, can lead to irreversible consequences. 4 Given that research shows adherence to micronutrient supplementation following surgery is low and long-term micronutrient deficiencies are high, it is critical that all members of the multidisciplinary care team work together to guide patients to improved adherence for improved outcomes. OVERVIEW At this time, research on adherence to micronutrient supplementation recommendations in the metabolic and bariatric surgery patient population is limited, although improving adherence recommendations seems to be important to most clinicians. Early research indicates that adherence to micronutrient supplementation is low and declines drastically in the months following surgery, while micronutrient deficiency rates increase as the patient progresses from surgery. 5 In one of the first studies to evaluate adherence to micronutrient supplementation after metabolic and bariatric surgery, 6 approximately 90 percent of patients reported compliance with suggested supplement recommendations five months after surgery. Compliance was defined as taking one multivitamin supplement daily or every other day. By one year postoperative, self-reported micronutrient supplement intake had decreased to 50 percent. In another study of metabolic and bariatric surgery patients, 7 mean self-reported adherence to micronutrient supplementation at 2 to 3 years postsurgery was 57.6 percent. In a single site sub study of the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS), 8 adherence to micronutrient supplementation was investigated. Not only did this study use self- report methodology, it also utilized an electronic monitoring system that tracked the number and time of bottle openings for prescribed oral medications. The participants were instructed to take one multivitamin/multimineral supplement in the morning and one in the evening. Adherence to this recommendation was tracked prior to surgery and then again at 1 and 6 months postoperatively. At one month postoperative, the self-reported adherence to supplement intake was 88 percent; while the electronic monitoring device data showed a 37-percent adherence rate. At six months following surgery, the self-reported adherence rate was 78 percent; while the electronic monitoring device data showed a 27-percent adherence rate. The authors concluded that the adolescents demonstrated a declining adherence over the first six months postoperatively, and that self- reported adherence was significantly greater than adherence tracked by the electronic monitoring device. Another discovery was that the subjects took zero micronutrient Improving Adherence to Micronutrient Supplementation in the Metabolic and Bariatric Surgery Patient Population by CASSIE I. STORY, RDN Bariatric Times. 2017;14(2):10–16. CLINICAL NURSING EDUCATION 1 CONTACT HOUR ABSTRACT The improved health outcomes of metabolic and bariatric surgery are undeniable, however, the high frequency of micronutrient deficiencies, especially those that are under-recognized and left untreated, can lead to irreversible consequences. Given that research shows patient adherence to micronutrient supplementation following surgery is low, it is critical that all members of the multidisciplinary care team work together to guide patients to improved adherence for improved outcomes. This article provides an overview of the literature on patient adherence and discusses barriers uncovered, including "forgetting" and "difficulty swallowing." The author outlines the importance of patients' adherence to a micronutrient regimen, briefly reviewing common known clinical manifestations of deficiency, such as iron deficiency anemia and bone weakening. Strategies for improving patient adherence, including clinician familiarity with available professional guidelines for micronutrient supplementation in the metabolic and baraitric surgery patient population, are also discussed. KEYWORDS Adherence, bariatric and metabolic surgery, nutrition, micronutrients DEPARTMENT EDITOR Tracy Martinez, RN, BSN, CBN Tracy Martinez, RN, BSN, CBN, is Department Editor: Integrated Health Continuing Education, Bariatric Times; Program Director, Wittgrove Bariatric Center, La Jolla, California. AUTHOR Cassie I. Story, RDN Cassie I. Story, RDN, is Clinical Science Liaison for Bariatric Advantage, Aliso Viejo, California, and Network Assistant Director of the Weight Management Dietetic Practice Group of the Academy of Nutrition and Dietetics.