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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12 Clinical Nursing Education Bariatric Times • February 2017 supplements on 66 percent of days during the study. Nadkarni et al 9 also evaluated micronutrient supplementation adherence using electronic monitoring technology. They found an overall adherence rate of 44 percent, with rates of adherence declining as the patients progressed from surgery. The patients were instructed to take a multivitamin/multimineral supplement three times per day and were monitored for the first 50 days after surgery. During the first week adherence was 58 percent, by the last week it fell to 39 percent. Micronutrient deficiencies following metabolic and bariatric surgery may be avoided by adherence to appropriate micronutrient supplementation and regular follow up with nutrient specific screening. 10,11 Research shows that metabolic and bariatric surgery patients need several additional vitamin and mineral supplements, such as vitamin B12 and iron, to maintain optimal micronutrient status. Standard over- the-counter multivitamin and mineral supplements may not be adequate for preventing micronutrient deficiencies in this patient population (Table 1). 12–15 Unlike surgical complication rates, which have been declining over the past two decades, due in part to improved surgical techniques, improved medical devices, and improved standardization of tracking complications, reports of micronutrient deficiencies are on the rise. 16 One of the most likely long-term adverse events a patient faces following metabolic and b ariatric surgery is one or more micronutrient deficiencies. 17 One challenge in addressing micronutrient deficiencies in patients is a lack of consensus on the appropriate type and amount of m icronutrient supplementation needed to prevent deficiencies, which has led to varying recommendations across bariatric p rograms nationwide. 1 8 Additionally, varying levels of adherence to micronutrient supplementation make it difficult to know whether deficiencies are due to lack of adherence or increased malabsorption. Improved screening of micronutrient status would likely improve prevention and repletion recommendations and help to unify conflicting micronutrient supplementation recommendations that are given to patients. BARRIERS TO ADHERENCE While research specific to metabolic and bariatric surgery and adherence to micronutrient supplementation recommendations is in its infancy, other studies among the general population indicate complex various barriers to adherence of oral medications and offer multi-faceted solutions to improve adherence. 19 In the Teen- LABS adherence sub study, 8 the two primary barriers identified were "forgetting" and "difficulty swallowing multivitamins." Another barrier identified in this study was "difficult to understand doctors' instructions." The instructions for the majority of study participants were as follows: one tablet by mouth, twice daily. Less common, yet identified reported barriers were related to cost or gastrointestinal issues when taking micronutrient supplements. Table 2 outlines clinical applications to patient- reported barriers. Despite education regarding the need for lifelong micronutrient supplementation following surgery, many patients likely perceive this as a general recommendation rather than a critical component of their postsurgical life. Patient perceptions regarding the potential severity of micronutrient deficiencies and benefits of prevention may have a significant effect on adherence. Nutrition deficiencies can lead to permanent and occasionally irreversible diseases or disorders. Stein et al 17 conducted a review of the nutritional and pharmacological consequences of metabolic and bariatric surgeries. Given that research shows adherence to micronutrient supplementation following surgery is l ow and long-term MICRONUTRIENT DEFICIENCIES ARE HIGH, it is critical that all members of t he multidisciplinary care team work together to guide patients to IMPROVED ADHERENCE FOR I MPROVED OUTCOMES. T ABLE 1. Minimum daily recommended levels to prevent deficiency based on published metabolic and bariatric surgery guidelines compared to nutrient levels found in over-the-counter Centrum ® Chewables M ultivitamin/Multimineral Supplement. M ICRONUTRIENTS M INIMUM DAILY RECOMMENDED LEVELS TO PREVENT DEFICIENCY B ASED ON PUBLISHED METABOLIC AND BARIATRIC SURGERY G UIDELINES.* (ORAL DOSES) NUTRIENT LEVELS FOUND IN A STANDARD OVER THE COUNTER MULTIVITAMIN SUPPLEMENT (PER 1 CHEW) ^ Iron 18–60mg 8mg B12 350–500mcg 6mcg Folate 400–1000mcg 400mcg Thiamin 12–100mg 1.5mg Calcium 1200–2400mg 108mg Vitamin D 3,000 IU (titrate until serum levels of D,25 (OH) >30ng/mL) 400 IU Vitamin A 5,000–10,000 IU 1,500 IU Vitamin E 15mg 30 IU (33mg) Vitamin K 90–300mcg 10mcg Zinc 8–22mg 15mg Copper 1–2mg 2mg Selenium 26,33 *high potency multivitamin / mineral supplement Does not contain Magnesium 26 "contains magnesium" 40mg Additional B vitamins 100–200% DV 100% (riboflavin, niacin, pantothenic acid) Bolded values highlight nutrient levels that are not in line with recommendations for metabolic and bariatric surgery patients. *Range is given as there are specific recommendations based on procedure type and patient specific demographics. Please see referenced guidelines for more detailed guidance on recommended daily intake levels ^ Information gathered at time of article publication from product labeling on Centrum ® Chewables Multivitamin/Multimineral Supplement (http://www.centrum.com/centrum-chewables). Label states the following: suggested use for adults is chew one (1) tablet daily with food. Do not exceed suggested use. IU: International Unit; DV: Daily Value