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14 Clinical Nursing Education Bariatric Times • February 2017 and ineffective at building good rapport between the clinician and patient. Clinicians, who listen, maintain eye contact, ask evoking questions to affirm understanding, and explain treatment plans in an understandable and unrushed manner help to build the patient- clinician relationship. 24 Clinicians should be encouraged to pay attention to their language during interviews with patients. In addition, questioning patients on micronutrient supplementation should expand beyond "Are you taking your vitamins?" Some practices have found that the use intake questionnaires at each visit provide clinician insight to assess for the patients understanding of and adherence to micronutrient supplementation. Instructing the patient to write down the type of micronutrient supplements they are taking, including brand name, dosage, time of day taken, and how often they are taking them, allows the clinician to assess for understanding of recommended doses, suggest any changes needed to the current intake, and/or address barriers if the patient is not taking the recommended dose. Written plans should also be included in patient education and at each patient encounter as research has shown that written action plans eliminate the barrier of memorization. 25 Having a strong interdisciplinary team is also imperative in improving adherence within the metabolic and bariatric surgical patient population. Communication within the practice is essential to ensure the same message is being communicated to the patient across all disciplines. AVAILABLE GUIDELINES FOR MICRONUTRIENT SUPPLEMENTATION IN THE METABOLIC AND BARAITRIC SURGERY PATIENT POPULATION Being familiar with and following the established guidelines for micronutrient supplementation is a start to communicating the same recommendations throughout the practice. To date, we have several society endorsed guidelines to guide clinicians in supplement recommendations. They are as follows, listed in order of publication: 1. American Society for Metabolic and Bariatric Surgery (ASMBS): Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. 26 • Date: 2008 • Citation: Aills L, Blankenship J, Buffington C, et al. ASMBS Allied health nutritional guidelines for the surgical weight loss patient. Surg Obes Rela Dis. 2008;(4):S73–S108. 2. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient. 27 • Date: 2009 • Citation: Mechanick JI, Kushner RF, Sugerman HJ, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity (Silver Spring). 2009;17 Suppl 1:S1–70, v. 3. Endocrine Society Clinical Practice Guideline: Endocrine and Nutritional Management of the Post-bariatric Surgery Patient. 28 • Date: 2010 • Citation: Heber D, Greenway F, Kaplan L, et al. Endocrine and nutritional management of the post-bariatric surgery patient: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2010;95(11):4823–4843. 4. American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), and ASMBS: Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient—2013 Update. 29 • Date: 2013 • Citation: Mechanick J, Youdim A, Jones D, et al. American Association of Clinical Endocrinologists, Obesity Society, American Society for M etabolic & Bariatric Surgery. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical s upport of the bariatric surgery patient – 2013 update. Endocr P ract. 2013;19(2):337–372. 5. ASMBS Integrated Health Nutritional Guidelines For T he Surgical Weight Loss Patient— 2016 Update: Micronutrients. 30 • Date: 2017 • Citation: Julie Parrott, Laura Frank, Rebecca Dilks, Lillian Craggs-Dino, Kellene A. Isom and Laura Greiman, Asmbs Integrated Health Nutritional Guidelines For The Surgical Weight Loss Patient — 2016 Update: Micronutrients, Surg Obes Relat Dis. http://dx.doi.org/10.1016/j.soard.2 016.12.018 In the latest guideline document, the authors provide specific recommended dosages for key nutrients that are critical to metabolic and bariatric surgery patients. Development of protocols within each practice is likely necessary to ensure that each member of the team is recommending the same micronutrient supplementation dosages. These should be based on the procedure type, age, sex, and individual serum levels of the patient. Improving patient adherence to micronutrient supplementation starts at the clinic level with patient education and behavioral interventions that target barriers to taking the recommended micronutrient supplements. Recommendations for routine lab surveillance for micronutrients according to the ASMBS Nutrition Guideline 2016 update 30 include: preoperative screening for B1, B12, folate, vitamin D, calcium, iron, vitamins A, E, and K. Preoperative screening for zinc and copper is recommended for patients undergoing Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion/duodenal switch (BPD/DS). Within the first three months after surgery, iron should be assessed. Every 3 to 6 months after surgery and then annually screen for iron, B1, B12, folate, vitamin D. Annually screen for iron, vitamins A, D, E, K, B1, B12, folate, zinc, and copper. TABLE 3. Reported rates of most prevalent micronutrient deficiencies in metabolic and bariatric surgery patients, including examples of accompanying physical signs and symptoms M ICRONUTRIENT PRE-OPERATIVE DEFICIENCY RATES POST-OPERATIVE DEFICIENCY RATES EXAMPLES OF PHYSICAL MANIFESTATIONS TO PATIENT Vitamin D 25–68% 25–80% Often none until bone fracture occurs V itamin B12 1 8% 4 –62% Tingling extremities, confusion, depression, dementia Iron 8–18% 17-45% Fatigue, low productivity, iron deficiency anemia Vitamin B1 (Thiamin) 15–29% Up to 49% Mild to severe confusion, temporary to permanent paralysis, coma Folate 2–10% 9–38% Heart palpitations, fatigue, neural tube defects to fetus Zinc Up to 30% SG: 12%; RYGB: 21–33%; BPD/DS: 74–91% Skin lesions, poor wound healing, hair loss Table includes reported rates from all procedures unless otherwise specified. SG: Sleeve gastrectomy; RYGB: Roux-en-Y gastric bypass; BPD/DS: Biliopancreatic diversion/duodenal switch Sources: Stein J, Stier C, Raab H, et al. Review article: the nutritional and pharmacological Consequences of obesity surgery. Aliment Pharmacol Ther. 2014;40(6):582–609. ;Parrot J, Frank L, Dilks R, et al. ASMBS integrated health nutritional guides for the surgical weight loss patient – 2016 update: micronutrients. Surg Obe Rela Dis. http://dx.doi.org/10.1016/j.soard.2016.12.018