Bariatric Times - February 2009 - (Page 10) 10 Practice Management Bariatric Times • February 2009 dysmorphia.4 This distinction takes an expert. Encouraging a psychological consult can be a prudent and caring intervention by the integrative team. Part 2: NUTRITIONAL ASSESSMENT OF THE PERSPECTIVE BODY CONTOURING PATIENT by Christopher D. Still, FACN, FACP; and Tatiana Figueredo, MD, Center for Nutrition and Weight Management, Geisinger Medical Center, Danville, Pennsylvania INTRODUCTION Depending on which surgical procedure performed, post-bariatric surgery patients may be susceptible to a wide variety of nutritional deficiencies that plastic surgeons and other health care providers should be cognizant of before embarking on any other plastic surgical procedure. The two most common bariatric surgeries being performed in the United States are the Laparoscopic Adjustable Band (restrictive) and the Roux-en-Y gastric bypass (combined restrictive/malabsorptive). Since restrictive procedures create a small gastric pouch for early satiety and normal absorptive surfaces remains in place, nutrient deficiencies are uncommon. In the gastric bypass, and to a greater degree the biliopancreatic diversion (with or without duodenal switch), because of their alteration of GI tract affecting normal digestion and assimilation of nutrients and calories, macronutrients and micronutrients, deficiencies are common and should be assessed. Similar to preoperative bariatric surgery nutritional assessment, a thorough evaluation and, if required, supplementation is recommended for perspective body contouring patients. This will provide the opportunity to replete any deficiencies caused by the primary bariatric surgical procedure, but also optimize wound healing. serum prealbumin. Serum albumin, an acute phase protein, can be decreased due to a variety of metabolic stressors, or overhydration irrespective of nutritional status. The protein intake goal for patients contemplating plastic surgery should average 80 to 100g of protein per day. Although there are many types of protein supplements available for patients’ consumption, the best protein is classified as having the highest biological value protein. Products with amino acids in the hydrolyzed form are most commonly considered the most optimal. Adequate protein intake as reflected by a normal serum albumin/prealbumin levels should be obtained for at least four weeks prior to a body contouring procedure. This will hopefully decrease the amount of edema that can ensue from hypoalbuminemic states. VITAMINS AND MINERAL DEFICIENCIES Vitamins A, E, C, and K are instrumental in wound healing after body contouring surgery. Levels of B vitamins (thiamine-B1, cyanocobalamin-B12, and folate) can also be decreased following bariatric surgery and therefore should be accessed. Vitamins function as vital co-enzymes or co-factors in metabolic pathways involved in macronutrient metabolism as well as in oxidation/reduction reactions, hormones, or antioxidants.10 The trace elements that are required for adequate wound healing include; copper, magnesium, iron, and zinc. Although not necessarily important in wound healing, calcium and vitamin D assessment and supplementation is also recommended given the recent study showing the high prevalence of deficiencies.8,11 Any deficiencies in vitamin, minerals, or trace elements should be reversed for proper wound healing to proceed.12 Vitamin A. Vitamin A is a fatsoluble vitamin that can be depleted in times of metabolic stress or infection. It is important in collagen synthesis, immune response, and cellular adhesiveness. Decreased levels of vitamin A result in decreased in collagen production, delayed wound healing and, a predisposition to infection.13 The recommended daily allowance of vitamin A is approximately 2,500 IU,14 although this amount may need to be adjusted in gastric bypass patients given their altered anatomy/absorption. Vitamin C. Vitamin C (ascorbic acid) is an important water-soluble vitamin, which functions a co-factor in the formation of collagen. Deficiencies are not uncommon in the post-bariatric surgery patient 15 and, if present, can decrease the PROTEIN CALORIE MALNUTRITION Protein. Protein calorie malnutrition after bariatric surgery, as evidence by low-serum albumin/prealbumin serum level, is not uncommon.5 Several studies have documented inadequate protein consumption up to 18 months after bariatric surgery.6, 7 This can be due to a wide variety of reasons, ranging from changes in food preferences/tolerances,8, 9 such as red meat and other animal proteins, and alterations in digestion as evidenced by reduced availability of pepsin, renin, and hydrochloric acid, which all may limit protein digestion.7 The most sensitive screening for protein deficiency is a http://www.bariatricadvantage.com http://www.bariatricadvantage.com
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