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The Adjustable Gastric Band (AGB, LapBand®, Realize® Band) is a wonderfully simply surgical device for weight loss. Safe and effective, this procedure can allow people to lose large amounts of weight by simply restricting food intake. Because there is no removal of any portion of the stomach and no bypassing of any of the intestines, the risk for nutritional deficiency after AGB placement is often downplayed or ignored. But research going back many years shows that there is real risk for nutritional deficiencies with the band. This article will give an overview of why there is risk and what nutrients you need to be concerned about. Pre-operative Deficiency It is much more common than most people realize for patients preparing for bariatric surgery to already have nutritional deficiencies. Multiple studies looking both at nutritional deficiencies in obesity as well as examining them in patients preparing for surgery have come to the same conclusions: deficiencies are very common. The deficiencies seen before surgery include, but are not limited to Vitamin E (1), Vitamin A and the Carotenoids (2), Zinc (3), Selenium (3) and Thiamine (4). The most recent data from the Third National Health and Nutrition Examination Survey (NHANES III: 1988–1994) showed that higher BMI was associated with deficiency of Vitamins, A, E, C, D, selenium, folate and carotenoids. (5) Vitamin D deficiency is so common in morbid obesity that it should most likely be considered a comorbidity. (6) Why is this important? Because if you start out with low levels of nutrition before surgery and then you eat less food, it is pretty hard to keep up with your nutritional needs. Post-operative Nutrition One thing that is lucky for band patients is that they do not have the same level of nutritional concern as gastric bypass patients do. When you don’t have malabsorption, you mostly have to think about the ways that fewer calories, dietary changes and weight loss impact long-term nutrition. Fewer calories means less food. When you eat less it is simply harder to get all the nutrition in that you need each and every day. When it comes to dietary changes, most people really improve how they eat after bariatric surgery. But some of the common changes – for example, eating more Protein and less carbohydrate – can result in getting less of some key nutrients. One nutrient that is impacted this way is folic acid. Most folic acid is found in starch carbohydrates like Cereal, Pasta and bread. So if you eat a lot less of those foods, it can be very hard to get enough of that nutrient. Finally, weight loss itself may contribute to some nutritional issues. One good example of this is bone loss. As people lose weight, some bone loss seems to be inevitable. Good nutrition can be used to help reduce the amount of bone that is lost when you lose weight. The following are some of the nutritional concerns after adjustable gastric banding: 1. Thiamine. Thiamine deficiency is an established risk with all types of bariatric surgery. This is because most thiamine deficiency does not occur from malabsorption, but rather from low intake or from vomiting. Current data suggests that the greatest risk is in the first 6 to 12 months after surgery, especially in patients who have vomiting for any reason (7). There have been at least to published cases of severe thiamine deficiency (Wernicke’s Encephalopathy) with adjustable gastric bands (8,9). 2. B12 and Folic Acid. B12 and folic acid levels have been studied in adjustable gastric band patients in more than one trial. One study of nearly 300 patients examined serum B12, folate and homocysteine (10) levels over a 2-year period following AGB placement (11). The researchers found that those undergoing weight loss had significant elevations of total homocysteine levels compared to controls. Frankly low B12 or folate levels explained 35 % of the elevations. In the remainder of cases, higher than normal levels of these nutrients were required to maintain normal homocysteine levels. Another study conducted in Switzerland, found that by two years following adjustable gastric banding, folic acid levels had declined by 44.1% (12). 3. Bone Health. We already mentioned that one very important nutrient for bone – vitamin D – is very commonly deficient even before surgery. The other major nutrient for bone health – Calcium – is often a problem when it comes to intake. The recommendation for calcium intake after gastric banding is 1500 milligrams per day (13). The average calcium intake by adults aged 35 to 50 years is only 565milligrams (14). If you are now eating less after surgery, changes are your intake has gone down. Studies have shown evidence of bone loss after gastric banding. A one-year study found that there was significant evidence of bone loss, especially at the hip (15). 4. Iron. With no malabsorption, one might think that iron would really not be a potential problem after gastric banding. However, sometimes it is. This is in part because so many women have surgery and iron deficiency is simply more common in women. One study found evidence for iron deficiency in around 8 percent of patients preparing for surgery (16). A study presented to the American Society of Metabolic and Bariatric Surgeons in 2004 found anemia in 53% of patients and iron deficiency in 72% of patients 5 to 18 months after AGB placement (17). The likely reason for most iron deficiency after gastric banding would be low intake. Some patients have a hard time eating meat with a band, and this can result in a sort of “forced vegetarianism” that dramatically reduces dietary iron intake. Sometimes, this can occur if the band is to tight, and needs to be adjusted – so if this is happening to you, you should talk to your doctor. Conclusions Overall, the adjustable gastric band is a safe and effective device for weight loss. Because of dietary changes and weight loss, nutritional problems can arise. Simple nutritional strategies such as taking a Multivitamin and calcium can go a long way towards preventing future problems like anemia and bone loss. It is a good idea to work with your surgeon and dietitian to understand your risks, what you should take, and lab tests that should be done to check for potential problems. References: Ohrvall M, Tengblad S, Vessby B. Lower tocopherol serum levels in subjects with abdominal adiposity. J Intern Med 1993;234:53±60. Pereira S, Saboya C, Chaves G, et al. Class III Obesity and its Relationship with the Nutritional Status of Vitamin A in Pre- and Postoperative Gastric Bypass. Obes Surg. 2008 Apr 8. [Epub ahead of print] Madan AK, Orth WS, Tichansky DS, et al. Vitamin and trace mineral levels after laparoscopic gastric bypass. Obes Surg. 2006 May;16(5):603-6. Flancbaum L, Belsley S, Drake V, et al. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg. 2006 Jul-Aug;10(7):1033-7. Kimmons JE, Blanck HM, Tohill BC, et al. Associations between body mass index and the prevalence of low micronutrient levels among US adults. MedGenMed. 2006 Dec 19;8(4):59. Wortsman J, Matsuoka LY, Chen TC, et al. Decreased bioavailability of vitamin D in obesity. Am J Clin Nutr. 2000 Sep;72(3):690-3. Singh S, Kumar A. CME Wernicke encephalopathy after obesity surgery: A systematic review. Neurology 2007 Mar 13;68(11):807-11. Bozbora A, Coskun H, Ozarmagan S, Erbil Y, Ozbey N, Orham Y. A rare complication of adjustable gastric banding: Wernicke's encephalopathy. Obes Surg. 2000 Jun;10(3):274-5. Homocysteine is a substance in the body that increases when there is not enough folate and/or B12. High homocysteine is a risk for heart disease and other conditions. Solá E, Morillas C, Garzón S, Ferrer JM, Martín J, Hernández-Mijares A. Rapid onset of Wernicke's encephalopathy following gastric restrictive surgery. Obes Surg. 2003 Aug;13(4):661-2. Dixon, et al. Elevated homocysteine levels with weight loss after Lap-Band surgery: higher folate and vitamin B12 levels required to maintain homocysteine level. Int J Obes Relat Metab Disord. 2001 Feb ;25(2): 219-27. Gasteyger C, Suter M, Calmes JM, Gaillard RC, Giusti V. Changes in body composition, metabolic profile and nutritional status 24 months after gastric banding. Obes Surg. 2006 Mar;16(3):243-50. Aillis L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surgery for Obesity and Related Diseases. 2008 May: 4(5): S73-S108. USDA National Food Consumption Survey 1988 Giusti V, Gasteyger C, Suter M, Heraief E, Gaillard R, Burckhardt P. Gastric banding induces negative bone remodelling in the absence of secondary hyperparathyroidism. Int J Obes Relat Metab Disord. 2003 Jan;27(1):110-6. Flancbaum L, Belsley S, Drake V, et al. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg. 2006 Jul-Aug;10(7):1033-7. Vemulapalli P, McGinty A, Lopes J, Goodwin A, Teixaira J. Nutritional Deficiency in Laparoscopic Gastric Banding. ASMBS 2004.

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