Tag: INFORMATION FOR PATIENTS

Adult nutrition

Nutrition

 

Aging is characterized by diminished organ system reserves, weakened homeostatic controls, and increased heterogeneity among individuals, influenced by genetic and environmental factors.

Nutritional needs of the older individual are determined by multiple factors, including specific health problems and related organ system compromise; a human level of activity, energy expenditure, and caloric requirements; the flexibility to access, prepare, ingest, and digest food; and private food preferences.

This topic will discuss assessment of nutrition within the older adult, still because the etiology, evaluation, and treatment of weight loss, overnutrition, and specific common nutrient deficiencies. Related problems with geriatric health maintenance and nutritional assessment are discussed separately.

SCREENING FOR NUTRITIONAL STATUS
Data from studies of acute hospitalization in older patients suggest that up to 71 percent are at nutritional risk or are malnourished.
Malnutrition is related to increased mortality risk. the subsequent criteria for the diagnosis of malnutrition are recommended in an exceedingly consensus statement from the Academy of Nutrition and Dietetics (Academy) and also the American Society for Parenteral and Enteral Nutrition (ASPEN):
Two or more of the subsequent six characteristics:
• Insufficient energy intake
• Weight loss
• Loss of muscle mass
• Loss of subcutaneous fat
• Localized or generalized fluid accumulation which will mask weight loss
• Diminished functional status as measured by handgrip strength.


Weight

Serial measurements of weight offer the best screen for nutritional adequacy and alter in nutritional status in older adults.

Obtaining periodic body weights could also be challenging, particularly in frail patients. A chair or bed scale that’s regularly calibrated could also be needed for patients who cannot stand on an upright exerciser scale. Low weight is defined as <80 percent of the recommended weight .

Weight loss
Studies suggest that weight loss in older adults, especially if it’s not volitional, is predictive of mortality. Loss of as little as 5 percent of weight over a 3 year period is related to increased mortality among community-dwelling older adults .

Weight loss for those with a BMI below 30 likely poses a greater mortality threat to older adults than not losing weight or of getting a BMI of 25 to 30.

However, obesity (BMI ≥30) continues to own a negative impact on morbidity and mortality in older adults. The relative good thing about intentional weight loss in obese older adults with osteoarthritis, impaired activity tolerance, DM, and coronary heart condition, especially when combined with exercise, is becoming increasingly apparent .

Weight loss is taken into account to be clinically significant with the subsequent parameters
• ≥2 percent decrease of baseline weight in one month
• ≥5 percent decrease in three months, or
• ≥10 percent in six months
In the long run care setting, a clinically significant weight loss episode is defined by the long run care Minimum Data Set (MDS) as loss of 5 percent of usual weight in 30 days, or 10 percent in 6 months.

Screening tools
variety of screening tools are developed for identifying older adults in danger for poor nutrition.

• The Nutritional Risk Screening (NRS) 2002 has two components: a screening assessment for undernutrition and an estimate for disease severity. Undernutrition is estimated with three variables: BMI, percent recent weight loss, and alter in food intake . Disease severity ranges from a score of zero (for those with chronic illnesses or a hip fracture) to a few (for those within the ICU with an APACHE score of 10). In hospitalized patients, the NRS 2002 showed a sensitivity of 39 to 70 percent and a specificity of 83 to 93 percent when put next to the Mini Nutritional Assessment and therefore the Subjective Global Assessment .
• The Simplified Nutrition Assessment Questionnaire (SNAQ), a four item screener, was tested in community-dwelling older adults and long-term care residents . In those populations, it had a sensitivity and specificity of 88.2 and 83.5 percent, respectively, for identification of older persons in danger for five and 10 percent weight loss, respectively ( figure 1 ).
• SCREEN II (Seniors within the Community: Risk Evaluation for Eating and Nutrition) may be a 17-item tool that assesses nutritional risk by evaluating food intake, physiological barriers to eating (difficulty with chewing or swallowing), weight change, and social/functional barriers to eating. The tool has excellent sensitivity and specificity, yet as interrater and test/retest reliability .An eight-question abbreviated version of SCREEN II is additionally available .
• The Malnutrition Universal Screening Tool (MUST) incorporates BMI, weight loss in three to 6 months, and anorexia for five days thanks to disease. it’s commonly utilized in the uk and is especially sensitive for recognition of protein energy undernutrition in hospitalized patients .
• The Malnutrition Screening Tool (MST) was developed to be used in acutely hospitalized patients and also validated to be used in cancer patients (average age 57 to 60 years, range 15 to 89) . It asks two simple questions: “Have you been eating poorly due to a decreased appetite?” and “Have you lost weight recently without trying?” The sensitivity of the MST in hospitalized patients ranges from 74 to 100% with a specificity of 76 to 93 percent compared to the Subjective Global Assessment.
• The Mini Nutritional Assessment (MNA) consists of a world assessment and subjective perception of health, moreover as questions specific to diet, and a series of anthropomorphic measurements ( figure 2 ) .It has been widely validated and is predictive of poor outcomes .The Mini Nutritional Assessment-Short Form uses six questions from the total MNA and may substitute calf circumference if BMI isn’t available. A validation study demonstrated good sensitivity compared to the total MNA.
The two screening tools within the highest quartile for sensitivity (>83 percent) and specificity (>90 percent) were the MNA (SF) and therefore the MST.

UNDERNUTRITION SYNDROMES
The prevalence of malnutrition in older adults relies upon the population studied, varying by geography, age distribution, and living situation. A review of results of the Mini Nutritional Assessment across settings and countries in Europe, the u. s. and African nation, found the prevalence of malnutrition among 4507 people (mean age 82.3, 75.2 percent female) was 22.8 percent Highest rates were within the rehabilitation setting (50.5 percent) and lowest among community dwellers (5.8 percent).
Over a 3rd of hospitalized older adults (38.7 percent) during this study met the standards for malnutrition.
Compared to younger adults, undernutrition in older individuals is both more common and should have greater impact on outcomes, including physical function healthcare utilization, and length of stay for surgical hospitalizations
Inadequate energy intake is common in hospitalized older adults, with increased risk related to poor appetite, higher BMI, diagnosis of infection or cancer, delirium, and want for assistance with feeding .Some studies suggest that older adults are less ready to adapt to underfeeding.
One study found that, following a period of experimental underfeeding, older adults experienced less frequent hunger than younger adults, and didn’t regain the whole amount of weight they’d lost when allowed to consume food freely for 6 months while on the average younger adults regained all their lost weight.
In contrast, the same study didn’t demonstrate age differences in ad lib intake, anthropometric indices, gastric emptying rate, and cholecystokinin levels in blood after a period of underfeeding and so consumption of food freely
The lack of ability to catch up on periods of low food intake because of illness or other difficulties may end up in long-term, persistent weight changes, especially when combined with social, medical, or psychological factors which will negatively impact weight.
Involuntary weight loss is driven by:
• Inadequate dietary intake
• Appetite loss (anorexia)
• Disuse or muscle atrophy (sarcopenia)
• Inflammatory effects of disease (cachexia)
or a mixture of those factors.
Inadequate dietary intake
There are multiple causes of weight loss because of inadequate nutrient intake.
These include social (eg, poverty, isolation), psychological (eg, depression, dementia), medical (eg, edentulism, dysphagia), and pharmacological issues.

Social factors
Social factors contributing to weight loss include:
• Increased likelihood of isolation at mealtimes. One third of persons over 65, and half over 85 live alone, which usually decreases food enjoyment and calorie intake. Several studies have demonstrated that older adults who eat the presence of others consume quite those that eat alone.

• Financial limitations affecting food acquisition. A greater proportion of older adults live near the personal income, compared to the overall population. Individuals with fixed incomes may use money previously spent on food for medications and other needed items.

Medical and psychiatric factors
The most important medical and psychiatric causes of weight loss in older adults are malignancy and depression.
• Malignancy was identified because the cause for weight loss in 9 percent of older patients during a study of medical outpatients, and was second to depression because the most frequent identifiable reason for undernutrition .
• In another study of unexplained weight loss in 45 ambulatory older adults, the foremost common identified cause for weight loss was depression (18 percent), again followed by malignancy (16 percent).

• a 3rd report found cancer, predominantly of the digestive tube, as a reason for weight loss in 36 percent of the 154 patients evaluated .

• Depression and dysphoria are common in older adults and infrequently remain unrecognized and undertreated. Depression is a very important reason behind weight loss within the subacute care and home settings, furthermore as in older patients within the community.

• during a chart review of 1017 medical outpatients, as an example, depression was the explanation for weight loss in 30 percent of the older patients, compared to only 15 percent in younger patients .

• Dysphagia is present in approximately 7 to 10 percent of the older adult population and encompasses a negative effect on energy intake .

• Dysphagia occurs in about one half patients with acute first-ever stroke or with Parkinson disease .

• Oropharyngeal dysphagia may occur thanks to stroke, Parkinson disease, amyotrophic lateral sclerosis, Zenker’s diverticula, and other motility or structural disorders. Esophageal dysphagia are often thanks to motility problems (eg, achalasia, diffuse esophageal spasm, scleroderma) and structural issues.

Other important medical etiologies to contemplate include:
• Endocrine disorders (hyperthyroidism, new onset diabetes mellitus)
• End organ disease (congestive heart disease, end stage renal disease, chronic obstructive pulmonary disease, hepatic failure)
• Gastrointestinal disorders (celiac disease, ischemic bowel, inflammatory bowel disease, pancreatic insufficiency, ulceration disease, GERD)
Infections (tuberculosis)
• Rheumatologic disorders (polymyalgia rheumatica, arthritis)
• Neurological conditions (Parkinson disease, chronic pain)
• Alzheimer’s disease (especially among those with behavioral and psychological symptoms)
• Drug or alcohol dependence
• Medication side effects ( digoxin , opioids, serotonin-reuptake inhibitors, diuretics, and topiramate )
Additionally, medical or dental conditions in older adults may impair the flexibility to eat.
Paralysis from stroke, severe arthritis, hand tremors, and dementia may result in routine need for feeding assistance from others.

Chewing difficulty puts older adults in danger for poor intake. in a very study of non-institutionalized older adults, edentulousness doubled the chance for significant weight loss over a one-year period, after adjusting for gender, income, age, and baseline weight .

Physiologic factors
Physiologic factors related to weight loss include age-related decrease in taste and smell sensitivity, delayed gastric emptying, early satiety, and impairment within the regulation of food intake.
• Age raises the brink for odor detection and lowers perceived odor intensity .
• The number of taste buds remains constant, but thresholds for recognition of salt and other specific tastes increase.
• Impaired taste and smell likely alter the cephalic phase of digestion, affecting learned associations between the taste and smell of food with signals involved in meal initiation, volume of food intake, and meal termination.

• Decrease within the rate of gastric emptying in older adults may lead to prolonged antral distension with reduced hunger and increased satiety .

• Aging may influence production of, and/or CNS sensitivity to, several digestive hormones thought to be involved in satiety.

• Glucagon, glucagon-like peptide-1 (GLP-1), cholecystokinin (CCK), leptin, and ghrelin are peripheral satiety signals and appear to be less well detected by the brain with increased age .

• Causes of impaired regulation of food intake include decreased stimulatory effects of neurotransmitters involved in appetite (eg, opioids, neuropeptide Y, the orexins and ghrelin) and increased sensitivity to the inhibitory effects of corticotropin-releasing factor, serotonin, and cholecystokinin.

Anorexia
Anorexia, the decrease in appetite, in older adults is influenced by multiple physiological changes.
Food intake gradually diminishes with age .
Much of the intake reduction in early adulthood is an appropriate response to decreased energy needs because of reduced physical activity, decreased resting energy expenditure (REE), and/or loss of lean body mass.

Changes in taste and smell result in a decreased desire to eat and early satiety develops with age, associated with gastrointestinal changes and gastric hormone changes, as discussed above.

Appetite regulation is further tormented by illness, drugs, dementia, and mood disorders. In 292 older adults from assisted living facilities or senior centers, fair to poor emotional well-being was most closely related to poor appetite (OR 5.60, 95% CI 2.60-12.07) .

Cachexia
Cachexia has been defined as a “complex metabolic syndrome related to underlying illness, and characterized by loss of muscle with or without loss of fat mass” .
It is related to increased morbidity.
Anorexia, inflammation, insulin resistance, and increased muscle protein breakdown are frequently related to cachexia.

Cachexia is distinct from starvation, age-related loss of muscle mass, or psychiatric, intestinal, or endocrinologic causes of weight loss.
Cachexia involves many dysregulated pathways, resulting in an imbalance between catabolism and anabolism.
Because of the presence of underlying inflammation and catabolism, cachexia often is proof against nutritional intervention.
Cachexia usually occurs within the setting of underlying illness involving a cytokine-mediated response. Such illnesses include cancer, end-stage renal disease, chronic pulmonary disease, congestive cardiopathy, rheumatoid arthritis, and AIDS.

Pro-inflammatory cytokines commonly involved in cachexia include interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor-a (TNF-a) .
These cytokines contribute to lipolysis, muscle protein breakdown, and nitrogen loss, additionally to producing anorexia.
They augment the acute phase response, up-regulate the assembly of CRP and down-regulate the transcription of albumin .

In a study of older Framingham Heart Study participants, levels of insulin-like protein 1 (IGF-1) and muscle mass decreased, whereas interleukin 6 levels increased, with age .
These changes appear to occur even within the absence of overt disease, suggesting that a subclinical inflammatory process is also a part of normal aging.
Although elevated pro-inflammatory cytokines (especially IL-1, IL-6 and TNF-a) are commonly seen in older adults, levels are higher in those with cachexia.

Sarcopenia
Sarcopenia may be a syndrome characterized by the loss of muscle mass, strength, and performance .
Low muscle mass is defined as a decrease in appendicular muscle mass two standard deviations below the mean for young healthy adults , and is sometimes measured by DEXA or bio-electrical impedance in clinical practice.
Unlike cachexia, sarcopenia doesn’t require the presence of an underlying illness.
Also, whereas the majority with cachexia are sarcopenic, most sarcopenic individuals don’t seem to be considered cachectic .
Sarcopenia is related to increased rates of functional impairment, disability, falls and mortality .
The causes of sarcopenia are multifactorial and might include disuse, changing endocrine function, chronic diseases, inflammation, insulin resistance, and nutritional deficiencies .

Sarcopenia was identified in 53 to 57 percent of men, and 43 to 60 percent of ladies, over the age of 80 in one study.
Loss of muscle mass, in the course of decreased muscle strength, can occur in overweight individuals (sarcopenic-obese) additionally as in normal and underweight individuals.

Causes of sarcopenia include endocrine changes, activation of proinflammatory cytokines, reduced alpha motor units within the medulla spinalis, decreased physical activity, and suboptimal protein intake.
• Reductions in testosterone and estrogen that accompany aging appear to accelerate the event of sarcopenia .

• Relative deficiencies of estrogen and testosterone contribute to muscle catabolism and promotion of catabolic cytokines like IL-1 and IL-6 .
Testosterone replacement may increase muscle mass, but studies haven’t demonstrated similar benefit for estrogen replacement.
• Insulin resistance increases with age.
• Insulin inhibits muscle breakdown and therefore the reduction of insulin action on muscle may contribute to muscle catabolism .
• Physical activity declines with age. within the u. s., 28 to 34 percent of adults aged 65 to 74 and 35 to 44 percent of adults ages 75 or older are inactive .
• Inactivity exacerbates ongoing muscle loss and increases proportion of body fat mass .
• Inadequate protein intake may also contribute to sarcopenia. in an exceedingly small randomized study of postmenopausal women, consumption of inadequate dietary protein (0.45 g/kg/d) compared to adequate intake (0.92 g/kg/d) for 6 weeks led to deterioration in strength and lean body mass. In one US survey, over 10 percent of adults over age 60 within the US consumed but this RDA for protein .

A study within the uk of 2983 men and ladies aged 59 to 73 years found an independent correlation between increased grip strength and consumption of fatty fish .
The speculation is raised that the anti-inflammatory properties of omega-3-fatty acids is also an element in prevention of sarcopenia.

EVALUATION OF WEIGHT LOSS
Recommendations vary on the degree of weight loss, and also the period of your time for weight loss, that ought to prompt clinical investigation.
One commonly accepted definition for clinically important weight loss is loss of 4 to five percent of total weight over 6 to 12 months.
Unintentional weight loss should result in clinical concern no matter whether the patient is overweight at baseline. Whether or not intentional weight loss is of concern remains a matter of some speculation.

Initial evaluation
the subsequent steps are suggested within the initial evaluation of an older one who is noted to own lost weight, or for whom concern is raised about weight loss by the patient, relations, or caregivers.
• Document the load loss.
• While it’s important to notice objective evidence of weight loss from recorded serial weights over time, this information is commonly not available.

Body fat and lean muscle mass is also estimated using bioelectrical impedance or anthropometric measures like mean upper arm circumference (MUAC) or mid-arm circumference.
• MUAC measures the circumference of the left upper arm at the mid-point between the tip of the shoulder and also the tip of the elbow (olecranon process and also the acromium).
• MUAC of but 22 cm for girls and 23 cm for men are implicative chronic energy deficiency.
• Although connotative malnutrition, it’s unclear whether MUAC predicts mortality and morbidity. The MUST screening tool and therefore the MNA both use mid-arm circumference measures as a part of their assessment.

Bioelectrical impedance measures are available to be used with wheelchair bound and bedbound patients, although bioelectrical impedance is significantly influenced by hydration status.
• Evaluate appetite and dietary intake.
• Determining if there has been a change in hunger and satiety may provide more clinically revealing information than performing a proper dietary recall.
• Patients should be questioned regarding appetite, their dietary intake in regard to their usual pattern, the amount of meals they consume per day, portion size, snacks between meals, if and once they feel full during their meal, and whether the patient likes what he or she is eating.
• The SGA, MNA, and SNAQ all evaluate aspects of dietary intake during this way.
• A more formal dietary intake assessment are often obtained with a dietetic consult.
• Perform an entire history and physical examination, and order appropriate laboratory studies.
• As a baseline, we propose laboratory evaluation for evidence of metabolic or disease, to incorporate a basic chemistry profile including glucose and electrolytes, TSH, complete blood count (CBC), and CRP if cachexia is suspected.
• Chest and plain abdomen radiographs could also be considered.
• Although studies describing the causes of IVL have routinely performed chest x-rays and abdominal films, there’s no clear evidence of their value. Order addition studies supported suspicion of underlying disease from the patient’s history and examination.
Those with no localizing findings and with normal complete blood count, biochemical profile, or chest and plain abdomen radiographs are considered by some to possess isolated involuntary weight loss (IIVL).
In one series, a bit quite one-third of patients with IIVL were ultimately diagnosed with a malignancy.
statistical method found the strongest predictors of neoplasm within the setting of IIVL were age >80 years, white blood corpuscle count >12,000/mm3, albumen <3.5 g/dL, serum alkaline phosphatase > 300 UI/L, and serum lactate dehydrogenase (LDH) >500 IU/L.
These authors recommend CBC, ESR, albumin, liver function studies, LDH, and abdominal ultrasound.
Subsequent evaluation
There are not any clear guidelines for the way to proceed within the assessment of a patient with weight loss and negative initial findings.
The diagnostic yield of a thoracic/abdominal/pelvic CT examination to assess for occult or metastatic malignant disease has not been determined.
Incidental findings are common, the studies are costly, and will be inappropriate in patients who are frail or who have multiple comorbidities.
• In the absence of evidence-based recommendations, we advise ordering a thoracic/abdominal/pelvic CT scan with and without contrast for the patient with significant ongoing weight loss.
• An MRI is also ordered as an alternate when IV contrast can’t be administered, assuming there are not any contraindications; patients with chronic renal disorder shouldn’t be gadolinium.
• Upper gastrointestinal endoscopy is indicated for patients with early satiety.
• Colonoscopy isn’t indicated within the evaluation of weight loss, as carcinoma doesn’t usually induce weight loss or cachexia unless there’s obstruction or extensive metastases


TREATMENT OF WEIGHT LOSS

When an underlying explanation for weight loss is identified, like depression, a medical illness, or inability to chew food, it’s obviously important to treat the condition.
additionally, nutritional repletion should be provided to revive the patient to a target weight, with recognition that weight correction within the older population is a smaller amount readily accomplished than in younger people.
The Council for Nutritional Clinical Strategies in Long-Term Care has developed an evidence-based approach to nutritional surveillance and management for patients in long run care .
Treatment recommendations are supported common reversible causes of malnutrition, as described by the acronym “MEALS ON WHEELS” ( table 2 ). Likewise, the American Academy of Home Care Physicians has developed guidelines for unintended weight loss in home care patients .
Data from studies of acute hospitalization in older patients suggest that up to 71 percent are at nutritional risk or are malnourished .
One randomized trial found that individualized nutritional management by a dietician (involving one visit during hospitalization and three home visits following discharge) resulted in improved scores on the Mini Nutritional Assessment and better albumin levels within the intervention group, compared to manages .
Decreased mortality rates at six months were also found (3.8 versus 11.6 percent for intervention and controls respectively), although high study dropout rates and issues with randomization allocation may have impacted this finding.
Calorie and protein requirements
Calorie needs (the estimated energy requirement, or EER) are often calculated in older adults using the subsequent equations :
• For women: 354.1 – (6.91 x age [y]) + PAC x (9.36 x weight [kg] + 726 x height [m]).
• For men: 661.8 – (9.53 x age [y]) + PAC x (15.91 x weight [kg] + 539.6 x height [m]).
The Physical Activity Coefficient (PAC) is decided as follows:
• Sedentary PAC = 1.0
• Low activity PAC = 1.12
• Active PAC = 1.27
• Very active PAC = 1.45
Protein needs don’t appear to alter significantly with age, although studies evaluating protein intake in older adults have shown wide variation in optimal protein requirements.
A meta-analysis of information from 19 studies of balance in older adults found no significant effect old on the number of protein required per kilogram of weight .
The Institute of medication has determined that the recommended dietary allowance (RDA) for protein for men and girls 51 years old and older is 0.80 g/kg body weight/day .

Inadequate food intake

If the patient’s food intake is inadequate:
• Lift dietary restrictions whenever possible. In one study, undernutrition (average weight loss >1 pound per month, albumen <3.5 g/dl) was related to dietary restrictions .
• Fifty-nine percent of the patients with weight loss and 75.2 percent of these with hypoalbuminemia were on some kind of dietary restriction.

In older, nutritionally high risk adults with diabetes, regular monitoring of blood sugar and adjustment of medication is preferable to dietary restriction or maybe a “no concentrated sweets” prescription.
• The short-term substitution of an everyday diet for a diet increased calorie consumption and failed to cause gross deterioration of glycemic control in an exceedingly study of chronic care patients with type 2 diabetes .

• Make sure that feeding or shopping assistance is accessible, if appropriate. in an exceedingly crossover controlled trial of feeding assistance in institution residents in danger of weight loss, those within the intervention group showed a big increase in daily caloric intake and either maintained or gained weight, whereas those within the control group lost weight.

• Feeding assistance was resource-intensive and required a mean 37 more minutes of staff time per meal .

• Social work support could also be important if inadequate finances are contributing to poor intake.
• Assure that meals and foods meet individual tastes. Suggest offering foods that fit the patient’s ethnic or regional preferences.
• Consider ways to supplement the patient’s diet.
• Increase the nutrient density of food. as an example, increase protein content by adding milk, whey protein (found in many food stores), egg whites, or tofu.
• Increase fat content by adding oil (or other “good fat”) in preparation of sauces, fresh or cooked vegetables, and grains or pasta.
• If weight doesn’t improve, offer daytime snacks between meals.
• Give a daily multivitamin and mineral supplement until the reason behind inadequate intake is set.
• Consider a liquid dietary supplement

Nutritional supplements
A meta-analysis evaluated 55 randomized trials of nutritional supplements containing protein and energy to stop malnutrition in older, high-risk patients.
Studies were generally judged to be of poor quality, because of lack of blinding and intent to treat analysis.
The trials evaluated supplements providing between 175 and 1000 additional kcal/day and between 10 and 36 g protein/day.
Most subjects (45 percent) were hospitalized for stroke; 16 percent were community-based and 10 percent in long-term care facilities.
Nutritional supplementation resulted in modest improvement in percentage weight change (weighted mean difference 1.75 percent, 95% CI 1.2 to 2.3), with slightly greater weight increase in patients reception or in long-term care.
Overall mortality was reduced within the groups receiving nutritional supplement, compared to control, but there was no mortality impact for patients living reception, and no improvement in functional status.
The greatest mortality impact was found in hospitalized undernourished patients who were 75 years or older, and who received supplements with higher calorie content.
Complication rates were lower for hospitalized patients who received supplementation, but there was no change in hospital length of stay.
In another meta-analysis, there was some evidence that volitional nutrient support (VNS) improved survival among malnourished geriatric patients .
Findings were significant for low-quality trials; two top quality trials found benefit for VNS during this population, but the difference from control failed to reach statistical significance.
A randomized crossover trial of organic compound supplements in 41 sarcopenic older adults demonstrated increases in whole-body lean mass at six and 12 months. This study also demonstrated that supplementation led to improved nutrition as reflected by Mini Nutritional Assessment (MNA) scores, improved albumin levels, decreased scores for depression measured by the Geriatric Depression Scale (GDS), and better hand grip strength .
More studies are needed within the sarcopenic geriatric population before aminoalkanoic acid supplementation will be generally recommended in clinical practice .
Appetite stimulants
Use of appetite stimulants (orexigenics) could also be considered, although there are few studies of use of those medications within the older population with weight loss and failure to thrive.
There is inadequate information to work out the suitable use of orexigenics in older adults with cachexia.
The complex interplay between inflammation, catabolism, and nutritional substrate in cachexia demands multimodal interventions that address all three elements.
Megestrol acetate — progestogen , a progestational agent, has been shown to yield weight gain in patients with anorexia and cachexia. progestogen has demonstrated weight gain and improved quality of life for patients with cancer .
In a randomized trial, progestin 800 mg daily for 12 weeks improved appetite and sense of well-being during a group of home residents.
However, weight gain wasn’t found to be significant (>4 lbs) until three months after treatment .
Weight gain was more prominent in residents with elevated cytokine concentrations.
Patients treated with progestin should be watched closely for edema and worsening of congestive failure.
Small studies have also demonstrated impaired function of the corticoadrenal axis ,and increased incidence of deep thrombosis in patients treated with megestrol.
Megestrol may have adverse effects on muscle. in a very randomized trial of exercise training and megestrol in older veterans, subjects who took megestrol had less gain in muscle strength or functional performance.

Dronabinol

Dronabinol has been shown to boost appetite in patients with AIDS; it had been not as effective as megestrol in patients with advanced cancer .
Dronabinol has not been well-studied in older adults. A limited non-randomized trial showed that dronabinol could also be useful for anorexia, weight gain, and behavior problems in patients with advanced Alzheimer disease who were refusing food .

Dronabinol has significant CNS side effects, limiting its use for many older adult populations.

Mirtazapine

Mirtazapine , an antidepressant that ends up in more weight gain than SSRI antidepressants, is often used for management of depression and weight loss in older adults.
However, few studies are specifically performed to judge its impact on weight among older adults with weight loss.
Two studies in rest home residents didn’t show conclusive benefit for mirtazapine over other non-tricyclic antidepressants .

OVERNUTRITION

The National Heart, Lung and Blood Institute clinical guidelines define overweight as a BMI of 25 to 29.9 and obesity as a BMI of 30 or greater .
For the population as an entire, higher body weights are related to increase in all-cause mortality, moreover as morbidity associated with hypertension, dyslipidemia, type 2 diabetes, coronary cardiovascular disease, stroke, gallbladder disease, osteoarthritis, sleep disorder and respiratory problems, and endometrial, breast, prostate, and colon cancers.

Several studies suggest that the link of overweight or obesity to mortality declines over time:
• Data from the Longitudinal Study of Aging found that a comparatively high BMI (30 to 35 for ladies and 27 to 30 for men) was related to minimal excess risk for mortality in adults older than 70 years old .
• A longitudinal study of over 500,000 adults within the US found a decrease within the association of obesity with upset mortality over time .
• Data from several other long-term observational studies, including the Cardiovascular Health Study, the Medicare Current Beneficiary Surveys , and also the National future Care Survey have also found that being overweight doesn’t increase mortality risk for people age 65 years and older.
However, BMI and weight might not be reliable indicators of overweight or obesity in older populations, where normal weight may reflect loss of muscle mass instead of decreased adiposity.
A few studies suggest that being overweight as an older adult is related to increased mortality:
• In a study of men 60 to 79 years within the uk, mortality wasn’t increased for overweight or obese participants as defined by BMI .
• However, mortality risk was increased with increasing waist circumference and with BMI, when data were corrected for differences in midarm muscle circumference. These findings suggest that cardiorespiratory fitness and muscle mass may play a very important role within the relationship between BMI and mortality.
• Another report found a U shaped pattern in women ≥65 years old, comparing mortality across weight quintiles, with lower mortality for ladies within the middle 3 quintiles .
• A J-shaped pattern for BMI and mortality was demonstrated in another study of adults, predominantly men, over age 60.
• In this study, BMI within the overweight range was protective.
Though the mortality risk of obesity may lessen with age, there are still potential metabolic and functional benefits to weight loss within the obese older adults.
Increasing obesity in older adults is related to new or worsening disability and weight loss can improve physical function and quality of life for several older adults.
Recommendations to lose or not has to be individualized to the chance profile of particular patients.
Those who are experiencing significant adverse effects related to obesity (such as pain from osteoarthritis or obstructive sleep apnea) should be encouraged to pursue cautious weight loss, but only within the context of normal exercise and appropriate calcium and ergocalciferol supplementation.
Negative outcomes related to weight loss in overweight older adults include loss of muscle mass and reduce in bone mineral density; both of those could also be mitigated with regular exercise .

MICRONUTRIENT DEFICIENCIES IN OLDER ADULTS
Vitamin B12 deficiency
The prevalence of B12 deficiency in older adults ranges between 10 and 20 percent .
Some persons with low normal serum B12 levels may of course be deficient, with resultant neurologic, psychological, or hematologic disease.
The diagnosis might have to be made by measurement of methyl malonic acid, which is elevated with B12 deficiency.

In the past, a majority of B12 deficiencies were thought to result from factor deficiency.
It is now known that approximately 15 percent of older adults (>60 years) poorly absorb protein-bound B12.
This is a results of malabsorption of the food-protein-B12 complex within the stomach, associated with gastric achlorhydria and infrequently related to atrophic gastritis .
This may be consequent to current or past H pylori infection.
Concern had been raised that folate fortification of foods may mask macrocytic anaemia in those with B deficiency. However, a study using NHANES data for older adults within the post-folate fortification years found that those with B12 deficiency and better folate levels were more likely to be anemic and to own cognitive impairment than patients with normal folate levels .

Given the high prevalence of B12 deficiency and therefore the ease and safety of treatment, some have advocated routinely screening adults over the age of 65 with a serum B complex assay .
However, this policy has not been endorsed in formal screening guidelines for the geriatric population.
Patients with B12 deficiency can generally be treated with oral B12 and will like increasing the intake of B12 in food.
Because B12 malabsorption is common in older adults, with potentially significant effects of B deficiency on the system, individuals >51 years old should take supplements containing antipernicious anemia factor, or eat fortified food products.
it’s prudent to advocate a daily intake of 10 to fifteen mcg .
For food cobalamin malabsorption-induced B12 deficiency, ongoing therapy with 1,000 mcg per day of oral crystalline cyanocobalamin may correct serum B-complex vitamin levels and yield adequate hematological responses .

Vitamin D deficiency
Lack of sun exposure, impaired skin synthesis of previtamin D, and decreased hydroxylation within the kidney with advancing age contribute to marginal cholecarciferol status in many older adults .
additionally, dietary D intake is commonly low in older subjects.
it’s been estimated that approximately one-half of older women consume but 137 international units (units)/day of fat-soluble vitamin from food, and nearly one-quarter consume but 65 units/day .

Inadequate fat-soluble vitamin status has been linked with muscle weakness, functional impairment, depression, and increased risk of falls and fractures .
An observational study during a large integrated healthcare system found an association between low D and increased prevalence of diabetes, hypertension, hyperlipidemia, and peripheral vascular disease .
Lower serum 25-hydroxyvitamin D concentrations in older persons have also been related to a greater risk of future rest home admission .
Patients with calciferol insufficiency can also have relative hypocalcemia and high serum internal secretion (PTH) concentrations; this secondary hyperparathyroidism is attenuated by the administration of fat-soluble vitamin supplements .

Many older adults will have low levels of serum of 25-hydroxyvitamin D levels (<20 ng/mL or 50 nmol/L).
Older individuals at higher risk for cholecarciferol deficiency include those that are institutionalized, homebound, have limited sun exposure, obesity, dark skin, osteoporosis, or malabsorption. Monitoring of serum levels of 25-hydroxyvitamin D (25-OHD) is suggested for those at high risk, with the goal of achieving levels ≥30 ng/mL. Testing at three to four months following initiation of D supplements, if needed, should be done to assure that the target has been achieved.

Increased consumption of dietary sources of viosterol should be encouraged all told older adults.
In 2010, the Institute of drugs (IOM) released a report on dietary intake requirements for calcium and calciferol for normal healthy persons .
The Recommended Dietary Allowance (RDA) of fat-soluble vitamin for adults through age 70 years is 600 IU with the RDA increasing to 800 IU after age 71.

Vitamin D supplementation with cholecalciferol (vitamin D3) in doses of 600 to 800 mg daily is recommended for people with serum 25OHD level within the range of 20 to 30 ng/mL. Some individuals may have higher doses.
Regimens for ergocalciferol supplementation for those with serum 25OHD levels <20 ng/mL are discussed separately

Inadequate intake of calcium
Calcium nutrition is strongly influenced by age. The efficiency of calcium absorption from the canal decreases significantly after age 60 in both sexes.
Individuals between 70 and 90 years old absorb about one third less calcium than do younger adults.
Osteoporosis affects quite 10 million people within the u. s., and causes over 1.5 million fractures within that population every year .

Given the impact of calcium deficiency on cortical bone loss, the adequate intake (AI) reference value for Ca for those >51 years old was increased from 800 (1989 RDA) to 1200 mg/d.
Food sources of calcium and available calcium supplements are shown in tables ( table 3 and table 4 ).
Multivitamin supplementation
Whether multivitamin (MVI) supplementation should be routinely recommended to older adults remains a source of some controversy and confusion.
Many older adults use MVI supplements.
within the 1999-2000 National Health and Nutrition Examination Survey (NHANES), 35 percent of adults within the us used multivitamin-multimineral supplements (MVM) and older adults were more likely than younger groups to use them (OR 1.7, 95% CI 1.3-2.2).
In a longitudinal cohort study of predominantly white older women, the employment of dietary supplements increased significantly between 1986 and 2004 (from 63 to 85 percent of girls reporting use of a minimum of one supplement daily) .

MVM supplementation has been recommended for older adults who are more likely to own compromised nutritional status (such as those within the long run care setting), to assist achieve recommended intakes of certain micronutrients .
evidence, however, provides only weak support for this practice:
• In a study of 263 older adults attending senior centers, nutrient intake was estimated from dietary recalls and reported use of MVM supplementation .
• Subjects who reported taking MVM were calculated to own improved intakes of vitamins E, D, B6, folic acid , and calcium, but were likely to exceed the Tolerable Upper Limit for niacin, folic acid, and antiophthalmic factor.
• In a study of 4384 adults 51 years old and older, supplements improved the nutrient intake of older adults. After accounting for the contribution of supplements, 80 percent or more of users met the estimated average requirement (EAR) for vitamins A, B6, B12, C, and E yet as for folate, iron, and zinc, but not for magnesium.
• However, some supplement users, particularly men, exceeded Tolerable Upper Intake Levels for iron and zinc and atiny low percentage of ladies exceeded the Tolerable Upper Intake Level for antiophthalmic factor .
• A few studies have suggested that MVM might reduce the incidence of infections, and upper tract infections particularly.
• during a systematic review of eight randomized trials of multivitamins and mineral supplements primarily involving older adults, three studies found that MVM reduced the amount of days spent with infection by 17.5 (95% CI 11-24) but analysis of 4 studies showed no impact on the infection rate .
• In an 18-month randomized trial involving 763 institutionalized older adults from 21 long-term care facilities, there was no statistically significant difference within the rate of infections within the supplement and placebo groups .
• In a cohort study of 38,772 older women followed for over 20 years with a mean age of 61.6 at baseline, supplementation with daily multivitamins was related to alittle increase in total mortality (HR 1.06, 95% CI 1.02-1.10) .

Therefore, routine supplementation with multivitamins and minerals isn’t indicated to scale back infections in frail seniors and is probably going not beneficial unless it’s clear that the older adult isn’t meeting his or her micronutrient needs because of low overall intake. The 2006 NIH Consensus Conference on the employment of MVM found evidence insufficient to recommend for or against the employment of MVMs to stop chronic disease for the US population generally .

INFORMATION FOR PATIENTS
UpToDate offers two kinds of patient education materials, “The Basics” and “Beyond the fundamentals.” the fundamentals patient education pieces are written in plain language, at the 5 th to six th grade reading level, and that they answer the four or five key questions a patient might need a couple of given condition.
These articles are best for patients who need a general overview and preferring short, easy-to-read materials. Beyond the fundamentals patient education pieces are longer, more sophisticated, and more detailed.
These articles are written at the ten th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to the current topic.
We encourage you to print or e-mail these topics to your patients. (You also can locate patient education articles on a range of subjects by searching on “patient info” and therefore the keyword(s) of interest.)
• Basics topics

SUMMARY and suggestions

• The involuntary loss of quite 5 to 10 percent of an older person’s usual weight during one year is a vital clinical sign related to increased risk for mortality.
• Weight loss should thus be met concernedly and prompt a groundwork for the cause.
• Involuntary weight loss is mostly associated with one or a mix of 4 conditions: inadequate dietary intake, appetite loss (anorexia), muscle atrophy (sarcopenia), or inflammatory effects of disease (cachexia).
• Inadequate dietary intake may relate to social, psychological, medical, and physiologic issues. Depression is that the most prevalent associated condition in several studies, with cancer because the second most typical cause.
• Pro-inflammatory cytokines are common in older adults and are particularly elevated in patients with cachexia.
• Sarcopenia is commonly associated with a discount in testosterone and estrogen and increase in insulin resistance
• Evaluation of weight loss should include serial weight measurements, dietary or appetite assessment, history, physical examination, and screening laboratory studies (CBC, chemistry profile, thyroid studies). Additional studies should be supported findings of the initial evaluation and will include upper GI endoscopy for patients with early satiety or thoracic/abdominal/pelvic CT scan for patients with unexplained ongoing weight loss.
• Treatment should be directed at the underlying cause (ie, treatment for depression) still as dietary modification.
• Nutritional restrictions should be lifted; patients with diabetes may had best with an everyday diet and adequate monitoring.
• High-calorie foods should be provided.

We suggest providing oral nutritional supplementation for patients who don’t regain weight with adjustments in meal preparation and diet ( Grade 2B ). we advise not treating patients with appetite stimulants ( progestogen or dronabinol ) because of marginal benefit and potential side effects ( Grade 2B
• Mortality risk in people over age 70 isn’t significantly impacted by an elevated BMI within the 25.0 to 29.9 range.
• Advice regarding weight loss for the overweight older person should be tailored to the individual, assessing the impact of excess weight on their quality of life, and will include the requirement for normal exercise.
• Vitamin B12 deficiency affects about 15 percent of individuals >60 years within the US and most typically relates to malabsorption of food-protein-B12 complexes.
• Oral B12 supplements, 1000 mcg daily, can usually correct B12 deficiency within the older adult. Daily intake of B12 10 to fifteen mcg, by supplement or fortified products within the diet, is suggested for people >50 years.

• Vitamin D deficiency is additionally common within the older population. viosterol supplements or fortified foods should supply 600 to 800 IU of D per day for older adults. Additionally, 1200 mg/d of elemental calcium should be provided daily.

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Treatment of hypocalcemia  

Dietary Supplements

 

— Hypocalcemia is also related to a spectrum of clinical manifestations, starting from few if any symptoms if the hypocalcemia is mild and/or chronic, to severe life-threatening symptoms if it’s severe and/or acute. Thus, the management of hypocalcemia depends upon the severity of symptoms. In patients with acute symptomatic hypocalcemia, intravenous calcium gluconate is that the preferred therapy, whereas chronic hypocalcemia is treated with oral calcium and viosterol supplements. The treatment of hypocalcemia are reviewed here. The etiology, clinical manifestations, and diagnostic approach to hypocalcemia are reviewed separately.

INTERPRETATION OF SERUM CALCIUM

— Calcium in serum is absolute to proteins, principally albumin. As a result, total serum calcium concentrations in patients with low or high albumen levels might not accurately reflect the physiologically important ionized (or free) calcium concentration. As an example, in patients with hypoalbuminemia, total serum calcium concentration is also low when serum ionized calcium is normal. The serum total calcium concentration falls approximately 0.8 mg/dL for each 1 g/dL reduction within the albumin concentration. Thus, in patients with hypoalbuminemia or hyperalbuminemia, the measured serum calcium concentration should be corrected for the abnormality in albumin or for traditional units If there’s uncertainty whether the corrected serum calcium is reflective of the ionized calcium, and if a laboratory known to live ionized calcium reliably is obtainable, some authorities opt to measure the ionized calcium directly. Direct measurement of the ionized calcium concentration might be considered in patients with symptoms of hypocalcemia within the setting of a traditional total calcium concentration. Symptomatic hypocalcemia with normal total calcium but low ionized calcium can occasionally occur in patients with acute alkalosis thanks to increased binding of calcium to albumin. In patients with asymptomatic hypocalcemia, it’s important to verify with repeat measurement (ionized calcium or total serum calcium corrected for albumin) that there’s a real decrease within the calcium concentration.

THERAPEUTIC APPROACH

— The treatment of hypocalcemia varies with its severity and therefore the underlying cause. The severity of symptoms (paresthesias, carpopedal spasm, tetany, seizures) and signs (Chvostek’s or Trousseau’s signs, bradycardia, impaired cardiac contractility, and prolongation of the QT interval) depends upon absolutely the level of calcium, furthermore because the rate of decrease. Patients with acute hypocalcemia are symptomatic at serum calcium values that might not cause symptoms in patients with chronic hypocalcemia (eg, hypoparathyroidism). Clinical manifestations also vary with other factors like the arterial pH and therefore the reason for hypocalcemia. There are few studies examining the optimal treatment of hypocalcemia. Most recommendations are based upon accepted practice or clinical experience We recommend intravenous calcium for symptomatic patients (carpopedal spasm, tetany, seizures), for patients with a chronic QT interval, and for asymptomatic patients with an acute decrease in serum corrected calcium to ≤7.5 mg/dL (1.9 mmol/L). For those with milder symptoms of neuromuscular irritability (paresthesias) and corrected calcium concentrations greater than 7.5 mg/dL, oral calcium supplementation may be initiated. If symptoms don’t improve with oral supplementation, we recommend switching to intravenous calcium. When vitamin D deficiency or hypoparathyroidism is that the reason for hypocalcemia, administration of calcium alone is typically only transiently effective. Long-term management requires the addition of cholecarciferol. Recombinant human internal secretion is approved for the treatment of osteoporosis but isn’t yet standard look after hypoparathyroidism due to high cost and also the necessity for subcutaneous administration. Intravenous calcium — Intravenous calcium is indicated for acutely symptomatic patients, as can occur when there’s a rapid and progressive reduction in serum calcium (eg, acute hypoparathyroidism following post-radical neck dissection for head and neck cancer). it’s also indicated for asymptomatic hypocalcemia in several other settings. These include patients with acute decreases in serum calcium to ≤7.5 mg/dL (1.9 mmol/L) who may develop serious complications if untreated, and patients with milder degrees of hypocalcemia or with chronic hypocalcemia (due to hypoparathyroidism) who become unable to require or absorb oral supplements, as may occur after complex surgical procedures requiring prolonged recuperation. Intravenous calcium isn’t warranted as initial therapy for asymptomatic hypocalcemia in patients with impaired renal function in whom correction of hyperphosphatemia and of low circulating 1,25-dihyroxyvitamin D are usually the first goals Initially, intravenous calcium (1 to 2 g of calcium gluconate , adore 90 to 180 mg elemental calcium, in 50 mL of 5 percent dextrose) is infused over 10 to twenty minutes. The calcium mustn’t tend earlier, due to the chance of great cardiac dysfunction, including systolic arrest This dose of calcium gluconate will raise the serum calcium concentration for less than two or three hours; as a result, it should be followed by a slow infusion of calcium in patients with persistent hypocalcemia. Either 10 percent calcium gluconate (90 mg of elemental calcium per 10 mL) or 10 percent salt (270 mg of elemental calcium per 10 mL) is wont to prepare the infusion solution. Calcium gluconate is sometimes preferred because it’s less likely to cause tissue necrosis if extravasated. An intravenous solution containing 1 mg/mL of elemental calcium is ready by adding 11 g of calcium gluconate (equivalent to 990 mg elemental calcium) to normal saline or 5 percent dextrose water to produce a final volume of 1000 mL. This solution is run at an initial infusion rate of fifty mL/hour (equivalent to 50 mg/hour).

The dose are often adjusted to take care of the serum calcium concentration at the lower end of the traditional range (with the serum calcium corrected for any abnormalities in albumin as noted above). Patients typically require 0.5 to 1.5 mg/kg of elemental calcium per hour. The infusion should be prepared with the subsequent considerations

: • The calcium should be diluted in dextrose and water or saline because concentrated calcium solutions are irritating to veins.

  • The intravenous solution shouldn’t contain bicarbonate or phosphate, which might form insoluble calcium salts. If these anions are needed, another intravenous line (in another limb) should be used. Intravenous calcium should be continued until the patient is receiving a good regimen of oral calcium and vitamin D. Calcitriol, in a very dose of 0.25 to 0.5 mcg twice daily, is that the preferred preparation of ergocalciferol for patients with severe acute hypocalcemia thanks to its rapid onset of action (hours Concurrent hypomagnesemia  — Hypomagnesemia could be a common explanation for hypocalcemia, both by inducing resistance to hormone (PTH) and by diminishing its secretion. In patients with hypomagnesemia, hypocalcemia is difficult to correct without first normalizing the serum magnesium concentration. Thus, if the serum magnesium concentration is low, 2 g (16 meq) of sulphate should be infused as a ten percent solution over 10 to twenty minutes, followed by 1 gram (8 meq) in 100 mL of fluid per hour. Magnesium repletion should be continued as long because the serum magnesium concentration is a smaller amount than 0.8 meq/L (1 mg/dL or 0.4 mmol/L). More careful monitoring is required in patients who have impaired renal function who would be at greater risk of developing hypermagnesemia. Persistent hypomagnesemia, as occurs in some patients with ongoing gastrointestinal (eg, malabsorption) or renal losses, requires supplementation with oral magnesium, typically 300 to 400 mg daily divided into three doses. Oral calcium — Oral calcium supplementation is preferred for patients with milder degrees of acute hypocalcemia (serum corrected calcium concentration of seven.5 to 8.0 mg/dL [1.9 to 2.0 mmol/L] or a serum ionized calcium concentration above 3.0 to 3.2 mg/dL [0.8 mmol/L]) or for chronic hypocalcemia. Such patients are typically asymptomatic or at the most mildly symptomatic (eg, oral paresthesias). they will be treated initially with 1500 to 2000 mg of elemental calcium given as carbonate or calcium citrate daily, in divided doses. As an example, carbonate is 40 percent elemental calcium, so 1250 mg of carbonate contains 500 mg of elemental calcium. The dose of elemental calcium is listed on most supplement labels. The role of oral calcium as a phosphate binder in patients with chronic nephrosis is presented elsewhere. additionally to calcium, patients with ergocalciferol deficiency or hypoparathyroidism require D supplementation, which frequently permits a lower dose of calcium supplementation. viosterol and metabolites  — Several preparations of ergocalciferol are available for the treatment of hypocalcemia thanks to hypoparathyroidism or viosterol deficiency. The role of calciferol therapy in patients with chronic renal disorder is discussed separately. viosterol requirements vary considerably from patient to patient and therefore the correct dose in any given patient is primarily determined by trial and error. Because PTH is required for the renal conversion of calcidiol (25-hydroxyvitamin D) to the active metabolite calcitriol (1,25-dihydroxyvitamin D), patients with hypoparathyroidism are preferably treated with calcitriol. The initial dose of calcitriol is often 0.25 to 0.5 mcg twice daily. the varied preparations differ in onset of action, duration of action, and cost. the most important side effects are hypercalcemia and hypercalciuria, which, if chronic, can cause nephrolithiasis, nephrocalcinosis, and nephropathy Hypercalciuria is that the earliest sign of toxicity and may develop within the absence of hypercalcemia; it’s presumably to occur in patients with hypoparathyroidism since internal secretion stimulates renal calcium reabsorption. However, in patients with ergocalciferol deficiency, enhanced intestinal absorption of calcium with fat-soluble vitamin therapy and also the resulting increases in serum calcium may additionally reduce PTH concentrations, potentially leading to hypercalciuria before hypercalcemia occurs. Thus, both serum and urinary calcium should be measured frequently (two-week intervals) initially so every six months to 1 year once a stable dose is achieved. Hypercalciuria and, if present, hypercalcemia usually resolve in a very few days after cessation of therapy in patients treated with calcitriol. In contrast, recovery is slower (as long as two to a few weeks thanks to storage in fat) in patients treated with viosterol, but are often accelerated by a brief course of glucocorticoid therapy. Vitamin D — ergocalciferol deficiency is often treated with ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3). ergocalciferol is obtainable in several doses for oral administration. In some countries (not within the United States), it’s is also available for parenteral administration the foremost advantage of fat-soluble vitamin is its low cost, which is approximately 20 percent that of the ergocalciferol metabolites. Disadvantages include the need for hepatic and renal metabolism and slow onset and long duration of action. It must lean daily for several weeks before the complete effect becomes evident and hypercalcemia, should it occur, can persist for 2 to a few weeks after it’s discontinued. Calcitriol — Calcitriol (1,25-dihydroxyvitamin D, Rocaltrol) is most useful in diseases within which its renal synthesis is impaired, like nephropathy or hypoparathyroidism. it’s the foremost active metabolite of fat-soluble vitamin. the benefits of calcitriol include lack unavoidably for endogenous activation, rapid onset of action (hours), and a biologic half-life of about four to 6 hours. While hypercalcemia is more common during treatment with calcitriol than with viosterol, cessation of treatment is followed by resolution of hypercalcemia in a very few days instead of some weeks Other vitamin D analogues   — fat-soluble vitamin metabolites may be wont to treat hypocalcemia, particularly when there’s abnormal viosterol metabolism (renal or liver disease). The recommended preparation and dose vary with the clinical condition.
  • • Alfacalcidol (1-alpha-hydroxyvitamin D3) could be a synthetic analog of calciferol that’s converted within the liver to the active metabolite 1,25-dihydroxyvitamin D. just like calcitriol, it’s a rapid onset of action and comparatively short half-life. Although it’s not available within the us, it’s utilized in other countries for the treatment of hypocalcemia related to hypoparathyroidism and as a treatment adjunct in chronic renal disorder.
  • • Dihydrotachysterol is that the functional equivalent of 1-hydroxyvitamin D, in this only 25-hydroxylation within the liver is required to make the active drug. As a result, dihydrotachysterol is effective in patients in whom renal 1-hydroxylation is impaired, like those with chronic nephropathy. it’s a rapid onset of action and a comparatively short duration of action, so toxicity resolves in a very few days.
  • • Calcidiol (25-hydroxyvitamin D) doesn’t require hepatic 25-hydroxylation, and is therefore most useful in patients with disease. Its action is more rapid and not as prolonged as that of cholecarciferol, but slower in onset and more prolonged than that of calcitriol.

 DISEASE SPECIFIC APPROACH Hypoparathyroidism

— Hypoparathyroidism occurs when there’s abnormal endocrine gland development, destruction of the parathyroid glands (autoimmune, surgical), altered regulation of hormone (PTH) production, or impaired PTH action. Most patients with hypoparathyroidism require lifelong calcium and vitamin D supplementation. An exception is that the occurrence of transient hypoparathyroidism after thyroidectomy or parathyroidectomy. The goals of therapy in patients with hypoparathyroidism are to alleviate symptoms and to lift and maintain the serum calcium concentration within the low-normal range, eg, 8.0 to 8.5 mg/dL (2.0 to 2.1 mmol/L). Attainment of upper values isn’t necessary and is sometimes limited by the event of hypercalciuria because of the loss of renal calcium retaining effects of PTH. The initial dose of oral calcium should be 1.0 to 1.5 g of elemental calcium daily, in divided doses Although carbonate is commonly used (it is that the least expensive), it should be less well-absorbed in older patients and people who have achlorhydria. These patients could be treated with another preparation, like calcium citrate . Although a range of viosterol preparations will be wont to treat hypoparathyroidism calcitriol is commonly thought to be the treatment of choice A typical starting dose is 0.25 mcg twice daily, with weekly dose increments to realize a low-normal serum calcium. Many patients require up to 2 mcg daily. Monitoring of urinary and serum calcium and serum phosphate are required weekly initially, until a stable serum calcium concentration (at the low end of the conventional range) is reached. Thereafter, monitoring at three- to six-month intervals is sufficient Preventing hypercalciuria  — a rise in urinary calcium excretion could be a predictable consequence of raising the serum calcium in patients with hypoparathyroidism These patients lack the conventional stimulatory effect of PTH on renal tubular calcium reabsorption and so excrete more calcium than normal subjects at the identical serum calcium concentration. Thus, completely correcting hypocalcemia may cause hypercalciuria, which may produce nephrolithiasis, nephrocalcinosis, and possible chronic nephropathy To prevent these complications, urinary calcium excretion should be measured periodically and therefore the dose of calcium and calciferol reduced if it’s elevated (≥300 mg in 24 hours). Some patients with hypoparathyroidism require a thiazide diuretic (25 to 100 mg daily), with or without dietary sodium restriction, to decrease urinary calcium excretion A thiazide is usually added when the 24-hour urinary calcium approaches 250 mg In patients who develop thiazide-induced hypokalemia, potassium supplementation is important. The mechanism by which both PTH and thiazides enhance distal calcium reabsorption is reviewed elsewhere. Recombinant human PTH  — The administration of recombinant internal secretion (PTH), which is obtainable for the treatment of osteoporosis, holds promise as a treatment for hypoparathyroidism. Subcutaneous administration of PTH 1-34 and PTH 1-84 are investigated, as illustrated by the following:

  • In two randomized trials from the identical group, subcutaneous administration of synthetic PTH 1-34 controlled hypocalcemia with a lower risk of hypercalciuria in comparison with calcitriol (all subjects received oral calcium supplementation) Twice-daily administration of PTH 1-34 provided better metabolic control and allowed a discount in total daily PTH dose (46 versus 97 mcg daily) Similar findings were noted during a trial comparing once- versus twice-daily PTH administration in 14 children with chronic hypoparathyroidism (total daily dose 25 versus 58 mcg

In an open label study of PTH 1-84 (100 mcg every other day) in 30 hypoparathyroid patients, PTH 1-84 significantly reduced supplemental calcium and calcitriol requirements without altering serum and urinary calcium concentrations Bone mineral density significantly increased within the lumbar spine (2.9 percent) and decreased within the distal one-third radius (2.4 percent). Recombinant human PTH may additionally improve abnormal skeletal properties in hypoparathyroidism. in a very histomorphometric analysis of paired iliac crest biopsy samples from 30 patients with primary hypoparathyroidism, PTH treatment of hypoparathyroidism was related to a rise within the remodeling rate in both trabecular and cortical compartments with tunneling resorption within the trabecular compartments These findings suggest that PTH restores bone metabolism to levels more typical of euparathyroid individuals. Recombinant human PTH isn’t yet approved to be used in hypoparathyroidism, primarily since the long-term safety of this dose (relative to its skeletal effects) has not been established, particularly in growing children who is also at greater risk of osteosarcoma. additionally, recombinant PTH is way costlier than standard therapy with calcitriol and calcium. Thyroidectomy or parathyroidectomy — Hypocalcemia could be a common problem after total or near-total thyroidectomy and partial or total parathyroidectomy in patients with primary hyperparathyroidism. As an example, hypoparathyroidism is that the most frequent complication of near-total thyroidectomy. Transient hypoparathyroidism occurs in up to twenty percent of patients after surgery for thyroid cancer and permanent hypoparathyroidism occurs in 0.8 to 3.0 percent of patients after total thyroidectomy, particularly when the goiter is extensive and anatomic landmarks are displaced and obscured. The management of post-thyroidectomy hypoparathyroidism is reviewed elsewhere. vitamin D deficient patients undergoing parathyroidectomy are at increased risk for developing postoperative hypocalcemia and hungry bone syndrome [ 21 ]. Hungry bone syndrome most frequently occurs in hyperparathyroid patients who developed bone disease preoperatively because of a chronic increase in bone resorption induced by high levels of PTH (osteitis fibrosa). In these patients, calcium is avidly obsessed by the demineralized bone after surgery, and calcium supplementation is required to take care of a standard serum calcium concentration. vitamin D deficient postparathyroidectomy patients may require prolonged, massive calcium and D therapy thanks to hungry bone syndrome. Hypoparathyroidism during pregnancy   — Special care should be taken within the management of girls with hypoparathyroidism during pregnancy and following delivery. There are conflicting data on whether calcitriol requirements fall or don’t fall during pregnancy On the opposite hand, there’s uniform agreement that calcitriol requirements decrease during lactation Serum concentrations of 1,25-dihyroxyvitamin D (calcitriol) double during a traditional pregnancy. However, intact PTH concentrations remain low-to-normal, suggesting that PTH doesn’t mediate the late partum rise in 1,25-dihydroxyvitamin D (1,25D) production. the rise in serum 1,25D is also regulated by other pregnancy hormones, which are normal in hypoparathyroid women, like PTH-related protein (PTHrP), prolactin, estrogen, and placental hormone Thus, serum calcium concentrations should be measured frequently during late pregnancy and lactation in women with hypoparathyroidism who may have an increase in serum calcium, requiring a decrease in calcitriol dose If the calcitriol dose isn’t reduced, the mix of elevated serum 1,25D and PTHrP can result in increases in intestinal absorption and bone resorption and hypercalcemia [ 28 ]. the necessity for calcitriol will return to antepartum levels with cessation of lactation.

Autosomal dominant hypocalcemia

— Autosomal dominant hypocalcemia could be a rare disorder caused by an activating mutation within the calcium-sensing receptor (CaSR). Increased activity of this receptor within the renal tubules ends up in normal or high urinary calcium excretion despite hypocalcemia; raising the patient’s serum calcium concentrations with cholecarciferol may result in additional hypercalciuria, nephrocalcinosis, and renal disorder. Fortunately, most patients with this disorder have few if any symptoms of hypocalcemia and frequently require little or no therapy. When approved, recombinant human parathormone , which reinforces calcium absorption within the tubules, could also be an alternate if therapy is required. It can raise the serum calcium concentration during this disorder with a coffee risk of exacerbating hypercalciuria. Alternatively, calcilytics, a category of medication in development that inhibit the CaSR, may provide a useful therapeutic approach within the future.

cholecarciferol deficiency

— Nutritional cholecarciferol deficiency is often treated with 50,000 international units of vitamin D2 or D3 weekly for 6 to eight weeks. Chronic renal disorder   — Few patients with chronic nephropathy have symptomatic hypocalcemia. Such patients are often treated with oral calcium to bind intestinal phosphate and to stop bone disease instead of hypocalcemia in and of itself. The addition of a vigorous sort of viosterol is required in a number of these patients. These issues are discussed very well elsewhere Hypercatabolic state — Unless they’re symptomatic from hypocalcemia (eg, tetany or cardiac arrhythmia), patients with acute hypocalcemia and hyperphosphatemia thanks to a hypercatabolic state like the tumor lysis syndrome or massive trauma mustn’t be treated with calcium until the hyperphosphatemia is corrected to stop calcium-phosphate precipitation. Hemodialysis is commonly indicated in such patients who have symptomatic hypocalcemia.

  • Pseudohypoparathyroidism  — Pseudohypoparathyroidism (PHP) refers to a bunch of heterogeneous disorders defined by targeted organ (kidney and, perhaps, bone) unresponsiveness to PTH . it’s characterized by hypocalcemia, hyperphosphatemia, and in contrast to hypoparathyroidism, elevated instead of reduced PTH concentrations. The clinical manifestations and diagnosis of this disorder are reviewed elsewhere The long-term treatment of hypocalcemia in adults with pseudohypoparathyroidism is analogous to the treatment of hypocalcemia caused by other kinds of hypoparathyroidism. However, patients with pseudohypoparathyroidism infrequently develop hypercalciuria with calcium and fat-soluble vitamin therapy Therefore, the goal of treatment with calcium and ergocalciferol is to keep up normocalcemia (rather than low-normal serum calcium as for other types of hypoparathyroidism). A typical starting dose of calcitriol is 0.25 mcg twice daily. The dose should be increased weekly to realize a standard serum calcium. Many patients require up to 2 mcg daily Approximately 1 to 2 gm of elemental calcium daily (in divided doses) is usually recommended. Patients with pseudohypoparathyroidism can also require screening for other endocrinopathies, particularly hypothyroidism and hypogonadism.

INFORMATION FOR PATIENTS

— UpToDate offers two varieties of patient education materials, “The Basics” and “Beyond the fundamentals.” the fundamentals patient education pieces are written in plain language, at the 5 th to six th grade reading level, and that they answer the four or five key questions a patient may need a few given condition. These articles are best for patients who desire a general overview and preferring short, easy-to-read materials. Beyond the fundamentals patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the ten th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to the current topic. We encourage you to print or e-mail these topics to your patients. (You also can locate patient education articles on a range of subjects by searching on “patient info” and also the keyword(s) of interest.) SUMMARY and proposals Calcium   — The treatment of hypocalcemia varies with its severity and also the underlying cause.

  • Patients with hypocalcemia who are severely symptomatic (carpopedal spasm, tetany, seizures, decreased cardiac function, or prolonged QT interval) require rapid correction of calcium levels with IV calcium therapy. We also suggest IV calcium therapy in asymptomatic patients with an acute decrease in serum corrected calcium to ≤7.5 mg/dL (1.9 mmol/L) Intravenous calcium isn’t warranted as initial therapy for asymptomatic hypocalcemia in patients with impaired renal function in whom correction of hyperphosphatemia and of low circulating 1,25-dihyroxyvitamin D are usually the first goals.
  • For those with milder symptoms of neuromuscular irritability (paresthesias) and corrected serum calcium concentrations greater than 7.5 mg/dL (1.9 mmol/L), initial treatment with oral calcium supplementation is sufficient. If symptoms don’t improve with oral supplementation, intravenous calcium infusion is required.
  • To effectively treat hypocalcemia in patients with concurrent magnesium deficiency, hypomagnesemia should be corrected first. Vitamin D

— When hypoparathyroidism (transient or permanent) or fat-soluble vitamin deficiency are the explanation for hypocalcemia, administration of intravenous calcium is merely transiently effective (as long because the infusion continues), and oral calcium might not be absorbed. In these cases, successful management requires the addition of D, which frequently permits a lower dose of calcium supplementation.

  • For the initial management of patients with hypoparathyroidism, we recommend cholecarciferol supplementation additionally to calcium ). Calcitriol is that the viosterol metabolite of choice because it doesn’t require renal activation, it’s a rapid onset of action (hours), and a shorter half-life. Other acceptable options include alfacalcidol, calciferol (ergocalciferol or cholecalciferol), or dihydrotachysterol
  • In individuals with hypocalcemia thanks to cholecarciferol deficiency, we recommend cholecarciferol repletion Nutritional deficiency (25OHD <20 ng/mL [50 nmol/L]) requires initial treatment with 50,000 units of vitamin D2 or D3 orally once per week for 6 to eight weeks, then 800 to 1000 international units of vitamin D3 daily thereafter. Permanent hypoparathyroidism
  • In patients with permanent hypoparathyroidism, the goals of therapy are to alleviate symptoms, to lift and maintain the serum calcium concentration within the low-normal range (eg, 8.0 to 8.5 mg/dL [2.0 to 2.1 mmol/L]), and to avoid hypercalciuria (maintain 24-hour urinary calcium below 300 mg
  • All patients with permanent hypoparathyroidism require adequate calcium intake (1.0 to 1.5 g elemental calcium daily).
  • Along with calcium supplementation, we recommend calcitriol instead of recombinant human parathormone (PTH) The long-term safety of PTH has not been established. additionally, recombinant PTH is far dearer than standard therapy with calcitriol. However, in patients with refractory hypercalciuria, PTH could be a reasonable option.
  • The initial treatment of hypercalciuria in patients with hypoparathyroidism is reducing the dose of calcium and fat-soluble vitamin. Some patients would require the addition of thiazide diuretics.
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Calcium and D supplementation in osteoporosis

Dietary Supplements

Osteoporosis may be a disorder of bone characterized by reduced mineral density and bone mass. Multiple therapeutic regimens are designed to forestall or treat bone loss in postmenopausal women and also the elderly. the primary step within the prevention or treatment of osteoporosis is ensuring adequate nutrition, particularly maintaining an adequate intake of calcium and cholecarciferol. Adequate calcium and ergocalciferol nutrition is vital in people of all ages, especially in children and therefore the elderly within the latter group, as an example, the administration of calcium and viosterol reduces the speed of bone loss and will decrease fracture risk during this same population, calcium and D supplementation also reduces tooth loss Calcium and calciferol supplementation within the treatment of osteoporosis are reviewed here. Detailed information regarding pharmacologic therapy for osteoporosis and also the role of calcium within the pathogenesis of osteoporosis is discussed separately.

 EFFICACY

— Calcium and vitamin D are necessary for normal skeletal homeostasis. D enhances intestinal absorption of calcium. Low concentrations of D are related to impaired calcium absorption, a negative calcium balance, and a compensatory rise in internal secretion, which ends in excessive bone resorption.

Careful calcium balance studies have shown that calcium balance is said to calcium intake; the less calcium one takes in, the more negative the calcium balance. this will be reversed by increasing calcium intake and maintaining adequate fat-soluble vitamin stores. In general, calcium balance becomes positive at a mean calcium intake of 1000 mg/day in premenopausal women and 1500 mg/day in postmenopausal women who don’t take estrogen The importance of adequate calcium and viosterol intake for skeletal health is supported by several observational studies and by randomized trial data. Observational data — Many studies have shown an inverse relationship between serum concentrations of 25-hydroxyvitamin D (25OHD) and hormone (PTH) The maximal suppression of PTH by vitamin D is one criterion by which the optimal serum 25OHD concentration is defined. Estimates vary widely but range from 20 to 40 ng/mL (50 to 100 nmol/L) Other experts support the thesis that suppression of PTH by 25OHD follows a continuum across a large range of viosterol concentrations, and levels above 20 ng/mL are capable suppress PTH, assuming normal renal function The compensatory rise in hormone, which occurs within the setting of low calciferol, leads to excessive bone resorption. Many studies, including an outsized population-based study (NHANES-III) that included 13,432 participants, have shown a positive association between serum 25OHD and bone mineral density additionally, in an exceedingly prospective cohort study of 1279 community-dwelling older men, those with 25OHD <20 ng/mL (50 nmol/L) had significantly higher rates of hip bone loss over time (approximately 0.5 compared with 0.3 percent/year in men with serum 25OHD >20 ng/mL In several but not all observational studies, lower serum concentrations of 25-hydroxyvitamin D (25OHD, calcidiol) were related to the next risk of hip fracture. In one in every of the most important of those studies, 400 women with hip fracture were compared with 400 matched controls and followed for seven years The mean serum 25OHD concentrations measured at study entry were significantly lower in patients who subsequently had a hip fracture (22 versus 24 ng/mL [56 versus 60 nmol/L]) The increased risk of hip fracture was most apparent in women with very cheap serum 25OHD concentrations (OR 1.7, 95% CI 1.0-2.8 for girls in quartile one [<19 ng/mL (47.5 nmol/L)]) compared with women in quartile four (>28 ng/mL [70.7 nmol/L]). Similar findings were reported in men (hazard ratio 2.36, 95% CI 1.08-5.15 for men within the lowest versus highest quartile of total 25OHD) additionally to hip fracture, serum 25OHD concentrations below 20 ng/mL (30 nmol/L) are related to the next risk of other osteoporotic fractures, including vertebral, wrist, and proximal humerus fractures in a very prospective cohort study of elderly Swedish men (mean age 71 years), serum 25OHD levels below 16 ng/mL (40 nmol/L) were related to a modestly increased risk for fracture (HR 1.65, 95% CI 1.09-2.49 within the aggregate, these observations suggest that calcium and D supplementation could protect bone by preventing bone loss and by healing subclinical osteomalacia. Although the optimal serum 25OHD concentration to keep up skeletal health isn’t firmly established, serum values exceeding 19 to 24 ng/mL (47.5 to 60 nmol/L) are supported by observational studies Randomized trial data — Evidence supporting the advantage of calcium and D supplementation in patients with osteoporosis comes largely from prospective, randomized, placebo-controlled trials Although variety of trials have reported a beneficial effect of calcium or calcium plus cholecarciferol on bone density in postmenopausal women and older men the information on fracture rates are more variable Some trials have reported a discount in fracture but large randomized trials haven’t shown any reduction in fracture risk with calcium plus viosterol In the most important of those trials (Women’s Health Initiative), however, subgroup analysis revealed that calcium and calciferol supplementation was related to reduced fracture incidence in those subjects who were most compliant The Women’s Health Initiative trial randomly assigned 36,282 postmenopausal women ages 50 to 69 years (not selected for low bone density or osteoporosis) to calcium (1000 mg/day) plus D (400 int. units/day) or placebo (personal supplementation of up to 1000 mg additional calcium and 600 units fat-soluble vitamin was also allowed, as was bisphosphonate, calcitonin, and hormone therapy use [over one-half of subjects were taking hormone therapy the subsequent results were seen: • After a mean follow-up period of seven years in a very subset of girls who had bone mass measurements performed, hip bone mineral density was 1.06 percent higher within the calcium-vitamin D group compared with the placebo group.

• The risk of hip fracture with calcium-vitamin D (intention-to-treat analysis) was not up to placebo although this wasn’t statistically significant (HR 0.88, 95% CI 0.72-1.08). However, when only compliant subjects were analyzed (predefined as people who took over 80 percent of medication), a big decrease in hip fracture was seen (HR 0.71, 95% 0.52-0.97).

• In all subjects, the danger of kidney stones was increased with calcium-vitamin D supplementation (HR 1.17. 95% CI 1.02-1.34). The trial had variety of limitations: a greater fracture reduction may need been seen if subjects had been selected on the premise of low bone density or low calcium/vitamin D intake at baseline. additionally, the high percentage of ladies taking hormone therapy may have made it difficult to determine an impression of the calcium-vitamin D on bone, and lastly, the ergocalciferol supplementation may are too low

Calcium versus D

— In many of those trials, it’s difficult to differentiate the effect of calcium from that of viosterol. Randomized trials of calcium only or cholecarciferol only have shown mixed results, likely because of differences in patient populations and study design. A meta-analysis of 5 trials comparing fat-soluble vitamin (400 to 1370 units/day) with placebo in over 14,500 elderly men and ladies reported that cholecarciferol supplementation alone failed to reduce fracture risk (RR 1.03, 95% CI 0.84-1.26) within the same review, a separate meta-analysis of 11 trials comparing calcium (500 to 1200 mg/d) plus cholecarciferol (300 to 1100 units/day) with placebo showed that combined supplementation reduced the danger for total fractures (RR 0.88, 95% CI 0.78-0.99 in a very subgroup analysis, the danger reduction was larger among institutionalized elderly than community dwelling individuals (RR 0.71 versus 0.89) Other meta-analyses of trials comparing calcium, vitamin D, or both with placebo or no treatment reported a beneficial reduction in fracture with calcium and calcium plus ergocalciferol but not with D alone Relative risk reductions for hip fracture ranged from 0.81 to 0.87 for combined calcium plus D supplementation These findings suggest that supplementation with both calcium and calciferol reduces the danger of fracture.

 OPTIMAL INTAKE

— The optimal dose of calcium and vitamin D is uncertain. during a number of trials that reported a beneficial effect of calcium on bone density in postmenopausal women and older men, calcium supplement doses ranged from 500 to 1200 mg daily Baseline calcium from diet varied from approximately 600 to 1000 mg daily. Thus, total (diet plus supplement) calcium intake ranged from approximately 1100 to 2000 mg daily. a good range of ergocalciferol doses were utilized in the clinical trials. a number of the trials were designed to review intermittent dosing of viosterol, specifically 100,000 units administered every three to four months whereas others used 400 units of cholecarciferol daily One meta-analysis of randomized trials didn’t show differential effects on fracture risk reduction based upon the dose of viosterol However, another analysis showed a big effect of vitamin D dose when the particular fat-soluble vitamin intake (rather than assigned fat-soluble vitamin dose) was calculated during this pooled analysis of patient level data from 11 randomized trials (31,022 persons, mean age 76 years) of oral viosterol supplementation, with or without calcium, compared with placebo or calcium alone, there was a major reduction in incidence of hip (RR 0.70, 95% CI

0.58-0.86) and nonvertebral (RR 0.86, 95% CI 0.76-0.96) fracture within the individuals with the very best calculated actual vitamin D intake (median 800 units daily, range 792 to 2000 units daily) compared with controls. There was no reduction in risk of hip fracture at actual intake levels but 792 units daily. only a few of the trials included within the meta-analysis provided information on baseline and follow-up serum 25-hydroxyvitamin D levels and, therefore, the optimal serum 25-hydroxyvitamin D concentration for fracture prevention couldn’t be established. In two placebo-controlled trials of high-dose (300,000 to 500,000 units) viosterol administered once yearly (without calcium supplementation), vitamin D didn’t reduce the chance of fracture In one in all the trials, the chance of falls and fracture was increased within the fat-soluble vitamin group (RRs 1.15, 95% CI 1.02-1.30 and 1.26, 95% CI 1.00-1.59 for falls and fracture, respectively) within the ergocalciferol group, the median 25OHD concentrations after one and three months were approximately 48 and 36 ng/mL (120 and 90 nmol/L), respectively. Based upon the meta-analyses discussed above, we recommend 1200 mg of calcium (total of diet and supplement) and 800 int. units of fat-soluble vitamin daily for many postmenopausal women with osteoporosis. Although the optimal intake (diet plus supplement) has not been clearly established in premenopausal women or in men with osteoporosis, 1000 mg of calcium (total of diet and supplement) and 400 to 600 int. units of vitamin D daily are generally suggested. We recommend not administering yearly high-dose (eg, 500,000 units) D. These recommendations are in step with the Institute of drugs Dietary Reference Intakes for calcium and vitamin Certain coexisting medical problems may alter these requirements. In patients at very high risk for fracture in whom there’s a clinical suspicion that the standard doses are inadequate (malabsorption, decreasing bone mass), measurement of 25OHD concentrations could also be necessary to make sure that supplementation is adequate. Commercial assays measure total 25OHD, but some labs report vitamin D2 (25OHD2) and D3 (25OHD3) values separately. The optimal serum concentration refers to the combined total. The optimal serum 25OHD concentration for skeletal health is controversial. The Institute of drugs supports 25OHD concentrations above 20 ng/mL (50 nmol/L) but not chronically exceeding 50 ng/mL (125 nmol/L) the next serum concentration could also be necessary for skeletal benefits, particularly in older individuals at greater risk. Thus, some patients require quite 800 units daily to take care of serum levels of 30 to 40 ng/mL (75 to 100 nmol/L Optimal serum 25OHD concentrations are discussed in additional detail elsewhere. Optimal intake may be achieved with a mixture of diet plus supplements. Calcium appears to be also absorbed from supplements as from milk and supplements were employed in the above trials demonstrating get pleasure from increased calcium intake. it’s likely, therefore, that supplements aren’t less effective than calcium found naturally in dairy products. it’s important for patients to remember that calcium and calciferol alone are probably insufficient to forestall bone loss although they’ll be beneficial in some subgroups (the elderly, those with low intake at baseline). ergocalciferol supplementation is important for variety of other reasons independent of bone health; these are reviewed separately .

DIETARY SOURCES Calcium

— A rough method of estimating dietary calcium intake is to multiply the quantity of dairy servings consumed per day by 300 mg. One serving is 8 oz (240 mL) of milk or yogurt or 1 oz of bad luck. farmer’s cheese and frozen dessert contain approximately 150 mg of calcium per 4 oz (120 mL). Other foods during a well-balanced diet (dark green vegetables, some nuts, breads, and cereals) supply a median of 100 mg of calcium daily Some cereals, soy products, and fruit juices are fortified with up to 1000 mg of calcium. While it’s possible to estimate the quantity of calcium in other sources of dietary calcium like green vegetables and nuts, calcium absorption from these sources is more variable.

additionally, vegetables and nuts have much lower calcium content than dairy products in order that way more would wish to be consumed to fulfill daily requirements. Detailed lists of the calcium content of assorted foods are available from the US Department of Agriculture Calcium supplements or increased intake of dairy products should be recommended if dietary calcium intake is below recommended levels. If supplements are needed, it’s important to notice that the intake suggested above reflects the quantity of elemental calcium in supplements, not the entire calcium content. additionally, the overall intake of calcium (diet plus supplements) shouldn’t routinely exceed 2000 mg/day due to the chance of adverse effects ergocalciferol — within the u. s., commercially fortified milk is that the largest source of dietary ergocalciferol, containing approximately 100 int. units of calciferol per 8 oz Thus, cholecarciferol intake is estimated by multiplying the quantity of cups of milk consumed per day by 100. viosterol is additionally found in cod liver oil, but some fish oils also contain high doses of antiophthalmic factor, and so they’re not the most effective source of ergocalciferol Sunlight exposure also increases vitamin D concentrations. However, the employment of sunscreen products effectively blocks vitamin D synthesis. additionally, the skin of these older than 70 years old doesn’t convert D as efficiently as in younger individuals. Thus, fat-soluble vitamin supplements are generally necessary. The safe upper limit for calciferol is unclear but is above 2000 units daily.

SUPPLEMENTS

— In patients requiring calcium and calciferol supplementation, a daily multivitamin is both convenient and economical. However, most multivitamins contain only 400 int. units of fat-soluble vitamin, which is insufficient, and not all individuals require or tolerate multivitamins .) Postmenopausal women with osteoporosis can even increase viosterol and calcium intake by taking plain ergocalciferol supplements (usually 400 units per tablet) and/or calcium supplements that also contain fat-soluble vitamin, usually 200 units per 500 mg or 600 mg of calcium. it’s important to notice that there’s not an instantaneous linear relationship between supplemental dosing and level of serum 250HD. Individuals with low levels at baseline (<10 ng/mL) generally have a rise in 250HD of 1.0 to 1.5 ng/mL for each 100 IU of vitamin D; however, individuals at levels above 20 ng/mL show an attenuated increase in serum 250HD (ie, usually 0.5 ng/mL for each 100 units). Calcium — the foremost widely available calcium supplements are carbonate and calcium citrate carbonate is cheapest and thus often a decent first choice. However, there are some limitations to its use compared with calcium citrate:

  • Calcium carbonate absorption is healthier when crazy meals; compared, calcium citrate is well absorbed within the fasting state and is best or equally absorbed compared with carbonate dotty a meal. this could be particularly important in patients with achlorhydria. Thus, it seems prudent to require carbonate with meals, since it’s often hard to grasp who has achlorhydria.
  • Calcium carbonate is additionally poorly absorbed in patients taking proton pump inhibitors or H2 blockers. We usually recommend calcium citrate as a primary line calcium supplement in these patients.
  • Many natural carbonate preparations like oyster shells or bone meal contain some lead, and tiny amounts are present in refined (antacid) carbonate or calcium citrate The low lead levels in calcium supplements are unlikely to be a health risk, because calcium blocks lead absorption Dosing  — The intake recommendations given above seek advice from the number of elemental calcium . As an example, carbonate is 40 percent elemental calcium, in order that 1250 mg of carbonate contains 500 mg of elemental calcium. The dose of elemental calcium is listed on most supplement labels. Calcium supplementation in more than 500 mg/day should be in divided doses. Higher individual doses are related to a plateau in calcium absorption that will prevent the attainment of positive calcium balance Side effects   — normally, concern that prime dietary calcium increases the chance of nephrolithiasis in otherwise healthy patients is unfounded, because the incidence of stone formation appears to be reduced in both men and ladies This issue is discussed well separately. However, calcium supplements are related to an increased risk of kidney stones . The Women’s Health Initiative (WHI) trial described above also reported an increased risk of kidney stones in postmenopausal women who were supplemented with calcium and cholecarciferol compared with placebo Other potential side effects of high calcium intake include dyspepsia and constipation. additionally, calcium supplements interfere with the absorption of iron and hormone and, therefore, these medications should be taken at different times. The effect of calcium supplementation on risk of upset is controversial There is also benefits of calcium supplementation on risk factors, like a discount in weight, pressure, and in serum cholesterol concentrations (of about 5 percent) in patients with mild to moderate hypercholesterolemia. .) within the WHI trial described above, 36,282 postmenopausal women ages 50 to 69 years were randomly assigned to calcium (1000 mg/day) plus fat-soluble vitamin (400 int. units/day) or placebo (personal supplementation of up to 1000 mg additional calcium and 600 units viosterol was also allowed) upset was a prespecified secondary outcome . At baseline, mean calcium intake (diet plus supplements) was approximately 1150 mg/day, and 54 percent of participants were taking non-protocol calcium supplements. After seven years, calcium plus viosterol supplementation had no significant effect on the incidence of myocardial infarct (confirmed in 411 and 390 women assigned to calcium/vitamin D and placebo, respectively; HR 1.05, 95% CI 0.91-1.20) or stroke (362 versus 377 strokes, HR 0.95, 95% CI 0.82-1.10). However, the findings of two meta-analyses evaluating calcium or calcium with or without ergocalciferol supplementation (eight and nine trials, respectively) raised some concern about an increased risk of infarct (MI) in patients randomly assigned to calcium versus placebo (166 versus 130 MIs, pooled relative risk 1.27, 95% CI 1.01-1.59) or calcium with or without D versus placebo (374 versus 302 MIs, RR 1.24, 95% CI 1.07-1.45 . The meta-analyses had several limitations. The trials within the meta-analyses weren’t designed to explore cardiovascular outcomes, which weren’t uniformly collected or adjudicated. Patient level data weren’t available from all the trials. In one in all the meta-analyses, only data from a subgroup of participants within the Women’s Health Initiative (those not taking personal calcium supplements at randomization), instead of all participants, were included within the analysis The baseline dietary calcium intake within the trials ranged from 750 to 1240 mg daily and therefore the addition of calcium supplements raised total intake over 1500 to 2000 mg daily in many patients, which is on top of recommended. Another meta-analysis evaluated the consequences of supplementation with calcium, vitamin D, or both on upset (CVD), including CVD death, nonfatal coronary cardiopathy or MI, and nonfatal stroke in a very pooled analysis of 4 trials, calcium supplementation failed to significantly increase the chance of CVD events compared with placebo (RR 1.14, 95% CI 0.92-1.41). In these trials, dietary intake of calcium ranged from 800 to 900 mg daily and also the dose of calcium supplements ranged from 600 to 1200 mg daily. during a pooled analysis of two trials (one of which was the Women’s Health Initiative and included data from all participants), combined vitamin D and calcium supplementation versus double placebos (RR 1.04, 95% CI 0.92-1.18) and ergocalciferol alone compared with placebo (RR 0.90, 95% CI 0.77-1.05) also failed to significantly increase the danger of CVD, and there was a suggestion of a benefit in CVD reduction with vitamin D alone. As within the meta-analyses described above, none of the trials were designed to assess the consequences of calcium or cholecarciferol on cardiovascular outcomes. A prospective cohort study (23,980 participants with mean follow-up of 11 years) published after the meta-analyses showed a big reduction in MI risk in patients with higher versus lower total dietary calcium intake (HR 0.69, 95% CI 0.50-0.94 for the third compared with lowest quartile of total dietary calcium intake) . in an exceedingly separate analysis using the identical cohort, there was a big increased risk of myocardial infarct in users versus nonusers of calcium supplements (HR 1.86, 95% CI 1.17-2.96). However, there have been only 20 events within the calcium group, which reduced the precision of the analysis. Thus, it’s unclear from the current data whether intake of dietary calcium versus calcium supplements confers different cardiovascular risks. Randomized trials of calcium and vitamin D supplementation with CVD events ascertained as a primary endpoint are required to see if calcium supplementation is related to an increased occurrence of those events . within the interim, we advise combined calcium and vitamin D supplementation, as reviewed above Vitamin D  — D is mostly easier to soak up than calcium and it should be taken together dose with or without food. the 2 commonly available varieties of fat-soluble vitamin supplements are ergocalciferol and cholecalciferol. Some but not all studies suggest that cholecalciferol (vitamin D3) increases serum 25OHD more efficiently than does ergocalciferol (vitamin D2 . additionally, ergocalciferol2 isn’t accurately measured all told vitamin D assays For these reasons, we recommend supplementation with cholecalciferol when possible, instead of ergocalciferol. Calcitriol is that the most active metabolite of ergocalciferol. It can frequently cause hypercalcemia and/or hypercalciuria, necessitating close monitoring and adjustment of calcium intake and calcitriol dose. Therefore, we don’t recommend calcitriol for fat-soluble vitamin supplementation in osteoporosis. However, calcitriol or other D analogs are a crucial component of therapy for secondary hyperparathyroidism in chronic nephrosis .)

 Adverse effects

— The intake at which the dose of D becomes toxic isn’t clear. In 2010, the Institute of medication defined the Safe Upper Limit for viosterol as 4000 int. units per day However, higher doses are sometimes required for the initial treatment of viosterol deficiency. .) it’s important to inquire about additional dietary supplements (some of which contain viosterol) that patients could also be taking before prescribing extra vitamin D [ 83 ]. Excessive D, especially combined with calcium supplementation, may cause hypercalcemia, hypercalciuria, and kidney stones. additionally, chronically high levels of 250HD (exceeding 40 and 50 ng/mL [100 and 125 nmol/L], respectively) are found in some association studies to be linked to a modest increase in risk of some cancers (eg, pancreatic) and mortality. and “Vitamin D and extraskeletal health”, section on ‘Mortality’ .) More studies are needed to define the upper level of serum 250HD that’s safe. Coexisting medical problems   — Many individuals with osteoporosis have underlying medical conditions that predispose to osteoporosis. Recommendations for calcium and viosterol supplementation may vary with the underlying condition

. fat-soluble vitamin deficiency

— viosterol deficiency may result from inadequate intake combined with lack of sun exposure, malabsorption, or genetic abnormalities in vitamin D metabolism. viosterol deficiency or insufficiency is commonly overlooked, unless 25OHD concentrations are measured. Commonly used antiresorptive agents, like bisphosphonates, could also be less effective in patients with occult cholecarciferol deficiency. additionally, hypocalcemia can occur in patients with D deficiency who are treated with bisphosphonates, particularly when administered intravenously, before repletion of fat-soluble vitamin Individuals with ergocalciferol deficiency generally require higher doses of viosterol initially, followed by maintenance doses as described above. The treatment of calciferol deficiency is reviewed separately Primary hyperparathyroidism   — Adequate dietary calcium (800 to 1000 mg daily) and viosterol supplementation (400 to 600 units daily) is inspired for patients with primary hyperparathyroidism. Cautious calcium supplementation is safe in individuals with poor dietary intake. Patients with overt calciferol deficiency may have more clinically significant hyperparathyroidism and will require cautious supplementation with higher doses of vitamin D Underlying gastrointestinal disease   — Patients with malabsorption or short-bowel syndrome may have beyond normal calcium and calciferol requirements thanks to diminished calcium absorption. This problem can occur even with relatively minor disruption of gastrointestinal function, as in patients who have undergone gastrectomy Several factors can contribute to the malabsorption of calcium in these patients:

  • Reduced gastric acidity and mild generalized malabsorption thanks to impaired mixing of food with pancreatic secretions and decreased gut transit time.
  • Binding of calcium to fatty acids in patients with steatorrhea
  • Vitamin D deficiency because of both malabsorption and also the tendency to avoid milk Optimal calcium and D supplementation must be determined empirically and must be adjusted so as to normalize the serum concentrations of calcium, phosphate, alkaline phosphatase, 25OHD, and endocrine, and 24-hour urinary calcium excretion The American Gastroenterological Association (AGA) technical review and guideline for osteoporosis in gastrointestinal diseases yet as other AGA guidelines, will be accessed through Proton pump inhibitor therapy  — carbonate is poorly absorbed in patients taking proton pump inhibitors or H2 blockers. We usually recommend calcium citrate as a primary line calcium supplement in these patients. Diuretic therapy  — Concomitant administration of diuretics can influence calcium balance. Loop diuretics increase calcium excretion, while thiazide diuretics have a hypocalciuric effect that may protect against calcium stones and possible bone loss. The effect of diuretics on optimal dietary calcium intake isn’t known. monogenic disorder   — Patients with advanced monogenic disorder are usually deficient in ergocalciferol, and that they require quite the standard recommended dose for young adults (eg, over 400 int. units/day).

Granulomatous diseases

— Individuals with granulomatous diseases, like sarcoidosis, are often treated with glucocorticoids and thus have an increased risk of osteoporosis. However, they also tend to own hypercalcemia and hypercalciuria because of extrarenal production of calcitriol by activated macrophages and consequent increased intestinal absorption of calcium In patients with sarcoidosis and osteoporosis, serum and urinary calcium and ergocalciferol concentrations must be carefully monitored if supplements are required

 INFORMATION FOR PATIENTS

 

— UpToDate offers two varieties of patient education materials, “The Basics” and “Beyond the fundamentals.” the fundamentals patient education pieces are written in plain language, at the 5 th to six th grade reading level, and that they answer the four or five key questions a patient might need a couple of given condition. These articles are best for patients who need a general overview and preferring short, easy-to-read materials. Beyond the fundamentals patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the ten th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to the current topic. We encourage you to print or e-mail these topics to your patients. (You also can locate patient education articles on a spread of subjects by searching on “patient info” and also the keyword(s) of interest.) SUMMARY and proposals   — Adequate calcium and cholecarciferol intake may end up in positive calcium balance and a discount within the rate of loss of bone; the effect upon fracture risk is a smaller amount clear, although combined calcium and calciferol supplementation appears to cut back fracture risk. Calcium and viosterol supplementation are relatively inexpensive and appear reasonable to recommend in patients with a coffee dietary intake.

  • We suggest calcium and D supplementation in patients with osteoporosis and inadequate dietary intake In postmenopausal women, 1200 mg of elemental calcium daily, total diet plus supplement, and 800 int. units of calciferol daily are suggested. Although the optimal intake (diet plus supplement) has not been clearly established in premenopausal women or in men with osteoporosis, 1000 mg of calcium (total diet plus supplement) and 400 to 600 int. units of calciferol daily are generally suggested. The dose of calcium and cholecarciferol may vary in individuals with coexisting medical conditions.
  • Individuals with cholecarciferol deficiency require higher doses of ergocalciferol. The evaluation and treatment of fat-soluble vitamin deficiency are reviewed separately
  • In most people, carbonate loving meals is adequate for supplementation and is inexpensive. However, we recommend calcium citrate in patients taking proton pump inhibitors or H2 blockers or who have achlorhydria
  • We suggest cholecalciferol (vitamin D3), when available, instead of ergocalciferol (vitamin D2) for calciferol supplementation
  • The total intake of calcium (diet plus supplements) mustn’t routinely exceed 2000 mg/day. The safe upper limit for D is 4000 int. units daily
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Surgical management of severe obesity

Remedies

 

Obesity is defined as body mass index (BMI) >30 kg/m 2 . Obesity is increasing in prevalence in the United States and worldwide   Centers for Disease Control and Prevention (CDC) data on obesity show a steady and appreciable increase in obesity in the United States from 1985 to 2008   More than 33 percent of adults in the United States (approximately 72 million people) are obese [ 4,5 ]. Furthermore, more than 64 percent of Americans are overweight (BMI ≥25 kg/m 2 ).

The economic costs of obesity are staggering   The cost of treating obesity and its complications in the United States is approximately 100 billion dollars per year   . Additionally, obesity and its complications lead to other significant costs, such as missed days of work and a decrease in life expectancy   Similar trends have been reported in other parts of the world

There are several well-established health hazards associated with obesity, including type 2 diabetes, heart disease, stroke, certain cancers, osteoarthritis, liver disease, obstructive sleep apnea, and depression  . The risk of development of complications rises with increasing adiposity, while weight loss can reduce the risk.

There are many behavioral, medical, and surgical options for achieving weight loss. Bariatric surgical procedures are increasingly common. Data from the Nationwide Inpatient Sample from 2003 through 2008 documented that the number of bariatric operations in the United States peaked in 2004 at 135,985 cases and plateaued at 124,838 cases in 2008

This topic review will focus on surgical procedures, which have been collectively referred to as “bariatric” surgery (from the Greek words “baros” meaning “weight” and “iatrikos” meaning “medicine”. Complications of bariatric procedures are discussed elsewhere.

The general approach to the management of obesity and clinical practice guidelines from the American College of Physicians for management of obesity in primary care are discussed elsewhere.

BODY MASS INDEX  —

Body mass index (BMI) is considered to represent the most practical measure of a person’s adiposity. It is calculated by dividing the weight in kilograms by the height in meters squared (kg/m 2  ). In adults, a BMI of:

  • 25 to 29.9 kg/m 2 is considered overweight
  • 30 to 34.9 kg/m 2 is considered obese (class I obesity)
  • 35 to 39.9 kg/m 2 is considered moderately obese (class II obesity)
  • 40 to 49.9 kg/m 2 is considered severely or extremely obese (class III obesity)
  • >50.0 kg/m 2 is considered super obese (class IV obesity)

MECHANISM OF WEIGHT LOSS 

— Bariatric surgical procedures affect weight loss through two fundamental mechanisms: (1) malabsorption and (2) restriction   Some procedures have both a restrictive and malabsorptive component. There is also growing recognition that bariatric surgical procedures contribute to neurohormonal effects on the regulation of energy balance

Restriction  — Restrictive procedures limit caloric intake by reducing the stomach’s reservoir capacity via resection, bypass or creation of a proximal gastric outlet. Vertical banded gastroplasty (VBG) and laparoscopic adjustable gastric banding (LAGB) are purely restrictive procedures, and share similar anatomical configurations. Both limit solid food intake by restriction of stomach size as the only mechanism of action, leaving the absorptive function of the small intestine intact. Although these procedures are simpler in comparison to malabsorptive procedures, they tend to produce more gradual weight loss.

Malabsorption  — Malabsorptive procedures decrease the effectiveness of nutrient absorption by shortening the length of the functional small intestine, either through bypass of the small bowel absorptive surface area or diversion of the biliopancreatic secretions that facilitate absorption. Jejunoileal bypass (JIB) and the duodenal switch operation (DS) are examples of malabsorptive procedures. Profound weight loss can be achieved by a malabsorptive operation, depending upon the effective length of the functional small bowel segment. However, the benefit of superior weight loss can be offset by significant metabolic complications, such as protein calorie malnutrition and various micronutrient deficiencies.

Combination of restriction and malabsorption  — The Roux-en-Y gastric bypass (RYGB), the biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS) are both restrictive and malabsorptive. In the RYGB, a small gastric pouch limits oral intake. However, the small bowel reconfiguration provides additional mechanisms favoring weight loss including dumping physiology and mild malabsorption.

EFFECTIVENESS OF BARIATRIC SURGERY  — The goal of surgery is to reduce the morbidity and mortality associated with obesity, and to improve metabolic and organ function. Several studies have demonstrated that bariatric surgery is effective in reducing obesity-related comorbidities, while having additional benefits such as reducing monthly medication costs and the number of sick days, and improving quality of life   A significant reduction in overall and cause-specific mortality has also been clearly demonstrated  ]. Although there have been dramatic improvements in the safety of bariatric procedures in the past decade, bariatric surgery is not without serious risks, including significant perioperative complications and mortality

Reduction of comorbidities  — Meta-analyses have summarized data from numerous, mainly observational studies   Findings are summarized here:

  • Evidence supporting a benefit of bariatric surgery was strongest in patients with a BMI of >40, while the benefits in those with BMI of 35 to 39 were less clear
  • The mean overall percentage of excess weight lost was 61 percent, varying according to the specific bariatric procedure performed Excess weight loss refers to the difference between the preoperative BMI and a BMI of 25 kg/m 2 (depending upon the study). Greater weight loss was observed with gastric bypass procedures compared with gastroplasty
  • Overall mortality was less than 1 percent while adverse events occurred in approximately 20 percent of patients 30-day mortality was 0.1 percent for purely restrictive procedures (defined below), 0.5 percent for gastric bypass, and 1.1 percent for biliopancreatic diversion or duodenal switch
  • Diabetes completely resolved in 77 percent and resolved or improved in 86 percent.
  • Hyperlipidemia improved in 70 percent or more of patients.
  • Hypertension resolved in 62 percent and resolved or improved in 79 percent.
  • Obstructive sleep apnea resolved in 86 percent and resolved or improved in 84 percent.
  • Gastroesophageal reflux symptoms improved and complete or partial regression of Barrett’s esophagus has been demonstrated.
  • Urinary stress incontinence episodes decreased by 47 percent in women who achieved 8 percent weight loss

Reduction in mortality

  — The reduction in comorbidities appears to translate into a 29 percent reduction in mortality  . These findings were confirmed in a large cohort study, in which nearly 8000 patients who had undergone RYGB were matched to a similar sized obese cohort   Deaths from all causes were reduced by 40 percent, from diabetes by 92 percent, from coronary disease by 56 percent, and from cancers by 60 percent.

Although the majority of mortality data for bariatric surgery comes from patients under age 65, retrospective studies suggest that survival is improved, even in patients over age 65   However, most studies have included a primarily female population. In a retrospective study of 850 patients who were predominantly male (74 percent), bariatric surgery was not associated with improved survival in older severely obese patients after almost seven years of follow-up

Surgery compared to medical treatment 

— The striking benefits on important obesity-related morbidity contrast with relatively disappointing results in the management of severe obesity with medical and behavioral therapy. The Swedish Obese Subjects Trial (SOS) is the largest trial comparing surgical versus medical treatment of severe obesity. A total of 6328 obese (BMI >34 kg/m 2 for men and >38 kg/m 2 for women) subjects were recruited of whom 2010 underwent surgery for obesity (gastric banding, gastroplasty or gastric bypass) while 2037 chose conventional treatment. Although the study was not randomized, there was an attempt to match patients by relevant covariates. Begun in 1987, the SOS has spawned multiple publications; the following summarizes the major observations

  • Weight decreased by 23 percent after two years in the surgery group while it increased in the control group by 0.1 percent After 10 years, weight had decreased by 16 percent in the surgery group and increased in the control group by 1.6 percent. Energy intake was lower and the proportion of physically active subjects was higher in the surgery group.
  • The surgery group had better 2- and 10-year incidence rates of diabetes, hypertriglyceridemia, lowered HDL levels, improved hypertension and hyperuricemia rates.
  • Surgically treated patients were significantly less likely to require medications for cardiovascular disease or diabetes at two and six years Among those not already requiring such medications, surgery reduced the proportion of those who required initiation of treatment. Costs of medications were reduced significantly in the surgically treated group
  • Surgically treated patients had dramatic improvement in scores on validated measures of quality of life and psychiatric dysfunction compared with only minor and sporadic improvement in medically treated patients at two years The magnitude of benefit was related mostly to the degree of weight loss, which was greater in the surgical group. After 10 years of follow-up, the improvements in quality of life diminished somewhat in the surgery group due to weight regain, but overall outcome was still significantly better in the surgical than the medically treated group

The longer-term weight loss benefits of RYGB were confirmed by another population-based study. In a prospective study of 418 severely obese patients undergoing RYGB, 96 percent had maintained at six years more than 10 percent weight loss from baseline and 76 percent maintained more than a 20 percent weight loss  . The mean weight loss at six years was 27.7 percent (95% CI 26.6-28.9 percent). In comparison, there was no significant decrease from baseline weight at six years for 417 severely obese patients who sought surgical advice but did not undergo the operation, or for 321 randomly selected severely obese individuals from the general population. In addition, diabetes remission rates at six years were significantly higher for patients undergoing a RYGB compared with the patients seeking advice/not undergoing surgery and the population-based patients (62 versus 8 versus 6 percent, respectively). Patients undergoing RYGB also had better remission rates of hypertension (42 versus 18 versus 9 percent, respectively).

Treatment for type 2 diabetes

  — The predominantly observational studies described above have generated much interest in the role of weight loss surgery in the treatment algorithm of diabetes, with some suggesting that bariatric surgery is one of the best treatments for type 2 diabetes. Data from randomized trials comparing surgical versus medical therapy, specifically in obese patients with diabetes, have reported a significant rate of remission of diabetes, and the cost-effectiveness of surgery   In one trial, for example, 60 obese subjects (BMI between 30 and 40 kg/m 2 ), with type 2 diabetes diagnosed within the previous two years, were randomly assigned to conventional therapy (lifestyle modification and medical therapy) or laparoscopic adjustable banding and conventional therapy   Remission of diabetes occurred more often in the surgical group (73 versus 13 percent). Remission was related to lower baseline A1C values and to weight loss.

All commonly performed procedures for weight loss seem to improve glucose metabolism. The optimal surgical approach for improvement and remission of diabetes has yet to be fully elucidated.

The mechanism for diabetes improvement depends upon the type of surgery performed   In a meta-analysis of predominantly observational studies, diabetes resolution was highest after biliopancreatic diversion/duodenal switch (95 percent) and lowest after laparoscopic adjustable gastric banding (57 percent)   One study suggested that insulin sensitivity improved in proportion to weight loss with the use of predominantly restrictive procedures, but was reversed completely by predominantly malabsorptive approaches long before normalization of body weight

The rapid normalization of insulin sensitivity after bypass types of bariatric procedures may be related to duodenal isolation following the bypass surgery and subsequent changes in gastrointestinal hormones (the incretins, glucagon-like peptide and glucose-dependent insulinotropic polypeptide) following surgery. In a study of eight obese women with type 2 diabetes, the release of incretins after oral glucose and their effect on insulin secretion improved within one month of Roux-en-Y gastric bypass surgery  ]. The role of gastrointestinal peptides in glucose homeostasis is reviewed in detail elsewhere .)

Liver disease 

— Obese patients are at risk for fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) which may progress to cirrhosis and hepatocellular carcinoma. NALFD can be considered part of the metabolic syndrome (insulin resistance)   Insulin resistance improves after significant prolonged weight loss and may also improve immediately after bypass of the duodenum as with the RYGB   Accordingly, some studies note improvement of NAFLD and metabolic syndrome with bariatric surgery   In addition, the measurement of adipokines used to measure fatty liver disease and insulin resistance improve after weight loss surgery  .

While the cornerstone of therapy for NALFD and NASH is weight loss, no randomized trials of bariatric surgery for these diagnoses have been performed and the surgical approach remains controversial   A review of 21 retrospective cohort studies showed improvement in steatosis and inflammation, with surgery  ]. However, four studies reviewed showed deterioration in the degree of fibrosis. In addition, none of the studies provided adequate follow up to document whether surgery had any effect on progression to cirrhosis and hepatocellular carcinoma.

Preoperative assessment may also need to be altered to help determine the best course of action in bariatric patients with liver disease as the presence of fatty liver disease does not predict poor outcome after bariatric surgery

Cirrhosis is found incidentally during weight loss surgery in 1.4 to 3.2 percent of patients because preoperative liver function tests do not predict the extent of cirrhosis  ]. The diagnosis of cirrhosis can be confirmed with an intraoperative biopsy. In a retrospective study of 30 patients with cirrhosis who underwent laparoscopic RYGB, there were no perioperative deaths, conversions to laparotomy, or liver-related complications   However, data from the Nationwide Inpatient Sample on patients who underwent bariatric surgery demonstrated lower mortality rates in patients without cirrhosis as compared with patients with compensated and decompensated cirrhosis (0.3, 0.9 and 16 percent, respectively). In addition, the average length of stay was longer for patients with decompensated and compensated cirrhosis, compared with patients without liver disease (7, 4, and 3 days, respectively)   However, portal hypertension with large esophageal or gastric varices makes all bariatric procedures very risky. The safest approach when portal hypertension is detected intraoperatively is to perform a liver biopsy and conclude the procedure. The patient should then be evaluated by a hepatologist to help control the portal hypertension. Patients with mild portal hypertension may be candidates for restrictive procedures. Bariatric surgery is not recommended for patients with severe portal pressure

The model for end-stage liver disease (MELD) score can be used to predict mortality in patients with cirrhosis or fatty liver disease being considered for bariatric surgery   Those with high MELD scores should be referred to a hepatologist for evaluation. If possible, bariatric surgery for these risk patients should be performed in a high-volume tertiary referral center  ]. The MELD score is discussed in detail elsewhere.

Transplant patients 

— Elevated BMI is associated with poor outcomes after transplantation, thus the need for preoperative weight loss, surgical or nonsurgical, has been questioned.

A retrospective study of 51,927 primary, adult renal transplants registered in the United States Renal Data System (USRDS) showed that elevated BMI was significantly associated with worse graft survival and mortality  ]. The impact of BMI on outcomes is likely due to associated comorbid conditions and altered pharmacokinetics

The USRDS data included 188 patients who underwent bariatric surgery, 72 before being listed for transplant, 29 on the transplant waitlist, and 87 post-transplant   Thirty-day mortality after bariatric surgery performed on the waitlist and post-transplant was 3.5 percent. Some centers now limit transplant to patients with a BMI <35, deferring transplant evaluation until appropriate weight loss has been achieved

 

ACCREDITATION OF BARIATRIC PROGRAMS 

— The ultimate goal of The American Society of Metabolic and Bariatric Surgeons (ASMBS) and the American College of Surgeons (ACS) is to improve patient safety and outcomes by reducing medical errors, and hence in 2012, these two organizations have combined their criteria for Bariatric Centers of Excellence into the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBS-AQIP) [ 69 ]. The recommendations of the MBS-AQIP should be the standard under which hospital programs providing bariatric services should function.

The goals of MBS-AQIP include:

  • Accredit Metabolic and Bariatric Surgery Programs according to outcomes based standards
  • Establish national/regional and state collaboratives to improve care
  • Decrease morbidity by 50 percent throughout five years
  • Decrease readmissions, reoperations
  • Improve the value of metabolic surgery by increasing safety, improving efficacy and decreasing cost of care
  • Share best practices

The benefits of these guidelines include the improved ability to compare short-term and long-term results across institutions providing medical and surgical bariatric services. For those hospitals that do provide bariatric care, the recommendations of the MBS-AQIP should be the standard under which they operate.

INDICATIONS  — Indications for the surgical management of severe obesity were first outlined by the National Institutes of Health (NIH) Consensus Development Panel in 1991   Potentially eligible patients should:

  • Be well-informed and motivated
  • Have a BMI >40
  • Have acceptable risk for surgery
  • Have failed previous nonsurgical weight loss
  • Adults with a BMI >35 who have serious comorbidities such as diabetes, sleep apnea, obesity-related cardiomyopathy, or severe joint disease may also be candidates

Bariatric surgery should be performed in conjunction with a comprehensive follow-up plan consisting of nutritional, behavioral, and medical programs. Clinical practice guidelines from the American College of Physicians for management of obesity in primary care are discussed elsewhere.

CONTRAINDICATIONS  — Contraindications to bariatric surgery include patients with untreated major depression or psychosis, binge-eating disorders, current drug and alcohol abuse, severe cardiac disease with prohibitive anesthetic risks, severe coagulopathy, or inability to comply with nutritional requirements including life-long vitamin replacement. Bariatric surgery in advanced (above 65) or very young age (under 18) is controversial, but is considered when comorbidity is severe

CHOOSING A PROCEDURE  — The most commonly performed bariatric surgery procedures are laparoscopic adjustable gastric banding (LAGB) and Roux-en-Y gastric bypass (RYGB). There are benefits and risks associated with each procedure.

The comparative efficacy and safety of the procedures were evaluated in a five-year trial of 50 obese patients (mean BMI 43 kg/m 2 ) randomly assigned to LAGB versus laparoscopic RYGB (LRYGB)   After five years, patients in the LRYGB group lost a greater percentage of excess body weight (67 versus 47 percent) and had a lower failure rate (4 versus 35 percent). A similar study of 250 patients randomly assigned to gastric bypass or gastric banding showed that LRYGB resulted in better weight loss, but was associated with more complications and a higher 30-day readmission rate

A meta-analysis of 14 studies (13 observational and one randomized trial   evaluating clinical outcomes after LAGB and RYGB showed the following advantages and disadvantages of RYGB

  • Weight loss at one year was superior (median difference 26 percent, 95% CI 19-34 percent)
  • Resolution of comorbidities, such as diabetes and dyslipidemia, was better
  • Operative times and length of hospitalization were longer (median differences of 68 minutes and two days, respectively)
  • Perioperative complications (9 versus 5 percent) were greater, but reoperation rates (16 versus 24 percent) lower
  • Mortality was higher, although it was low in both groups (0.06 and 0.17 percent for LAGB and RYGB, respectively)

Thus, in this meta-analysis of predominantly observational studies, RYGB was associated with greater long-term success but higher short-term morbidity.

In addition to laparoscopic Roux-en-Y gastric bypass and adjustable gastric band, biliopancreatic diversion with duodenal switch, and primary laparoscopic sleeve gastrectomy are also effective means of treating severe obesity  ]. In the United States, two national databases, Bariatric Outcomes Longitudinal Database™ (BOLD) and National Surgical Quality Improvement Program (NSQIP) are being implemented to track weight loss surgery outcomes. Results from these prospective, risk-adjusted and benchmarked data collection systems will hopefully provide useful data for further comparison of procedures

The choice of procedure depends upon patient preference, the institution, and expertise of the surgeons. The surgeons, and all members of the multidisciplinary bariatric team, should educate patients fully regarding the risks, benefits and alternatives to weight loss surgery   Data from the National Inpatient Sample database on 304,515 patients showed that male gender (odds ratio 1.7), age >50 years (odds ratio 3.8), congestive heart failure (odds ratio 9.5), peripheral vascular disease (odds ratio 7.4), chronic renal failure (odds ratio 2.7), and open surgery (odds ratio 5.5), were associated with greater mortality  ]. Ethnicity, hypertension, diabetes, liver disease, chronic lung disease, sleep apnea, and alcohol abuse, had no significant association with mortality. These factors should be considered when counseling patients preoperatively.

A thorough discussion of the pros and cons of the various surgical approaches as part of the informed consent is very important. Patients need to understand the need to make major dietary and lifestyle changes postoperatively, and must have realistic expectations. The medical management of patients after bariatric surgery is discussed elsewhere.

Many accredited multidisciplinary programs hold information sessions to discuss different weight loss surgery options and provide extensive nutritional education. Patients planning surgery are usually tested on their understanding

BARIATRIC SURGICAL PROCEDURES

Roux-en-Y gastric bypass  — The Roux-en-Y gastric bypass (RYGB) was developed in the 1960s based on the observation that patients who underwent partial gastrectomy experienced significant long-term weight loss  . Many subsequent modifications have been made to improve the weight loss outcome and limit operative complications. It is the most common bariatric procedure performed in the United States and is considered the gold standard among bariatric procedures.

Surgical procedure  — The Roux-en-Y gastric bypass configuration is characterized by a small (less than 30 mL) proximal gastric pouch divided and separated from the stomach remnant, with drainage of food to the rest of the gastrointestinal tract via a small gastrojejunal anastomosis and a Roux-en-Y small bowel arrangement   The small pouch and the small outlet act to restrict caloric intake, as seen in VBG and LAGB. A much larger gastric remnant becomes disconnected from the food stream while secretion of gastric acid, pepsin, and intrinsic factor continues.

The small intestine is then divided at a distance of 30 to 50 cm distal to the Ligament of Treitz. By dividing the bowel, the surgeon creates a proximal biliopancreatic limb that transports the secretions from the gastric remnant, liver, and pancreas. The Roux limb (or alimentary limb) is anastomosed to the new gastric pouch, and functions to drain consumed food. The cut ends of the biliopancreatic limb and the Roux limb are then connected 75 to 150 cm distally from the gastrojejunostomy. Major digestion and absorption of nutrients then occurs in the common channel where pancreatic enzymes and bile mix with ingested food.

Minimally invasive technique 

— Most bariatric procedures are now performed laparoscopically. Data from the Nationwide Inpatient Sample from 2003 through 2008 documented that the proportion of laparoscopic bariatric operations increased from 20 percent in 2003 to 90 percent in 2008   . Minimally invasive techniques were first applied in bariatric surgery in the 1990s. The first laparoscopic RYGB series was reported in 1994 in the United States   Although technically challenging with a steep learning curve, laparoscopic RYGB can be performed safely by experienced surgeons  . The laparoscopic approach offers several advantages, such as reduced blood loss, lower incidence of incisional hernia, wound infection, faster recovery, and a shorter hospital stay than with open surgery  ]. Although the procedure can be limited by patient size, instrument and trocar length, even the extremely large patients have been successfully completed laparoscopically

Weight loss mechanism  — While the RYGB, with its small pouch, is primarily a restrictive operation, a malabsorptive component also contributes to weight loss. RYGB has been shown repeatedly to be better than purely restrictive procedures, such as the vertical banded gastroplasty (VBG), in long-term weight reduction [ 89 ]. Other mechanisms, such as dumping syndrome, Roux limb length, and gut hormones, may have a role in the weight loss seen following gastric bypass:

  • Gastrojejunostomy anatomy (connection between the stomach pouch and jejunum) is associated with dumping physiology, and causes unpleasant symptoms of lightheadedness, nausea, diaphoresis and/or abdominal pain, and diarrhea when a high sugar meal is ingested [ 90 ]. This response may serve as a negative conditioning response against consumption of a high sugar diet postoperatively.
  • The optimal length of the Roux limb in achieving the best balance between weight reduction and complications of malabsorption is controversial. Increasing Roux limb length can lead to increased malabsorption, since lengthening the Roux limb effectively shortens the common limb where major digestion and absorption of the ingested nutrients occur. At present, most surgeons do not make the Roux length longer than 150 cm. Distal gastric bypass with a short common limb has been used to treat patients with inadequate weight loss following standard RYGB, but the risk for metabolic complications increases similar to other malabsorptive operations
  • Ghrelin is a peptide hormone secreted in the foregut (stomach and duodenum) that stimulates the early phase of meal consumption. The normal pulsatile release of this orexigenic (appetite-producing) hormone appears to be inhibited in gastric bypass patients due to its unique foregut bypass configuration [  Such inhibition of ghrelin has also been observed in laparoscopic sleeve gastrectomy  The reduced ghrelin levels may contribute to the characteristic loss of appetite seen in post RYGB patients. An exaggerated response of peptide YY (PYY) may also contribute to the loss of appetite

Outcomes 

— Excess weight loss (EWL) after Roux-en-Y gastric bypass (RYGB) is durable and reliable. On average, 62 to 68 percent EWL is reported after the first year. Early weight loss following gastric bypass is typically rapid, but usually reaches a plateau after one to two years to an average EWL percent between 50 to 75 percent [   Sustained weight loss is seen up to 16 years  , which makes this procedure an excellent tool for a permanent surgical weight loss. Improvement and/or resolution of comorbid conditions (including diabetes, sleep apnea, hypertension, and dyslipidemia) following gastric bypass has also been well established

Some patients may experience a precipitous drop in blood glucose due to altered insulin metabolism after RYGB  ]. Clinical approaches to severe hypoglycemia after gastric bypass are addressed in detail elsewhere

Laparoscopic adjustable gastric banding

  — Laparoscopic gastric banding (LAGB) is a purely restrictive procedure that compartmentalizes the upper stomach by placing a tight, adjustable prosthetic band around the entrance to the stomach

Although LAGB was performed extensively in Europe and Australia for almost a decade, it was not until June 2001 that the first adjustable band (LapBand, Allergan) was approved for use in the United States. Another adjustable gastric band also received FDA approval (Realize band, Ethicon)   It works on similar principle, and has similar short-term outcomes to LapBand. In 2011, the FDA approved the laparoscopic adjustable gastric band for use in patients with BMI greater than 30 with one or more weight related comorbid conditions   Use of the gastric band for this population has not been universally embraced by the bariatric surgery community or the third party insurance payers because of the high complication rate.

The gastric band consists of a soft, locking silicone ring connected to an infusion port placed in the subcutaneous tissue. The port may be accessed with relative ease by a syringe and needle. Injection of saline into the port leads to reduction in the band diameter, resulting in an increased degree of restriction. The band is adjustable and is placed laparoscopically   Postoperatively, the patient must be followed with frequent office visits to the nutritionist for diet counseling and surgical staff for band adjustments  . The goal of band adjustments is to give the patient restriction of about a cup of dried food and satiety for at least 1.5 to 2 hrs after a meal.

Indications for the use of LAGB are similar to the indications for gastric bypass, and patients must meet full NIH criteria   LAGB is generally contraindicated in patients with portal hypertension, connective tissue disorders with severe esophageal dysmotility, or chronic steroid use (relative contraindication).

LAGB has gained significant attention among bariatric surgeons and patients primarily because of its perceived simplicity and lower perioperative complication rates when compared with more involved procedures such as RYGB   Because of its many advantages, it has largely replaced the conventional VBG as the main restrictive procedure for treatment of severe obesity:

  • LAGB does not require division of the stomach or intestinal resection. As a result, it has the lowest mortality rate (0 to 0.5 percent) among all bariatric procedures
  • The band eliminates the need for staple lines used in VBG that may break down and cause weight regain.
  • Avoidance of a fixed prosthetic mesh at the stoma reduces the incidence of stomal stenosis seen in VBG.
  • The adjustability of the outlet by the new band design offers a theoretical advantage of addressing various nutritional issues after surgery. As an example, a patient who becomes pregnant following this procedure may have her stoma widened to allow for greater caloric and fluid intake, if necessary. In addition, restoration of the original anatomy by the removal of the band is possible. A significant scar capsule remains after band removal, however, which may contribute to the increased rate of complications seen with revisional bariatric procedures following failed banding procedures

The effectiveness of the LAGB for achieving excess weight loss has been variable. As a general rule, weight loss following LAGB is more gradual and less, compared with gastric bypass procedures, but some have reported comparable long-term outcomes   Based on a few retrospective studies, there was a 15 to 20 percent EWL at three months, 40 to 53 percent EWL at one year, with eventual increases in up to 45 to 75 percent EWL at two years [   A retrospective review of 3227 obese patients undergoing LAGB identified a durable weight loss of 47 percent EWL at 15 years  . In addition to weight loss, LAGB is associated with improvements in various comorbidities (diabetes, asthma, sleep apnea, hypertension) and quality of life [

Complications of LAGB are discussed elsewhere

Sleeve gastrectomy

  — Sleeve gastrectomy (SG) is a partial gastrectomy, in which the majority of the greater curvature of the stomach is removed and a tubular stomach is created. SG was initially offered to patients with super severe obesity (BMI > 60kg/m 2 ) as the first stage in surgical management   The tubular stomach is small in its capacity (restriction), resistant to stretching due to the absence of the fundus, and has few ghrelin-producing cells (a gut hormone involved in regulating food intake)   . Although SG is a restrictive procedure, gastric motility changes also occur with surgery and may affect weight loss outcomes

SG is technically easier than RYGB, as it does not require multiple anastomoses. It is also safer, as it reduces the risks of internal herniation and protein and mineral malabsorption   SG can be considered a restrictive option for the treatment of severe obesity as a single stage primary operation, rather than just a bridge procedure to a more technically challenging gastric bypass or biliopancreatic diversion in high-risk patients    A randomized study of 80 patients showed that SG results in better weight loss and hunger control at three years after surgery than adjustable gastric banding (EWL of 66 versus 48 percent respectively  The benefits of SG have been attributed in part to better suppression of ghrelin compared with gastric bypass

SG is an effective and relatively safe procedure that appears to combine the safety profile of the gastric band with the effectiveness of the more complicated procedures, such as the gastric bypass. Data from the American College of Surgeons-Bariatric Surgery accreditation program on 944 SG, 12,193 gastric banding, and 15,479 RYGB patients showed no difference in mortality between procedures   SG had higher morbidity, readmission and reoperation rates than the gastric band, but less than the RYGB with one year follow up. Weight loss after SG also lies between that of the gastric band and the RYGB. Similar results were reported in other series  ]. One retrospective review of 176 patients shows that persistent reflux occurred in 47 percent of patients  ]. However, long term data are still lacking

Biliopancreatic diversion  — The biliopancreatic diversion (BPD) was introduced as a solution to the high rates of liver failure resulting from bowel exclusion in the jejunoileal bypass

The procedure consists of a partial gastrectomy and gastroileostomy with a long segment of Roux limb and a short common channel (the part of the small bowel that receives both food and biliopancreatic secretions) resulting in fat and starch malabsorption. Up to 72 percent excess weight loss at 18 years after surgery has been reported. Laparoscopic BPD has also been performed with acceptable outcomes  ]. Its use has been limited by the high rates of protein malnutrition, anemia, diarrhea, and stomal ulceration   In the United States, the role of BPD has generally been limited to revisional bariatric surgery.

Duodenal switch  — The duodenal switch (DS) procedure combines gastric restriction (sleeve gastrectomy or vertical gastrectomy) and malabsorption (DS with functional shortening of the small intestine) to attain weight loss   . The DS with shortening of the small intestine is achieved with division of the duodenum 4 cm distal to the pylorus, anastomosis of the duodenum to the distal ileum, and anastomosis of the biliopancreatic limb to the distal ileum to create a 100 cm common channel and a 150 cm enteric limb. A randomized trial of 60 patients who underwent either gastric bypass or DS showed greater weight loss with the duodenal switch procedure than the gastric bypass (25 versus 17 kg respectively)   However, patients who underwent the DS had a much higher rate of adverse events as compared with the gastric bypass (62 vs 32 percent of patients respectively). In the DS group, there were 3 cases of protein calorie malnutrition, 2 cases of night blindness and 1 case of severe iron deficiency. The DS patients also had lower levels of vitamin A and D. Thus, the DS procedure cannot be recommended for surgical management of obesity.

Biliopancreatic diversion with duodenal switch 

— The biliopancreatic diversion with duodenal switch (BPD/DS) is a variant of the BPD and is primarily a malabsorptive operation

The BPD/DS procedure involves a partial sleeve gastrectomy with preservation of the pylorus, and creation of a Roux limb with a short common channel. The BPD/DS procedure differs from the BPD in the portion of the stomach that is removed, as well as preservation of the pylorus [   It is associated with a lower incidence of stomal ulceration and diarrhea than with BPD alone. Although complex, BPD/DS has been performed laparoscopically by several groups   This procedure is performed at only a few centers in the United States.

This procedure has been advocated for patients with very severe obesity (BMI >50 kg/m 2 ), a group in which it has been associated with improved weight loss   BPD/DS is not widely accepted as a first-line surgical treatment for less severe obesity because of concerns regarding the risks of long-term malabsorption.

Intragastric balloon  — The intragastric balloon (Bioenterics Intragastric Balloon, Allergan) is a temporary alternative for weight loss in moderately obese individuals It consists of a soft, saline-filled balloon, placed endoscopically, which promotes a feeling of satiety and restriction

The intragastric balloon is not available for use in the United States, outside of clinical trials   Mean excess weight loss is reported to be 38 percent and 48 percent for 500 and 600 mL balloons, respectively   However, the results of a Brazilian multicenter study indicate weight loss is transient, with only 26 percent of patients maintaining over 90 percent of the excess weight loss out over one year   It appears to reduce the risk of conversion to open surgery and the risk of intraoperative complications when it is used for preoperative weight loss in super-obese patients before a definitive bariatric procedure  Side effects include nausea, vomiting, abdominal pain, ulceration, and balloon migration.

Vertical banded gastroplasty  — Vertical banded gastroplasty (VBG) is a purely restrictive procedure in which the upper part of the stomach is partitioned by a vertical staple line with a tight outlet wrapped by a prosthetic mesh or band

The small upper stomach pouch is filled quickly by solid food, and prevents consumption of a large meal. Weight loss occurs because of decreased caloric intake of solid food. Patients who have undergone VBG can be expected to have excess weight loss (EWL) of 58 percent   The effectiveness of such a restrictive mechanism depends upon the durability of pouch and stoma (outlet) size.

Ingestion of high-calorie liquid meals and gradually increased pouch capacity due to overeating has been some of the major causes of its failure. Sweets eaters who rely on soft meals (ie, ice cream, milk shakes) do not benefit significantly from this procedure

VBG has been replaced largely by other procedures and is rarely performed due to lack of sustained/desired weight loss, as well as the high incidence of complications requiring revision (20 to 56 percent  The majority of revisions are required for staple line disruption, stomal stenosis, band erosion, band disruption, pouch dilatation, vomiting, and gastroesophageal reflux disease.

Endoluminal vertical gastroplasty 

— Endoscopic methods for suturing the stomach have been developed, which offer the potential to perform gastric-restrictive procedures endoluminally. Initial experience is promising, but longer-term studies are needed

Jejunoileal bypass  — The jejunoileal bypass was one of the first bariatric operations, performed initially in 1969  ]. It has since been abandoned due to the high complication rate and frequent need for revisional surgery. Its importance lies in the care of surviving patients who have undergone this procedure.

The procedure was performed by dividing the jejunum close to the ligament of Treitz, and connecting it a short distance proximal to the ileocecal valve  ), thereby diverting a long segment of small bowel, resulting in malabsorption. Although excess weight loss was excellent, jejunoileal bypass was associated with multiple complications, such as liver failure (up to 30 percent), death, diarrhea, electrolyte imbalances, oxalate renal stones, vitamin deficiencies, malnutrition, and arthritis  ].

Patients who have undergone this procedure should be monitored closely for complications (particularly liver disease) and undergo reversal if such complications arise.

Liposuction  — Although not generally considered to be a bariatric procedure, removal of fat by aspiration after injection of physiologic saline has been used to remove and contour subcutaneous fat. While this can result in reduction in fat mass and weight, the amount of weight loss is insignificant in comparison with bariatric procedures, and it does not appear to improve insulin sensitivity or risk factors for coronary heart disease

COMPLICATIONS  — Bariatric surgery has serious risks   Complications of these procedures are discussed separately.  .)

INFORMATION FOR PATIENTS  — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

SUMMARY AND RECOMMENDATIONS

  • Obesity is a major health problem, and its incidence is increasing rapidly in developed countries. Severe obesity leads to numerous medical problems and a shortened life expectancy.
  • Body mass index (BMI) is the most practical measure of a person’s adiposity
  • Bariatric surgical approaches are based primarily on two main mechanisms: restriction of caloric intake via a small stomach reservoir and malabsorption of nutrients via reduced functional small bowel length. Restrictive procedures are generally simpler in techniques, but seem to achieve less weight loss. Malabsorptive procedures are highly effective in weight loss, but can carry significant metabolic complications.
  • Bariatric surgery is effective in reducing obesity-related comorbidities and mortality.
  • Bariatric surgery needs to be performed in conjunction with a comprehensive follow-up plan consisting of nutritional, behavioral, and medical programs. These complex procedures must be performed in appropriately accredited facilities and follow the combined guidelines of the American College of Surgeons and the American Society of Metabolic and Bariatric Surgeons (MBS-AQIP).
  • The Roux-en-Y gastric bypass has been the most commonly performed procedure in the United States due to its multiple mechanisms of action and durable long-term weight loss.
  • Laparoscopic Roux-en-Y gastric bypass, compared to the open approach, can decrease surgical pain, infectious and hernia complications, as well as allow for quicker postoperative recovery.
  • Laparoscopic adjustable gastric banding is becoming increasingly more popular in the United States due to its simplicity in technique, adjustability, reversibility, and relatively low perioperative mortality. Weight loss following gastric banding is more gradual and less, compared with gastric bypass procedures. Frequent band adjustments and revisional surgery may be required over time.
  • Laparoscopic vertical sleeve gastrectomy is an effective procedure to treat severe obesity. This procedure combines the nutritional benefits of a purely restrictive procedure, such as the adjustable gastric band, and the weight loss benefits of the gastric bypass
  • Laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) is an effective operation for very severe obesity (BMI >50.0 kg/m 2 ). BPD/DS is not widely accepted as a first-line surgical treatment in less severely obese patients because of concerns regarding the long-term risks of nutritional deficiencies.
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