Nutrition Support Blog: Micronutrients – Check or Treat; that is the Question?
April 19, 2012
In school I spent a lot of time memorizing factoids about individual vitamins and trace minerals; details such as their role in metabolic pathways and enzyme cofactors, deficiency signs and symptoms, routes of excretion, and food sources. However, in practice I quickly realized that micronutrient deficiencies almost never occurred in isolation. The vast majority of hospitalized patients I worked with either had decent nutrition status or had a generalized malnutrition with decreased intake of most nutrients. In most cases, there seemed little point in checking the status of individual nutrients, since we knew that the patient needed more of everything. Of course, we all know the usual exceptions – patients with alcohol abuse and thiamine, patients with chronic fat malabsorption and fat soluble vitamins, and nowadays- every human and vitamin D (but I digress – vitamin D needs to be the subject of several other blogs..).
One population where we have seen a number of cases of severe deficiencies of individual micronutrients are patients with a history of gastric bypass for weight loss. One patient had extensive facial rash from severe zinc deficiency similar to that seen in children with Acrodermatitis enteropathica. We have also uncovered a number of patients with copper deficiency in the gastric bypass population – some with severe neurological sequelae. Additionally, some individual patients also had deficiencies of other micronutrients such as selenium or particular B-vitamins, such as B-6. The unsettling part of these nutrient discoveries is that there was not a predictable pattern or consistent type of deficiency. Although copper is clearly a problem nutrient, deficiency is not universal, and some patients had normal copper status yet deficiencies of other nutrients. A new publication seems to confirm our suspicion that copper deficiency is more common after roux-en-y gastric bypass than suggested by conventional wisdom.
Gletsu-Miller N, Broderius M, Frediani JK, et al. Incidence and prevalence of copper deficiency following roux-en-y gastric bypass surgery. Int J Obes (Lond). 2012 Mar;36(3):328-35.
This observational study had a limited number of patients, but it clearly points to the need for further studies and monitoring of trace element status before and after gastric bypass. Currently, it is unclear if long-term risk for copper deficiency relates more to noncompliance with the need for lifelong vitamin-mineral supplementation, inadequate copper content of multivitamins, or some combination of factors. In the meantime, if you are seeing a patient more than a year after a roux-en-Y gastric bypass, it would be prudent to check serum copper and ceruloplasmin if they have not had these nutrients monitored.
The micronutrient deficiencies that we have seen in the gastric bypass population and in patients receiving long-term jejunal feeding (see our August 12th Blog post) have sensitized us to the potential for micronutrient deficiencies in other patients as well. However, in patients with malnutrition, it is difficult to know when to check a number of individual micronutrients versus just providing increased amounts of all nutrients. Naturally we want to be responsible with spending an excessive amount on lab fees, but need to balance fiscal responsibility with the risk of undertreated (and we are finding unappreciated) micronutrient deficiencies.
Unfortunately, at this point we don’t have any concrete answers – we just carefully consider the risks/benefits of each case in regards to checking and supplementing. We try to keep in mind the validity of serum nutrient levels (or lack of them in some cases), the turn around time for the test (will they be discharged before the result returns?), and the costs and potential negative effects of empiric nutrient supplementation (or lack of it). Clearly this is an area wide open for further study. In the meantime I would encourage clinicians that uncover surprising nutrient deficiencies to submit these cases or case series as a poster session at Clinical Nutrition Week so the rest of us can learn from your experiences. The practice poster sessions are some of the most useful information for clinicians, and are easy and fun to do. After all, if we don’t share what we have learned, someone out there may suffer the complications of nutrient deficiencies that go undiscovered.
“Just because nobody complains doesn't mean all parachutes are perfect.”
- Benny Hill
For more info, see the November 2011 article: O’Donnell, K. Severe Micronutrient Deficiencies in RYGB Patients: Rare but Potentially Devastating. Pract Gastro 2011;XXXV(11):13 on our website under the Practical Gastro series.