On this Bariatric Friday, Kemal Erkan, Chairman of American Surgery Center, joins Dr. Isaias Irgau, President of Christiana Institute of Advanced Surgery (CHRIAS). Dr. Irgau introduces himself and elaborates on the specialty he practices, bariatric surgery. At CHRIAS, the surgeons are the most experienced with bariatric surgery in the area. 

Today’s discussion is based around vitamin deficiency. For those who are morbidly obese, vitamin deficiency is a much bigger problem than for those with a lower body mass index. Erkan emphasizes that the topic of the day is targeting the bariatric population. Dr. Irgau makes the statement, “this is a critically important issue of vitamins and micronutrients after bariatric surgery”. 

  Dr. Irgau begins by defining bariatric surgery, “bariatric surgery is by far the most effective treatment we have for morbid obesity”. Morbid obesity is a chronic disease involving excess weight accumulation. To qualify for bariatric surgery, one has to have a weight that is one hundred pounds over their healthy, or ideal, body weight. Another way to determine this is to calculate one’s body mass index (BMI). A BMI of forty or greater qualifies a person to be categorized as morbidly obese; however, someone who has a slightly lower BMI can also be labelled as morbidly obese if they have developed related illnesses to obesity, such as type 2 diabetes, high blood pressure, and more. Bariatric surgery is a method to help the person who is morbidly obese. Because of the alteration in anatomy from bariatric surgery, it is essential that the patient is compliant in taking vitamins and minerals for their health post weight loss. 

  Dr. Irgau explains that it is important for the body to get vitamins and nutrients from fresh foods, and if fresh foods are not available, from a multivitamin. Dr. Irgau describes fresh foods using the following example: “Let’s say you have a garden in your backyard… if whenever you are going to eat fruit you went to your garden, picked up one of those fruits from the tree, and ate it, that would be fresh food… an apple that you get from the store may look fresh but is not really that fresh”. The apple from a store does not qualify as fresh because of where the apple was grown and the time it took to arrive at the store. The apple loses freshness over time and the availability of those small compounds, vitamins and nutrients, decreases. Food is not considered fresh unless it is picked from the original source and eaten immediately. Dr. Irgau continues by stating, “in modern society, a large portion of their food comes from preserved foods that have been altered… those foods will have very little essential minerals and vitamins that our body needs”. To compensate for this, it is pertinent for people to consume a daily multivitamin. For someone who has not undergone bariatric surgery, this is a suggested task to remain healthy; however, for a person who has had bariatric surgery, it is not a recommended habit, it is a necessity. This is due to the alteration of one’s anatomy that takes place during the procedure. The alteration causes the body’s ability to absorb the compounds it needs to decrease. 

  Regarding when to start taking vitamins, Erkan asks Dr. Irgau, “are we talking about before or after the surgery?”. Dr. Irgau replies, “we want our patients to be as healthy as they can be when they go through the process… we want them to have healthy habits”. Dr. Irgau states when he counsels patients, he emphasizes the importance of taking multivitamins before surgery. This will help ensure that after bariatric surgery taking a multivitamin will become a necessary daily task. “Knowing a person has been taking multivitamins even before bariatric surgery is a good start because it tells me they have a habit that they will likely continue,” Dr. Irgau expresses. 

  Erkan inquires, “who can provide this education for us?’ Dr. Irgau explains that nutritionists are the best providers of expertise in this area. They are able to talk to patients about optimization on how to take these vitamins and in what form is the best for them. With this, he explains how vitamin B12 is very important for a patient as well as vitamin D. In terms of the minerals, calcium and iron are pertinent post bariatric surgery. These are all available at CHRIAS but are also easily accessible in stores or online. The patient, however, needs to be aware of the dosage that is right for their individual needs. A lack of iron can also be a major health concern. Iron deficiency can be apparent in patients before bariatric surgery. This tends to be more common amongst women because of their menstrual cycle. Iron supplements are vital to the body’s daily intake. Erkan mentions, “some of these things should be identified by the primary care providers to the patients… annual physicals are extremely important… blood work is the only way the patient will know about this deficiency”. 

  Erkan then asks Dr. Irgau to elaborate on other important vitamins that patients need. Dr. Irgau replies, “the other one that we see being very deficient is vitamin D… it is critical for the metabolism of calcium and for the mineralization of all bones”. With this, it is also important to expose the body to sunlight. The sun activates vitamin D. Dr. Irgau explains that when he sees a deficiency in patients, he prescribes higher doses of supplementation to combat the deficiency. At CHRIAS, it is protocol that the patients participate in regular blood testing after bariatric surgery to ensure there are no complications. Erkan touches on the importance of communication between the patient and their primary care provider. Patients should be made aware there is a greater risk of complications if they suffer from any of the comorbidities related to morbid obesity. There is a major disconnect, and the pair emphasize that this is part of the reason they conduct the Bariatric Friday live sessions each week. They aim to raise awareness and educate individuals who may need the help that bariatric surgery can provide. 

  One thing that affects patients is the way our society functions. Dr. Irgau states, “we live in a society of plenty; we are heavy because we have excessive food, but at the same time we are malnourished”. By this he explains our lack of vitamins leads to being malnourished. “You could be heavy and have all of these problems,” he mentions, “that’s why we look at our patient’s blood tests even before bariatric surgery to make sure we know where we are starting”. The grocery stores overflow with food; however, this does not mean society is getting the nourishment and fresh foods it needs. Patients need to be prepared well before undergoing bariatric surgery to avoid being extremely malnourished after the operation. Erkan raises the question, as a patient, “how many total pills am I going to take?” Dr. Irgau answers with approximately six a day, including calcium, vitamin D, B12, and a multivitamin, all in various doses. He then mentions that it is easier to integrate vitamins into a patient’s routine by including it with current habits, such as meals. By taking a vitamin at mealtime, the act becomes part of the daily routine, and the patient will be more likely to remember it and integrate it. 

  The pair then clarify the post operation process and stress the importance of follow ups with the patient after they undergo bariatric surgery. Erkan states, “we are still seeing our patients on a regular basis… this is part of our accreditation process to remain a center of excellence for bariatric surgery. As the number one program in Delaware, we take this extremely seriously”. The patient should want to see change and progress continue long term, and follow up visits increase the likelihood that the patient will remain healthy and supported, as well as not revert back to old habits. 

  Erkan says, “you don’t have to be a bariatric patient, you don't have to have morbid obesity” to get regular blood work done and take care of your health. It is important to catch any issues before they develop and it is too late. Dr. Iragu elaborates on the importance of patient health, explaining patients should specifically be taking, “vitamin b12, vitamin d, calcium, and iron essentially”. These four nutrients are pertinent to maintaining a patient’s health, as well as receiving regular screening bloodwork. He then states, “the worst thing for us to see is bariatric patients not being followed up at all afterwards because that could put their long term health at risk”. 

  “I looked at our patient satisfaction scores,” Erkan explains, “the number is almost one hundred percent… out of one hundred sixty-two surveys, one hundred sixty-one would recommend our facility to a family member or a friend”. The rate of satisfied patients has remained at 99.4%, which is not common and wonderfully high compared to similar centers in the industry. “We are extremely happy to be able to provide this service and make differences in people’s lives,” Erkan expresses.