Nutritional deficiencies after bariatric surgery

Abstract

Lifestyle intervention programmes often produce insufficient weight loss and poor weight loss maintenance. As a result, an increasing number of patients with obesity and related comorbidities undergo bariatric surgery, which includes approaches such as the adjustable gastric band or the 'divided' Roux-en-Y gastric bypass (RYGB). This Review summarizes the current knowledge on nutrient deficiencies that can develop after bariatric surgery and highlights follow-up and treatment options for bariatric surgery patients who develop a micronutrient deficiency. The major macronutrient deficiency after bariatric surgery is protein malnutrition. Deficiencies in micronutrients, which include trace elements, essential minerals, and water-soluble and fat-soluble vitamins, are common before bariatric surgery and often persist postoperatively, despite universal recommendations on multivitamin and mineral supplements. Other disorders, including small intestinal bacterial overgrowth, can promote micronutrient deficiencies, especially in patients with diabetes mellitus. Recognition of the clinical presentations of micronutrient deficiencies is important, both to enable early intervention and to minimize long-term adverse effects. A major clinical concern is the relationship between vitamin D deficiency and the development of metabolic bone diseases, such as osteoporosis or osteomalacia; metabolic bone diseases may explain the increased risk of hip fracture in patients after RYGB. Further studies are required to determine the optimal levels of nutrient supplementation and whether postoperative laboratory monitoring effectively detects nutrient deficiencies. In the absence of such data, clinicians should inquire about and treat symptoms that suggest nutrient deficiencies.

Key Points

  • The rising prevalences of morbid obesity and type 2 diabetes mellitus have increased the number of patients undergoing bariatric surgery

  • Bariatric surgical approaches, including gastric bypass, the adjustable gastric band, vertical sleeve gastrectomy, the duodenal switch, and biliopancreatic diversion, can cause or exacerbate nutrient deficiencies

  • Standardized approaches to micronutrient supplementation and clinical and laboratory screening for micronutrient deficiencies after bariatric surgery are required

  • Vitamin D deficiency, a major clinical concern after bariatric procedures, must be aggressively treated with sufficient supplementation to prevent the development of metabolic bone diseases

  • Whether currently suggested laboratory blood tests that are intended to screen for micronutrient deficiencies identify all clinically relevant nutrient deficiencies is unclear

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Figure 1: Comparison of bariatric surgical procedures.

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B. S. Bal and T. R. Koch researched the data and contributed equally to writing the article. F. C. Finelli and T. R. Shope provided a substantial contribution to discussions of the content and reviewed and/or edited the manuscript before submission.

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Correspondence to Timothy R. Koch.

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Bal, B., Finelli, F., Shope, T. et al. Nutritional deficiencies after bariatric surgery. Nat Rev Endocrinol 8, 544–556 (2012). https://doi.org/10.1038/nrendo.2012.48

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