Micronutrient Deficiencies in Morbidly Obese Women Prior to Bariatric Surgery

Obesity influencing circulating levels of nutrients: Evidence from Mendelian randomization study

Observational studies have established that obesity is associated with nutritional deficiencies, but the exact causality remains uncertain. Thus, this Mendelian randomization (MR) study aimed to identify the causal associations between obesity and circulating levels of nutrients. Single-nucleotide polymorphisms associated with obesity (body mass index and waist-hip ratio), were extracted from a genome-wide association study of 694,649 European ancestry. Summary-level data for minerals (copper, selenium, zinc, calcium, magnesium, and potassium), and vitamins (folate, vitamins A, C, E, B6, and B12), albumin were obtained from the publicly available integrative epidemiology unit OpenGWAS database psychiatric genomics consortium. Inverse-variance weighted method several sensitivity analyses were conducted. Genetically predicted higher body mass index significantly decreased circulating levels of magnesium (β = -0.07, 95% confidence interval [CI]: -0.10 to -0.03, P = 1.47 × 10-4), folate (β = -0.07, 95% CI: -0.10 to -0.04, P = 5.61 × 10-5), vitamin A (β = -0.11, 95% CI: -0.14 to -0.07, P = 3.10 × 10-9), vitamin E (β = -0.10, 95% CI: -0.13 to -0.06, P = 1.84 × 10-8), albumin (β = -0.15, 95% CI: -0.17 to -0.12, P = 9.89 × 10-28); whereas genetically predicted higher waist-hip ratio decreased circulating levels of magnesium (β = -0.07, 95% CI: -0.11 to -0.02, P = 1.87 × 10-3), folate (β = -0.07, 95% CI: -0.11 to -0.03, P = 9.87 × 10-4), vitamin C (β = -0.08, 95% CI: -0.12 to -0.04, P = 2.40 × 10-4), albumin (β = -0.08, 95% CI: -0.11 to -0.04, P = 3.72 × 10-5). The study supports a causal effect of obesity on lower circulating levels of nutrients. Our findings highlight the necessity of adjuvant nutrients in obesity management.

The interaction of the FTO gene and age interferes with macronutrient and vitamin intake in women with morbid obesity

Fat mass and obesity-related (FTO) gene single nucleotide polymorphisms (SNPs) interferes with food preferences that impact macronutrient intake. Few studies have investigated the relationship of this polymorphisms with the intake of micronutrients. Moreover, studies have shown multiple micronutrient deficiencies in patients with obesity. This work evaluated the effect of the FTO rs9939609 gene polymorphism on dietary nutritional quality and food intake of macronutrients and vitamins in of women with obesity candidates for metabolic surgery. The study included 106 women (24 to 60 years old) with BMIs of 36.1 to 64.8 kg/m2. A food frequency questionnaire validated for the local population was applied to obtain information about food intake. The Index of Nutritional Quality (INQ) was used to assess the adequacy of macronutrient and vitamin intake. Energy, protein and lipid intakes were higher in carriers of the A allele compared to TT in the younger age groups but were similar in the class of subjects aged ≥45 years. The INQ for protein was higher in carriers of the A allele than in carriers of the TT allele. The INQs for protein, carbohydrate, vitamins B2, B3 and B6 decreased, whereas the INQ for vitamin C increased with advancing age. The INQ for vitamin A was lower in AA than in TT, regardless of age, whereas vitamin E was higher in younger AA than in older AA. The INQ for vitamin B9 was higher in younger women than in older women. In conclusion, the FTO gene contributed to the intake of more energy, protein and lipids and interfered with the intake of vitamins B9, A and E. With the exception of vitamin A, the effect of the genotype was attenuated with ageing.

Biofortification of Plant- and Animal-Based Foods in Limiting the Problem of Microelement Deficiencies-A Narrative Review

With a burgeoning global population, meeting the demand for increased food production presents challenges, particularly concerning mineral deficiencies in diets. Micronutrient shortages like iron, iodine, zinc, selenium, and magnesium carry severe health implications, especially in developing nations. Biofortification of plants and plant products emerges as a promising remedy to enhance micronutrient levels in food. Utilizing agronomic biofortification, conventional plant breeding, and genetic engineering yields raw materials with heightened micronutrient contents and improved bioavailability. A similar strategy extends to animal-derived foods by fortifying eggs, meat, and dairy products with micronutrients. Employing "dual" biofortification, utilizing previously enriched plant materials as a micronutrient source for livestock, proves an innovative solution. Amid biofortification research, conducting in vitro and in vivo experiments is essential to assess the bioactivity of micronutrients from enriched materials, emphasizing digestibility, bioavailability, and safety. Mineral deficiencies in human diets present a significant health challenge. Biofortification of plants and animal products emerges as a promising approach to alleviate micronutrient deficiencies, necessitating further research into the utilization of biofortified raw materials in the human diet, with a focus on bioavailability, digestibility, and safety.

Micronutrient status 2 years after bariatric surgery: a prospective nutritional assessment

Background

Among commonly performed bariatric surgeries, biliopancreatic diversion with duodenal switch (BPD-DS) provides greater weight loss than Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG), with sustained metabolic improvements. However, the risk of long-term nutritional deficiencies due to the hypoabsorptive component of BPD-DS hinders its widespread use.

Objective

The aim of the study was to examine nutritional status over 2 years after BPD-DS, RYGB or SG.

Methods

Patients were recruited in the REMISSION trial (NCT02390973), a single-center, prospective study. Out of 215 patients, 73, 48 and 94, respectively, underwent BPD-DS, RYGB or SG. Weight loss, micronutrient serum levels (including iron, calcium, parathormone, vitamins A, B12 and D), and nutritional supplementation were assessed over 2 years. Patients were supplemented according to the type of surgery and individual micronutrient level evolution.

Results

At baseline, BPD-DS patients were younger than SG patients (p = 0.0051) and RYGB patients had lower body mass index (p < 0.001). Groups had similar micronutrient levels before surgery, with vitamin D insufficiency as the most prevalent nutritional problem (SG: 38.3%, RYGB: 39.9%, BPD-DS: 54.8%, p = 0.08). BPD-DS patients showed lower levels of iron, calcium and vitamin A than SG patients at 24 months. Groups had similar levels of vitamin D at 24 months. Prevalence of vitamin D, calcium, iron, vitamin A and vitamin B12 deficiency was similar among groups at 24 months. Rates of vitamin D insufficiency and iron deficiency were lower at 24 months than at baseline. Micronutrient intake was consistent with recommendations in groups post-surgery, but most BPD-DS patients took vitamin A and vitamin D supplement doses above initial recommendations.

Conclusion

With appropriate medical and nutritional management, all surgeries led to similar rates of vitamin D, calcium, iron, vitamin A and vitamin B12 deficiencies at 24 months. However, initial vitamin A and vitamin D supplementation recommendations for BPD-DS patients should be revised upwards.

Challenges in identifying malnutrition in obesity; An overview of the state of the art and directions for future research

(Protein-energy) malnutrition in individuals living with obesity presents complex diagnostic challenges due to the distinctive physiological characteristics of obesity. This narrative review critically examines the identification of malnutrition within the population with obesity, distinguishing malnutrition in obesity from related conditions such as sarcopenic obesity. While noting some shared features, the review highlights key differences between these conditions. The review also highlights the limitations of current malnutrition screening tools, which are not designed for individuals living with obesity. These tools primarily rely on anthropometric measurements, neglecting (among others) nutrient intake assessment, which hinders accurate malnutrition detection. Additionally, this review discusses limitations in existing diagnostic criteria, including the Global Leadership Initiative on Malnutrition (GLIM) criteria, when applied to individuals living with obesity. Challenges include the identification of appropriate cut-off values for phenotypic criteria (unintentional weight loss, low body mass index and muscle mass) and aetiological criteria such as reduced food intake and inflammation for the population with obesity. Overall, this review emphasises the need for modified screening tools and diagnostic criteria to recognise and assess malnutrition in obesity, leading to improved clinical outcomes and overall wellbeing.

A Systematic Review and Meta-Analysis of Vitamin D Status of Patients with Severe Obesity in Various Regions Worldwide

INTRODUCTION

Managing nutritional deficiencies is an essential component in the treatment of severe obesity. Vitamin D deficiency is often reported in investigations in severely obese cohorts. However, no prior study has summarized findings on this topic. Consequently, the aim of this systematic review and meta-analysis was to investigate the 25-hydroxyvitamin D [25(OH)D] status in individuals with severe obesity in different regions worldwide. We also evaluated levels of calcium, parathyroid hormone (PTH), and magnesium as secondary outcome measures.

METHODS

We searched Medline, PubMed, Scopus, the Cochrane Library, and EMBASE for relevant observational studies published in English from 2009 to October 2021. The heterogeneity index among the studies was determined using the Cochran (Q) and I2 tests. Based on the heterogeneity results, the random-effect model was applied to estimate the prevalence of vitamin D deficiency.

RESULTS

We identified 109 eligible observational studies. Overall, 59.44% of patients had vitamin D deficiency [25(OH)D <20 ng/mL], whereas 26.95% had vitamin D insufficiency [25(OH)D 20-30 ng/mL]. Moreover, the mean 25(OH)D level was 18.65 ng/mL in 96 studies. The pooled mean estimate of the serum calcium, PTH, and magnesium was 9.26 mg/dL (95% confidence interval [CI]: 9.19-9.32, I2 = 99.7%, p < 0.001), 59.24 pg/mL (95% CI: 54.98, 63.51, I2 = 99.7%, p < 0.001), and 0.91 mg/dL (95% CI: 0.84, 0.98, I2 = 100.0%, p < 0.001), respectively. The results of the subgroup analysis indicated that the mean estimates of 25(OH)D were highest in North America (21.71 ng/mL [19.69, 23.74], [I2 = 97.2%, p < 0.001]) and lowest in Southeast Asia (14.93 ng/mL [14.54, 15.33], [I2 = 0.0%, p = 0.778]).

CONCLUSION

The results obtained showed a significant prevalence of vitamin D deficiency among severely obese individuals in various geographical regions, whereas the highest and lowest mean estimates were reported for North America and Southeast Asia, respectively.

Effects of Ethanolic and Aqueous Extracts of Garcinia gardneriana Leaves in an In Vivo Experimental Model Induced by a Hyperlipidic Diet

The study of medicinal plants, such as the genus Garcinia (Clusiaceae), in the treatment of non-communicable chronic diseases has aroused the interest of researchers. However, there are no studies in the literature that have investigated the effects of Garcinia gardneriana in experimental models of obesity for possible metabolic alterations. Swiss mice receiving a high-fat diet were supplemented with aqueous or ethanolic extract of G. gardneriana at doses of 200 or 400 mg/kg/day. It was found that there was a reduction in food consumption in experimental groups compared with the control groups, and the group supplemented with aqueous extract at a dose of 200 mg/kg/daydisplayed a reduction in weight. The results showed an increase in the values of high density lipoprotein (HDL-c), total cholesterol, triglycerides and fasting blood glucose. G. gardneriana did not protect against insulin resistance, and caused in an increase in monocyte chemoattractant protein-1 (MCP-1) concentrations and a reduction in interleukin 10 (IL-10). In addition, hepatic steatosis and microvesicular steatosis were indicated. It was revealed that, under the experimental conditions in the study, G. gardneriana did not prevent weight gain or comorbidities; that is, a different behavior was obtained from that described in the literature with regard to the medicinal potential of the Garcinia species, which is probably related to the phytochemical properties.

Assessment of the Clinical Condition and Way of Patients' Nutrition before and after Laparoscopic Sleeve Gastrectomy

One of the most commonly performed bariatric procedures is the laparoscopic sleeve gastrectomy (LSG). It is highly effective in reducing body weight, but it carries the risk of developing nutritional deficiencies and their consequences. The aim of the study was to determine the clinical condition of obese patients after LSG in terms of nutritional status, metabolic disorders, and way of nutrition. Thirty participants (15 women and 15 men) took part in the study. A statistically significant reduction in the total body fat mass (women by 37.5% p < 0.05, men by 37.06% p < 0.05) and total fat free mass (women by 10% p < 0,05, men by 12.5% p < 0.05) was demonstrated 6 months after LSG. Moreover, insufficient protein intake has been shown in over 73% of women and 40% of men. Before and 6 months after LSG, insufficient intake of calcium, magnesium, potassium, folate, vitamin D, and iron was observed. Six months after the LSG, significant decreases of fasting glucose (p < 0.05), insulin (p < 0.05), TG (p < 0.05), and AST (p < 0.05) concentrations, were observed in both groups. Optimization of nutrition in order to prevent nutritional deficiencies and their complications is a key element of the therapy of obese patients treated surgically.

Micronutrients Deficiencies in Candidates of Bariatric Surgery: Results from a Single Institution over a 1-Year Period

BACKGROUND

Micronutrient deficiencies represent a common condition after bariatric surgery (BS). The prevalence of these nutritional disorders before BS is still debated. The aim of our study was to retrospectively evaluate the prevalence of micronutrient deficiencies in candidates for BS.

METHODS

A prospectively maintained database of our institution was searched to find all patients who underwent surgery between January and December 2021. The following data were collected: age, gender, body mass index (BMI), obesity-associated diseases, and preoperative serum levels of vitamin B12, folate, and vitamin D.

RESULTS

A total of 174 patients were included in our study. Mean age and BMI were 39.2 ± 11.4 years and 44.3 ± 7.1 kg/m², respectively. One hundred and thirty-nine patients (79.9%) had at least one preoperative micronutrient disorder, with vitamin D deficiency being the most common (116, 66.7%), followed by a deficit of folate (76, 43.7%) and vitamin B12 (10, 5.7%). Forty-seven (27%) individuals had insufficient levels of vitamin D. Comparison of deficiencies between sexes showed that vitamin B12 < 20 ng/ml was significantly more frequent in women (p = 0.03). DLP showed a mild significant effect on folate levels (p = 0.01), while the association of HNT and T2DM had a mild significant effect on vitamin B12 (p = 0.02).

CONCLUSIONS

Preoperative micronutrient deficiencies were frequently found in candidates for BS. Approximately 90% of patients had deficient or insufficient serum levels of vitamin D preoperatively. Almost half of the patients had a preoperative deficit of folate, and vitamin B12 deficiency was significantly more frequent in the female population. It is mandatory to screen all patients undergoing BS for vitamin deficiencies before surgery.

The Association between Index of Nutritional Quality (INQ) and Obesity: Baseline Data of Kharameh Cohort

Obesity is an increasing problem that can lead to noncommunicable diseases. The role of dietary factors on one's obesity is confirmed in many studies. One nutritional approach that can be used for assessment of the foods and diets is the Index of Nutritional Quality (INQ). Our study is aimed at exploring the association between INQ and obesity. Our hypothesis is that enriched and high-quality diets reduce the risk of overweight or obesity. This study was carried out on 6248 overweight and obese participants, from whom 4356 (69.7%) and 1892 (30.3%) were overweight and obese, respectively. To assess the dietary intake for the participants, a valid food frequency questionnaire (FFQ) with 130 food items was utilized. The analysis revealed an inverse association between the overweight and the INQ of iron, thiamin, riboflavin, B6, folate, zinc, magnesium, calcium, and vitamin C and E. For the obese group, this inverse association was found for iron, B6, folate, zinc, magnesium, calcium, and vitamin C and E. These results approved our hypothesis that a rich nutrition diet may lead to a lower risk of obesity.

Nutritional Status in Chinese Patients with Obesity Following Sleeve Gastrectomy/Roux-en-Y Gastric Bypass: A Retrospective Multicenter Cohort Study

Metabolic surgery (MS) is one of the most effective therapies for treating obesity. Due to the lack of multicenter cohort research on nutritional evaluations after surgery in Chinese patients, we explored the changes in nutritional status following MS in Chinese patients. This was a retrospective study of patients (n = 903) who underwent sleeve gastrectomy (SG) (n = 640) or Roux-en-Y gastric bypass (RYGB) (n = 263) for obesity at five different hospitals in China between 17 February 2011, and 20 December 2019. Major nutrients were evaluated at baseline and 1, 3, 6, and 12 months postoperatively. Hb levels decreased, and anemia prevalence increased at 12 months after MS in the premenopausal female group. Moreover, patients with preoperative anemia had an increased risk of postoperative anemia. The ferritin levels (p < 0.001) decreased and iron deficiency increased (p < 0.001) at 12 months after MS among premenopausal females. No significant changes in folate deficiency and vitamin B12 deficiency were found throughout the study. The bone mineral density (BMD) of the femoral neck, lumbar spine, and total hip significantly decreased from baseline to 12 months after MS; however, no new patients developed osteopenia or osteoporosis after MS. Based on 12 months of follow-up, premenopausal females presented a high incidence of anemia after MS. Although we found no differences in osteopenia and osteoporosis prevalence after MS, the BMD did decrease significantly, which suggests that nutrient supplements and long-term follow-up are especially necessary postoperation.

Dietary supplements and bariatric surgery

Bariatric surgery or weight loss surgery has been in practice for achieving significant weight loss in patients who have failed to achieve weight loss after pharmacological interventions. The rising cases of obesity are a triggering factor for more bariatric surgeries worldwide. Interestingly, sustained weight loss achieved post-bariatric surgery offers metabolic advantages, and patients show improved glucose and lipid metabolisms. Bariatric surgery is directly linked to higher incidences of vitamin, mineral, and trace element deficiencies, thus making patients susceptible to anemia, osteoporosis, and cardiomyopathy. Reduced nutrient absorption capacity, dietary changes, dietary restriction, and altered gastrointestinal tract morphology are some reasons for nutritional deficiency observed in post-bariatric surgery procedures. Micro-and-macronutrient deficiency observed in patients during the postoperative phase requires continuous monitoring of nutritional parameters. Therefore, adequate multivitamin and mineral supplements become essential to prevent/overcome micronutrient deficiencies. Bariatric surgery also raises the risk of small for gestational age (SGA) babies. Hence, a 12 - 24 months gap is recommended between bariatric surgery and pregnancy to achieve desired weight loss targets. The topic of this review is the impact of bariatric surgery procedures on vitamin and mineral absorption and the role of dietary supplements in maintaining a healthy nutritional balance during the postoperative phase.

Nutritional Deficiencies Before and After Bariatric Surgery: Prevention and Treatment

PURPOSE OF REVIEW

Bariatric surgery has the unique ability to drive substantial and sustainable weight loss in people living with obesity. Non-reversibility of these surgical techniques provides lifelong benefits but entails the need for continuous medical follow-up. The purpose of the current paper is to review and summarize current data on nutritional deficiencies in patients before and after bariatric surgery.

RECENT FINDINGS

The cornerstone of preventing the emergence of disorders related to nutritional deficiencies is preoperative screening and correct supplementation since they may be exacerbated postoperatively. Following guidelines in conjunction to a lifelong personalized medical approach is of high importance. Bariatric surgery is a well-studied successful and durable means of weight loss that may lead to nutritional deficiencies. There is, thus, a medical need for careful monitoring and treatment of micro- and macronutrient deficiencies by an experienced multidisciplinary team.

Cutaneous signs of nutritional disorders

This review article focuses on the dermatologic manifestations of selected nutrient deficiencies, including protein-energy and micronutrient-related malnutrition. The various nutrient deficiencies presented may share common features. However, distinctive cutaneous signs may prompt clinicians to consider a nutritional cause and help distinguish a nutrient deficiency from other common dermatologic conditions. The recent reemergence of forgotten nutritional deficiencies, such as scurvy and pellagra, in the context of predisposing risk factors that may uniquely affect women more than men makes this topic timely. Recognition of nutritional disorders is important because appropriate treatment may reverse cutaneous signs and prevent irreversible sequelae.

Factors Associated with Nutritional Deficiency Biomarkers in Candidates for Bariatric Surgery: A Cross-Sectional Study in a Peruvian High-Resolution Clinic

Previous studies have described multiple nutritional deficiencies after bariatric surgery (BS). However, few studies have evaluated these deficiencies prior to BS, specifically in Latin America. This study aimed to determine the factors associated with nutritional deficiency biomarkers in candidates for BS in Peru. We included adults of both sexes, aged 18 to 59 years, admitted to a Peruvian clinic with a body mass index (BMI) ≥30 kg/m2; they were candidates for BS from 2017 to 2020. We considered the serum levels of hemoglobin and albumin (in tertiles) as the nutritional deficiency biomarkers. In order to assess the associated factors, we calculated crude (cPR) and adjusted prevalence ratios (aPR) with their respective 95% confidence intervals (95%CI). We analyzed 255 patients: 63.1% were males, with a mean age of 37.1 ± 10.3 years and mean hemoglobin and albumin values of 14.0 ± 1.5 g/dL and 4.6 ± 0.4 g/dL, respectively. We found that males (aPR = 1.86; 95%CI: 1.26–2.73; p = 0.002), participants between 30 and 49 (aPR = 2.02; 95%CI: 1.24–3.28; p = 0.004) or 50 years or more (aPR = 2.42; 95%CI: 1.35–4.35; p = 0.003), participants with a BMI ≥40 kg/m2 (aPR = 1.68; 95%CI: 1.09–2.60; p = 0.018), participants with impaired high-density lipoprotein levels (aPR = 1.43; 95%CI: 1.01–2.05; p = 0.049) and individuals in the high tertile of C-reactive protein (aPR = 6.94; 95%CI: 3.37–14.32; p < 0.003) had a higher probability of being in the lower tertile of albumin. In addition, we found that the male sex (aPR = 6.94; 95%CI: 3.37–14.32; p < 0.001) and elevated cholesterol levels (aPR = 0.71; 95%CI: 0.52–0.97; p = 0.034) were associated with the lowest hemoglobin tertile. In our setting, nutritional deficiency biomarkers were associated with sociodemographic, anthropometric and laboratory markers. The pre-bariatric surgery correction of nutritional deficiencies is essential, and can prevent major complications after surgery.

Malnutrition in Obesity: Is It Possible?

BACKGROUND

The World Health Organization (WHO) classifies malnutrition as the biggest threat to public health worldwide, and this condition is observed in 20-60% of hospitalized patients. Malnutrition is a state of the body in which due to insufficient supply or incorrect absorption of essential nutrients, the body composition changes and the body's functions are impaired. Malnutrition is associated not only with reduced body mass index but also with obesity.

SUMMARY

Obesity is defined as a paradoxical state of malnutrition, which despite excessive energy consumption is associated with a shortage of individual microelements. Deficiency or lack of homeostasis of essential micronutrients can significantly affect daily performance, intellectual and emotional state, but also the physical state of the body. Food deficiency can also contribute to further weight gain or the development of other metabolic diseases. Micronutrient deficiency may include not only incorrect dietary choices and insufficient access to nutrient-rich foods but also changes in the absorption, distribution or excretion of nutrients, and altered micronutrient metabolism resulting from systemic inflammation caused by obesity. An effective therapy method recommended for people with morbid obesity is bariatric surgery aimed at both weight loss and improving quality of life. Unfortunately, the effects of these treatments are often medium- and long-term complications associated with micronutrient deficiency as a result of reduced consumption or absorption. Therefore, the use of bariatric surgery in patients with extreme obesity can affect the metabolism of microelements and increase the risk of nutritional deficiencies. Key Messages: Studies by many authors indicate a higher incidence of food deficiency among people with excessive body weight, than in people with normal body weight of the same age and same sex. Monitoring the concentration of minerals and vitamins in blood serum is a good practice in the treatment of obesity. The proper nutritional status of the body affects not only the state of health but also the effectiveness of therapy. The aim of the review was to present the issue of malnutrition in the context of obesity.

Are There Ethnic Differences in Micronutrient Deficiencies in Preoperative Bariatric Patients? A Systematic Review and Meta-analysis

The purpose of this systematic review was to determine if in patients presenting for bariatric surgery, patients of different ethnicities, have different micronutrient deficiencies preoperatively. Databases searched were PubMed, Embase, MEDLINE and Cochrane Library. A meta-analysis of prevalence of vitamin D insufficiency (<20ng/ml) was carried out using a random effects model. Twenty-eight articles were included assessing preoperative micronutrient status across different ethnic groups. The most common micronutrient assessed was vitamin D, and the most assessed ethnicity was Caucasian. African Americans had the greatest prevalence of vitamin D insufficiency when compared to other ethnicities with a pooled prevalence and 95% confidence interval of 0.80 [0.74; 0.85]. There was a significant difference in vitamin D insufficiency when compared across ethnicities (p <0.01).

Perioperative nutrition care and dietetic practices in the scope of bariatric surgery in Saudi Arabia using adapted protocols for evaluation

Objectives:

This study evaluates the availability of perioperative nutritional care protocols and the practices of bariatric registered dietitians in Saudi Arabia. The primary outcomes of the study were conducted using an adapted American survey “with permission.”

Methods:

A cross-sectional survey of a selected 32 dietitians providing bariatric services completed a self-administered online questionnaire from 12 hospitals in Jeddah, Saudi Arabia.

Results:

All surveyed dietitians were females, mainly Saudi nationals (93.9%, n = 30), and accredited by the Saudi Commission for Health Specialties (93.8%, n = 30). Only 37.5% (n = 6) of the dietitians were specialized in bariatric surgery. Perioperative common practices of dietitians included a conduct of screening for nutrition risk before (44%, n = 14) and after surgery (62.5%, n = 20) and applied a nutrition management protocol that is mainly based on the application of nutrition care process (62.5%, n = 20). Dietitians (81%, n = 26) reported the importance of having standardized protocols for nutritional management of patients undoing bariatric surgery, where 69% (n = 22) confirmed the availability of pre-operative written protocols in hospitals and 75% (n = 24) confirmed the existence of post-operative protocols. Pre-operative practices included using approaches for weight loss before surgery, for example, very low and low-calorie diet. Dietitians (25%, n = 8) see two to ten patients per month. The sleeve gastrectomy procedure is the most often performed surgery.

Conclusion:

This is the first study to evaluate the perioperative nutrition care protocols and practices related to bariatric surgery in Saudi Arabia. Perioperative bariatric protocols are available, but some dietitians are not aware of their availability and contents. Researchers emphasize the importance of creating national protocols by the Saudi Credentials Body to standardize practices within the field.

A Pilot Study of Nutritional Status Prior to Bariatric Surgery in South China

Objective: The was a pilot study to assess the biochemical and historical information about bariatric patients before undergoing the surgery in the aim of identifying nutritional deficiencies and their prevalence from 2015 to 2020.

Methods: Clinical data of 247 patients (105 males and 142 females) were included. Vitamins, trace elements, electrolytes, albumin, globulin, hemoglobin, folate, ferritin, microalbuminuria (MAU), and parathyroid hormone (PTH) levels were determined to explore the nutritional status according to gender, age, high body mass index (BMI), and waist circumstance (WC).

Results: The mean age, mean BMI, and mean WC of the candidates were 32.95 ± 10.46 years, 38.01 ± 7.11 kg/m², and 117.04 ± 16.18 cm, respectively. The prevalence of preoperative nutritional deficiencies was 76.88% for 25 (OH) vitamin D, 19.84% for globulin, 11.74% for albumin, 11.02% for sodium, 8.33% for folic acid, 10.48% (male) and 6.34% (female) for chloride, 4.05% for calcium, 3.07% (male) and 0.70%(female) for ferritin, 11.90% for elevated PTH, and 44.96% for MAU. Males exhibited increased prevalence of globulin and MAU relative to females (P < 0.05). Older groups are more likely to exhibit albumin deficiency (P = 0.007), globulin deficiency (P = 0.003), and zinc deficiency (P = 0.015). In addition, 25 (OH) D deficiency and albumin deficiency were more common in patients with BMI ≥ 47.5 kg/m² (P = 0.049 and 0.015, respectively). Wider WC (≥150 cm) exhibited higher rates of albumin deficiencies (P = 0.011).

Conclusion: Electrolyte and nutritional deficiencies were common in patients prior to bariatric surgery in South China. Routine evaluation of electrolyte and nutritional levels should be carried out in this population.

Pre-operative micronutrient deficiencies in patients with severe obesity candidates for bariatric surgery

PURPOSE

In patients with obesity, micronutrient deficiencies have been reported both before and after bariatric surgery (BS). Obesity is a chronic pro-inflammatory status, and inflammation increases the risk of micronutrient malnutrition. Our objective was to assess in pre-BS patients the prevalence of micronutrient deficiencies and their correlation with blood values of C-reactive protein (CRP).

METHODS

Anthropometric data, instrumental examinations, and blood variables were centrally measured in the first 200 patients undergoing a pre-BS evaluation at the "Città della Salute e della Scienza" Hospital of Torino, starting from January 2018.

RESULTS

At least one micronutrient deficiency was present in 85.5% of pre-BS patients. Vitamin D deficiency was the most prevalent (74.5%), followed by folate (33.5%), iron (32%), calcium (13%), vitamin B12 (10%), and albumin (5.5%) deficiency. CRP values were high (> 5 mg/L) in 65% of the patients. These individuals showed increased rate of iron, folate, vitamin B12 deficiency, and a higher number of micronutrient deficiencies. In a multiple logistic regression model, increased CRP levels were significantly associated with deficiencies of vitamin B12 (OR = 5.84; 95% CI 1.25-27.2; p = 0.024), folate (OR = 4.02; 1.87-8.66; p < 0.001), and with the presence of ≥ 2 micronutrient deficiencies (OR = 2.31; 1.21-4.42; p = 0.01).

CONCLUSIONS

Micronutrient deficiencies are common in patients with severe obesity undergoing BS, especially when inflammation is present. In the presence of increased CRP values before surgery, it might be advisable to search for possible multiple micronutrient deficiencies.

Evaluation of Dietary Assessment Tools Used in Bariatric Population

Severe obesity is associated with major health issues and bariatric surgery is still the only treatment to offer significant and durable weight loss. Assessment of dietary intakes is an important component of the bariatric surgery process. Objective: To document the dietary assessment tools that have been used with patients targeted for bariatric surgery and patients who had bariatric surgery and explore the extent to which these tools have been validated. Methods: A literature search was conducted to identify studies that used a dietary assessment tool with patients targeted for bariatric surgery or who had bariatric surgery. Results: 108 studies were included. Among all studies included, 27 used a dietary assessment tool that had been validated either as part of the study per se (n = 11) or in a previous study (n = 16). Every tool validated per se in the cited studies was validated among a bariatric population, while none of the tools validated in previous studies were validated in this population. Conclusion: Few studies in bariatric populations used a dietary assessment tool that had been validated in this population. Additional studies are needed to develop valid and robust dietary assessment tools to improve the quality of nutritional studies among bariatric patients.

Nutritional Assessment and Preparation for Adult Bariatric Surgery Candidates: Clinical Practice

Bariatric surgery (BS) has proven to be highly efficacious in the treatment of obesity and its comorbidities. However, careful patient selection is critical for its success. Thus, patients should undergo medical, behavioral, and nutritional assessment by a multidisciplinary team. From the nutritional point of view, BS candidates should undergo nutritional assessment, preparation, and education by a registered dietitian in the preoperative period. Currently, detailed specified and comprehensive information on these topics is lacking. The present narrative review aimed to summarize the available literature concerning both the preoperative nutritional assessment components and the preoperative nutritional preparation and education components of patients planning to undergo BS. Current literature indicates that proper management before BS should include a comprehensive nutritional assessment, in which it is advisable to perform a clinical interview to assess patients' medical background, weight management history, eating patterns and pathologies, oral health, physical activity habits, nutritional status, supplementation usage, BS knowledge, surgery expectations and anthropometric measurements. Nutritional preparation and educational strategies should include an individualized preoperative weight-loss nutrition program, improvement of glycemic control, micronutrients deficiencies correction, eating and lifestyle habits adaptation, physical activity initiation, and strengthening knowledge on obesity and BS. At this stage, more well-designed intervention and long-term cohort studies are needed in order to formulate uniform evidence-based nutritional guidelines for patients who plan to undergo BS, including populations at higher nutritional risk. Moreover, postoperative outcomes of presurgical nutritional intervention programs should be studied.

The Effects of Bariatric Surgery on Vitamin B Status and Mental Health

Diet is a modifiable factor that ensures optimal growth, biochemical performance, improved mood and mental functioning. Lack of nutrients, notably vitamin B, has an impact on human health and wellbeing. The United Arab Emirates is facing a serious problem of micronutrient deficiencies because of the growing trend for bariatric surgery, including Roux-en-Y gastric bypass and sleeve gastrectomy. People undergoing bariatric surgery are at high risk of developing neurological, cognitive, and mental disabilities and cardiovascular disease due to deficiency in vitamin B. Vitamin B is involved in neurotransmitter synthesis, including γ-aminobutyric acid, serotonin, dopamine, and noradrenaline. Deficiency of vitamin B increases the risk of depression, anxiety, dementia and Alzheimer's disease. In addition, vitamin B deficiency can disrupt the methylation of homocysteine, leading to hyperhomocysteinemia. Elevated homocysteine levels are detrimental to human health. Vitamin B deficiency also suppresses immune function, increases the production of pro-inflammatory cytokines and upregulates NF-κB. Considering the important functions of vitamin B and the severe consequences associated with its deficiency following bariatric surgery, proper dietary intervention and administration of adequate supplements should be considered to prevent negative clinical outcomes.

An Innovative Approach to Designing Digital Health Solutions Addressing the Unmet Needs of Obese Patients in Europe

According to the World Health Organization (WHO), the worldwide obesity rate has tripled since 1975. In Europe, more than half of the population is overweight and obese. Around 2.8 million people die each year worldwide as a result of conditions linked to being overweight or obese. This study aimed to analyze the policies, approaches, and solutions that address the social and health unmet needs of obese patients, at different levels, in order to simulate the definition of an integrated approach, and to provide and share examples of innovative solutions supporting health promotion, disease prevention, and integration of services to improve the collaboration between the different health and care stakeholders involved across the country and in the lives of obese patients. A collaborative approach involving various levels of government and regional experts from different European countries was applied to identify, explore, and evaluate different aspects of the topic, from the innovation perspective and focusing on a European and a regional vision. Currently, people prefer more foods rich in fats, sugars, and salt/sodium than fruits, vegetables, and fiber. This behavior leads to a significant negative impact on their health-related quality of life. Changes in healthcare systems, healthy policy, and approaches to patient care and better implementation of the different prevention strategies between all the stakeholders are needed, taking advantage of the digital transformation of health and care. Such changes can support obese patients in their fight against an unhealthy lifestyle and at the same time reduce healthcare costs.

The hematologic consequences of obesity

The prevalence of obesity is increasing and progressively influencing physician-patient interactions. While there is a sizable amount of data demonstrating that obesity is a state of low-grade inflammation, to our knowledge, there is no single review summarizing its effects on hematologic parameters and thrombotic risk. We performed a literature search which largely surfaced observational studies, with a few systematic reviews and meta-analyses of these studies. We took care to review the mechanisms driving an inflammatory state and obesity's effect on white blood cells, red blood cells, platelets, and thrombotic risk. There is an observed relative, and sometimes absolute leukocytosis driven by this inflammatory state. Obesity is also associated with increased platelet counts and an increased risk for venous thromboembolism (VTE). Lastly, the association between obesity, iron deficiency (ID), and red blood cell counts may be present but remains uncertain. Recognizing the above associations may provide clinicians with reassurance regarding otherwise unexplained hematologic abnormalities in obese individuals. We hope this review will prompt future studies to further understand the underlying mechanisms driving these abnormalities and identify modifiable risk factors and potential therapeutic targets to prevent the development of probable obesity-associated conditions with significant morbidity and mortality, such as ID and VTE.

Prevalence of thiamine deficiency is significant in patients undergoing primary bariatric surgery

BACKGROUND

Patients undergoing metabolic and bariatric surgery are prone to developing micronutrient deficiencies, necessitating life-long nutritional supplementation and monitoring. Historically, these deficiencies were thought to be driven by postsurgical changes in absorption. Recent data, though, have demonstrated that obesity alone is also associated with micronutrient deficiencies. Thiamine deficiency, in particular, can lead to permanent neurologic deficits.

OBJECTIVE

Identify thiamine deficiency prevalence within the preoperative metabolic and bariatric surgery patient population.

SETTING

Single institution academic medical center.

METHODS

A retrospective review of deidentified data was examined that included whole blood thiamine measured from consecutive patients from April 2018 to June 2019 (n = 346). Cohort characteristics were assessed including age, operation, preoperative weight, and race/ethnicity. The majority of the cohort were women (83%) with an average age of 44.9 years. Racial representation included White/Caucasian (73%) and Black (21%), while operations included Roux-en-Y gastric bypass (58%), sleeve gastrectomy (31%), and revisions (10%).

RESULTS

Thiamine concentration was normally distributed with a mean of 144 nM. Overall, 3.5% of patients had thiamine concentrations below the lower limit of normal of <70 nM, while 35 additional patients (14%) were at risk for thiamine deficiency with concentrations <100 nM. On the average, these patients were of similar age and were all undergoing primary procedures (50% gastric bypass, 50% sleeve gastrectomy). Regression methods demonstrated that patients with thiamine deficiency tended to be females with higher body mass index, even after controlling for sex, height, and preoperative weight. After covariate adjustment, male sex and increasing height were both associated with higher thiamine concentration.

CONCLUSION

Previously quoted rates of thiamine deficiency in the preoperative patient are variable, but we describe a significant number of patients with, or at risk of, thiamine deficiency. Male sex and increasing height are likely associated with increased skeletal muscle mass, which is enriched with thiamine. Routine thiamine measurement, either preoperatively or at the time of surgery, is warranted given its limited stores within the body and potential catastrophic complications associated with acute or chronic deficiency.

Prevalence of nutritional deficiencies in bariatric surgery candidates and its effect on metabolic status

BACKGROUND

Nutritional deficiencies are common among obese individuals and constitute one of the main concerns in the bariatric field. The aim of this study was to investigate nutritional status in bariatric surgery candidates, comparing individuals with and without metabolic syndrome (MetS) and to explore possible associations between nutritional and metabolic status.

METHODS

Patients accepted for gastric sleeve surgery between 2010 and 2015 were included and anthropometric and metabolic parameters were recorded before surgery. Univariate and multivariate analyses were applied in order to find possible associations between MetS, nutritional, anthropometric, and metabolic parameters.

RESULTS

A total of 330 patients were evaluated (285 females, mean age of 41.88 ± 10.4 years old, mean body mass index 43.91 ± 6.2 kg/m²) and MetS was present in 47% of them. Patients without MetS presented a higher prevalence of folate deficiency (12 vs. 2%, p < 0.001). Male gender, older age, lower magnesium levels, and higher BMI and calcium levels were predictors of a greater number of MetS components. Male gender, a greater number of MetS components, and lower magnesium were predictors of higher homeostatic model assessment for insulin resistance (HOMA-IR).

CONCLUSIONS

The rising prevalence of obesity is causing a parallel increase in the use of bariatric surgery. The high occurrence of preoperative nutritional deficiencies can impair metabolic status and contribute to a worse outcome after surgery. Nutritional assessment and improvement before surgery may be crucial to optimize patient status, and future studies should explore the effect of the correction of these deficiencies in the metabolic status of these patients.

Essential trace elements in Norwegian obese patients before and 12 months after Roux-en-Y gastric bypass surgery: Copper, manganese, selenium and zinc

OBJECTIVES

The objective of the present study was to assess trace element status in morbidly obese subjects before and one year after Roux-en-Y gastric bypass (RYGB) in order to identify possible deficiencies.

METHODS

The study population included 46 patients in the age range 27-59 years, the majority (85 %) were women. The enrolled patients attended an eight week course on lifestyle changes before bariatric surgery. After RYGB they were recommended daily micronutrient supplements with a commonly used multivitamin-mineral tablet in addition to intramuscular vitamin B₁₂ injections (1 mg) every third month for 12 months. Whole blood concentrations of Cu, Mn, Se and Zn were determined using high resolution inductively coupled plasma mass spectrometry.

RESULTS

During the 12 months follow up after bariatric surgery, the patients had lost mean 32.3 kg and median whole blood concentrations of Cu (-16 %) were reduced, Mn (+14 %) and Zn (+6%) were increased, while the Se values were essentially unchanged. Compared with reference ranges, median postoperative concentrations of all essential trace elements were either below (Zn) or in the lower reference range (Cu, Mn, Se).

CONCLUSION

Essential trace elements were below or in the lower reference range twelve months after RYGB. Our results indicate a need for updated guidelines in Nordic countries for trace metal monitoring and supplements in patients after bariatric surgery, especially when gastric bypass surgery is used. Further studies are required to explore and prevent trace element deficiency related to obesity and bariatric surgery.

The Effect of Zinc Supplementation on Steatosis Severity and Liver Function Enzymes in Overweight/Obese Patients with Mild to Moderate Non-alcoholic Fatty Liver Following Calorie-Restricted Diet: a Double-Blind, Randomized Placebo-Controlled Trial

The role of zinc is known in balancing the oxidant/antioxidant system and also in improving insulin resistance in many diseases. Recently, in vivo and in vitro studies revealed roles of zinc on lipophagy and suppressing hepatic lipid deposition. The present study is the first double-blind randomized clinical trial that investigated the effect of zinc supplement on clinical manifestations and anthropometric parameters of overweight/obese non-alcoholic fatty liver patients following calorie-restricted diet. Fifty-six overweight/obese subjects with confirmed non-alcoholic fatty liver disease (NAFLD) using ultrasonography were randomized to treatment (calorie-restricted diet plus 30 mg/day zinc supplement) or placebo (calorie-restricted diet and placebo) groups. Serum liver enzymes and liver steatosis were measured at the baseline and 12 weeks post-intervention. Anthropometric measurements and food recalls were collected at the beginning, weeks 6 and 12. Zinc supplementation significantly elevated serum zinc concentrations in the treatment group (p < 0.001). Treatment also reduced alanine aminotransferase and γ-glutamyl transpeptidase enzymes in the treatment group (p < 0.05). Waist circumference was also significantly lowered in the zinc group (p < 0.05). Liver steatosis and fatty liver index changes were not significant between the groups. Overall, beneficial effects of zinc supplementation were shown on serum levels of zinc and liver enzymes in overweight/obese NAFLD patients.

Double burden of malnutrition in persons with obesity

A paradoxical double challenge has emerged in the last decades with respect to nutrition and nutrition-related clinical conditions. Hunger-related undernutrition continues to represent an unacceptable burden, although its prevalence has been encouragingly reduced worldwide. On the other hand, the prevalence of overweight and obesity, defined as fat excess accumulation with negative impact on individual health, has dramatically increased due to increasingly pervasive obesogenic lifestyle changes. Undernutrition and obesity may coexist in world regions, Countries and even smaller communities and households, being referred to as double burden of malnutrition. It is however important to point out that fat accumulation and obesity may also induce additional nutritional derangements in affected individuals, both directly through metabolic and body composition changes and indirectly through acute and chronic diseases with negative impact on nutritional status. In the current narrative review, associations between fat accumulation in obesity and malnutrition features as well as their known causes will be reviewed and summarized. These include risk of loss of skeletal muscle mass and function (sarcopenia) that may allow for malnutrition diagnosis also in overweight and obese individuals, thereby introducing a new clinically relevant perspective to the obesity-related double burden of malnutrition concept.

Bariatric Surgery in Vegetarians: Asia-Pacific Metabolic and Bariatric Surgery Society (APMBSS) survey of Asian surgeon experience

PURPOSE

Bariatric and metabolic surgery is increasing in Asia to address the growing obesity epidemic. Literature is scarce regarding this surgery in vegetarian patients. We aim to survey surgeons regarding their practices and experiences with the vegetarian population.

MATERIALS AND METHODS

The regional bariatric and metabolic surgery society distributed a multi-national electronic questionnaire to surgeon members. The questionnaire was in the English and Chinese languages.

RESULTS

Fifty-six bariatric and metabolic surgeons responded to the questionnaire (response rate 40.6%). Twenty-two respondents (48.9%) have vegetarian patients in their case volume. Patients mostly consume a vegetarian diet for religious (66.7%) and health (66.7%) reasons. More than 60% of surgeons are unsure of micronutrient deficiency status amongst these patients. Over half of the respondents (58.8%) reported that their vegetarian patients do not take multivitamins or vitamin supplements. Significant proportions of respondents (44.4-61.1%) were unsure of the iron, vitamin B12, vitamin D, zinc, and folic acid deficiency status of these patients. Only 38.9% of respondents routinely prescribe multivitamin supplementation.

CONCLUSIONS

Vegetarian bariatric patients in East and South-East Asia are an under-recognized patient cohort at risk of micronutrient deficiencies. There is a knowledge gap among regional surgeons in long-term nutritional assessment and management.

Recommendations Based on Evidence by the Andalusian Group for Nutrition Reflection and Investigation (GARIN) for the Pre- and Postoperative Management of Patients Undergoing Obesity Surgery

In order to develop evidence-based recommendations and expert consensus for nutrition management of patients undergoing bariatric surgery and postoperative follow-up, we conducted a systematic literature search using PRISMA methodology plus critical appraisal following the SIGN and AGREE-II procedures. The results were discussed among all members of the GARIN group, and all members answered a Likert scale questionnaire to assess the degree of support for every recommendation. Patients undergoing bariatric surgery should be screened preoperatively for some micronutrient deficiencies and treated accordingly. A VLCD (Very Low-Calorie Diet) should be used for 4-8 weeks prior to surgery. Postoperatively, a liquid diet should be maintained for a month, followed by a semi-solid diet also for one month. Protein requirements (1-1.5 g/kg) should be estimated using adjusted weight. Systematic use of specific multivitamin supplements is encouraged. Calcium citrate and vitamin D supplements should be used at higher doses than are currently recommended. The use of proton-pump inhibitors should be individualised, and vitamin B12 and iron should be supplemented in case of deficit. All patients, especially pregnant women, teenagers, and elderly patients require a multidisciplinary approach and specialised follow-up. These recommendations and suggestions regarding nutrition management when undergoing bariatric surgery and postoperative follow-up have direct clinical applicability.

Role of micronutrients in staging of nonalcoholic fatty liver disease: A retrospective cross-sectional study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) presents high incidence throughout the world and has been progressively increasing in prevalence. This disease has a heterogeneous natural history, including simple steatosis, nonalcoholic steatohepatitis (NASH), and cirrhosis. The factors that determine its evolution to more severe forms of the disease are still poorly understood, and micronutrients with antioxidant potential may be involved in the pathophysiology of the disease.

AIM

To evaluate the relationship between serum levels of micronutrients and the severity of NAFLD.

METHODS

A retrospective, observational and cross-sectional study was conducted. This study included all patients undergoing bariatric surgery who experienced liver biopsy during the procedure, and had serum levels of micronutrients (vitamin D, vitamin B12, zinc, iron, and magnesium), which was assessed in a preoperative evaluation conducted at a reference center in southern Brazil.

RESULTS

A total of 614 patients were analyzed, of which 93% had steatosis, 70.7% had NASH, and 49.3% had some degree of fibrosis. Serum levels of vitamin D were negatively correlated with the severity of steatosis and NASH, and serum levels of vitamin B12 were positively correlated with the severity of steatosis and fibrosis. The other micronutrients showed no association with NAFLD staging.

CONCLUSION

Serum levels of vitamin D are inversely related to the severity of steatosis and NASH, and serum levels of vitamin B12 are higher in more advanced stages of simple steatosis and liver fibrosis. Serum levels of zinc, iron, and magnesium were not associated with NAFLD severity.

Common and Rare Complications of Bariatric Surgery

As the prevalence of obesity has increased, bariatric surgery has become more common because of its proven efficacy at promoting weight loss and improving weight-related medical comorbidities. Although generally successful, bariatric surgery may also lead to complications and negatively affect health. This article highlights some common and rare complications of bariatric surgery. Specifically, it discusses the risk of nutrient deficiencies (which is influenced by surgery type) and their downstream effects, including ill-effects on bone health. Rarer complications, such as postbypass hypoglycemia and alcohol use disorder, are also discussed.

The interaction between dietary patterns and melanocortin-4 receptor polymorphisms in relation to obesity phenotypes

INTRODUCTION

Data shows that interactions between dietary factors and genetic variants can modulate the association of polymorphisms such as the Melanocortin-4 receptor (MC4R) gene with obesity. Considering the limited data available on this topic we aimed to investigate interactions between dietary patterns (DPs) and MC4R polymorphisms in relation to obesity phenotypes.

METHODS

This cohort study was performed in the framework of Tehran Lipid and Glucose Study; for eligible participants in this study (n=3850), the median follow-up was 4 years. DPs were determined using factor analysis. The genotypes of polymorphisms (17782313rs and 12970134rs) were identified and their interaction with DPs were assessed in relation to incidence of obesity phenotypes including central obesity, general obesity and visceral adiposity dysfunction.

RESULTS

The mean age of participants (62.5% females) were 37.0±13.7 years. Two main DPs (healthy and unhealthy) were extracted. C-allele carriers of rs17782313 in higher quartiles of the healthy DP score had a significant decrease in the incidence of general obesity, compared to those who had the TT genotype (HR=0.61, 95% CI=0.42-0.89, P interaction=0.01). For rs12970134 A-allele carriers, subjects in the second compared to the first quartile of the healthy DP score, had a significant decrease in the incidence of general obesity (HR=0.68, 95% CI=0.46-0.99). There were no significant interaction between DPs and MC4R variants in relation to other obesity phenotypes.

CONCLUSION

Our results indicate that the healthy DP could interact with rs17782313 in relation to incidence of general obesity.

Nutritional Deficiencies, Bariatric Surgery, and Serum Homocysteine Level: Review of Current Literature

Obesity is currently one of the biggest global health problems. In the case of severe obesity, bariatric surgeries are considered to be the most important method of treatment. The 2 most commonly performed bariatric surgery procedures include Roux-en-Y gastric bypass and sleeve gastrectomy. However, these methods are not free from complications, and the most common ones (moderately long or long term) are micronutrient deficiencies. The deficiency of vitamins B6, B12, and folic acid as cofactors of the folate cycle contributes to the development of hyperhomocysteinemia. It seems that apart from nutritional factors, there are other aspects that have a significant influence on the concentration of homocysteine in blood, such as the type of conducted bariatric surgery, the post-surgical concentration of betaine and creatinine, and the clearance of methionine (i.e., the mutations of the gene that encodes the MTHFR reductase as well as other genes associated with the process of methylation, e.g., methionine synthase). Their presence might be one of the causes of the increased concentration of homocysteine after surgery despite the fact that patients take vitamin-mineral supplementation.

Anemia Before and After Roux-en-Y Gastric Bypass: Prevalence and Evolution on Long-Term Follow-up

PURPOSE

Anemia due to iron deficiency or inflammatory state is often associated with obesity. Bariatric surgery is responsible for increasing iron deficiency, but weight loss decreases the inflammatory state associated with obesity. The objective of our study was to investigate the prevalence and causes of anemia before and after bariatric surgery for severe obesity in a 5-year follow-up.

MATERIALS AND METHODS

Retrospective study, with electronic record analysis of obese patients, submitted to Roux-en-Y gastric bypass. Laboratory data were collected before and up to 60 months after surgery. Diagnosis and classification of anemia were done according to hemoglobin levels, serum ferritin, and transferrin saturation.

RESULTS

Preoperatively, 8.8% of patients had anemia (93.2%, mild), and 43.8% of the patients had anemia due to chronic disease. After 24 months, there was a progressive increase of iron-deficiency anemia (72.4%) and decrease in anemia due to chronic disease (15.5%) and mixed (12.1%), with maintenance of this profile during long-term follow-up.

CONCLUSION

Anemia is very frequent in severely obese patients and must be investigated both before and after bariatric surgery. The cause of anemia must be determined in order to use the best treatment available. We observed a reduction in the prevalence of chronic disease anemia during long-term follow-up probably due to the improvement in the systemic inflammatory state.

Bone Metabolism in Adolescents and Adults Undergoing Roux-En-Y Gastric Bypass: a Comparative Study

OBJECTIVE

To compare the bone metabolism of adolescents and adults with obesity before undergoing a Roux-en-Y gastric bypass (RYGB) and 6 and 12 months after the surgery.

MATERIALS AND METHODS

Adolescents (G1) and adults (G2) with obesity assessed before (T0), six (T1), and 12 months after (T2) RYGB. Sun exposure, serum concentrations of 25(OH)D, calcium, phosphorous, magnesium, zinc, alkaline phosphatase, parathyroid hormone (PTH), and bone mineral density (BMD) were evaluated.

RESULTS

Sixty adolescents and 60 adults were assessed. At T0, there was no significant difference between the groups' serum 25(OH)D levels (G1 21.87 + 7.52 ng/mL, G2 21.73 + 7.60 ng/mL, p = 0.94) or sun exposure (G1 17 ± 2.0 min/day, G2 13.2 ± 5.2 min/day, p = 0.85). G1 had high levels of inadequacy of calcium (66.7%), phosphorous (80.0%), and zinc (18.3%) at T0 and had a significant fall in their 25(OH)D (p < 0.01) and magnesium (p < 0.01) levels from T1 to T2. G2 saw a significant lowering of their serum zinc levels from T0 to T1 and T2 (T1 p < 0.01; T2 p < 0.01). In both groups, there was a significant rise in PTH from T1 to T2 (G1 p = 0.04, G2 p = 0.02) and from T0 to T2 (G1 and G2 p < 0.01). In G2, 40.4% of individuals with osteopenia and osteoporosis presented inadequacy of 25(OH)D.

CONCLUSION

RYGB was found to worsen the inadequacy of micronutrients related to bone metabolism and was associated with secondary hyperparathyroidism and low BMD values, especially among the adolescents. The irreversible damaging effects of obesity on bone metabolism can occur in adolescence.

Review: Sex-Specific Aspects in the Bariatric Treatment of Severely Obese Women

This systematic literature review aims to point out sex-specific special features that are important in the bariatric treatment of women suffering from severe obesity. A systematic literature search was carried out according to Cochrane and Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines. After the literature selection, the following categories were determined: sexuality and sexual function; contraception; fertility; sex hormones and polycystic ovary syndrome; menopause and osteoporosis; pregnancy and breastfeeding; pelvic floor disorders and urinary incontinence; female-specific cancer; and metabolism, outcome, and quality of life. For each category, the current status of research is illuminated and implications for bariatric treatment are determined. A summary that includes key messages is given for each subsection. An overall result of this paper is an understanding that sex-specific risks that follow or result from bariatric surgery should be considered more in aftercare. In order to increase the evidence, further research focusing on sex-specific differences in the outcome of bariatric surgery and promising treatment approaches to female-specific diseases is needed. Nevertheless, bariatric surgery shows good potential in the treatment of sex-specific aspects for severely obese women that goes far beyond mere weight loss and reduction of metabolic risks.

Bariatric Surgery in Obesity: Effects on Gut Microbiota and Micronutrient Status

Obesity is associated with reduced gut microbial diversity and a high rate of micronutrient deficiency. Bariatric surgery, the therapy of choice for severe obesity, produces sustained weight loss and improvements in obesity-related comorbidities. Also, it significantly alters the gut microbiota (GM) composition and function, which might have an important impact on the micronutrient status as GM is able to synthesize certain vitamins, such as riboflavin, folate, B12, or vitamin K2. However, recent data have reported that GM is not fully restored after bariatric surgery; therefore, manipulation of GM through probiotics represents a promising therapeutic approach in bariatric patients. In this review, we discuss the latest evidence concerning the relationship between obesity, GM and micronutrients, the impact of bariatric surgery on GM in relation with micronutrients equilibrium, and the importance of the probiotics' supplementation in obese patients submitted to surgical treatment.

Nutritional Deficiencies in Patients with Severe Obesity before Bariatric Surgery: What Should Be the Focus During the Preoperative Assessment?

BACKGROUND

Nutritional deficiencies are a well-recognized long-term complication following bariatric surgery. The presence of preoperative deficiencies has been shown to be predictive of postoperative deficiencies.

OBJECTIVE

The aim of the study was to investigate the prevalence of micronutrient deficiency in a large sample of patients with severe obesity preoperatively, and to determine whether such deficiencies may be related to patient's sex, body mass index, or ethnic subgroup.

DESIGN

A cross-sectional study of data collected at the time of the preoperative evaluation.

PARTICIPANTS/SETTING

Data were collected during the preoperative evaluation of 872 bariatric surgery candidates in a university hospital in Israel between 2011 and 2018. The patients were 72.9% women, with a mean age of 37.9±12.1 years and mean body mass index of 42.4±4.7 MAIN OUTCOME MEASURES: Nutritional deficiencies according to blood assays. Data on anthropometrics, comorbidities, and demographic characteristics was also collected.

STATISTICAL ANALYSES

Baseline differences between patient subgroups were analyzed using independent-samples t test, analysis of variance, or χ² test.

RESULTS

Deficiencies of vitamin D, iron, folate, vitamin B-12, elevated parathyroid hormone and low transferrin saturation were present in 75.2%, 42.6%, 28.5%, 8.5%, 35.5%, and 70% of patients, respectively. Nutritional deficiencies were significantly more common among women compared with men for iron (45.9% vs 33.5%; P=0.002), low transferrin saturation (77.7% vs 44.6%; P<0.001), vitamin D (77.5% vs 69.2%; P=0.019) and elevated parathyroid hormone level (39.5% vs 22.9%; P=0.002). Iron, transferrin saturation, and vitamin D deficiencies were more prevalent in Arab patients compared with Jewish patients: 59.6% vs 36%; P<0.001, 80.2% vs 62.8%; P=0.003, and 85.1% vs 71.6%; P<0.001, respectively. Vitamin D and iron deficiency were more common among higher body mass index subgroups (P=0.004 and P=0.040, respectively).

CONCLUSIONS

The results indicate a high prevalence of nutritional deficiencies, mainly of iron and vitamin D in bariatric surgery candidates. Patients at higher risk for nutritional deficiencies include those with higher body mass index, women, and Arabs.

Prevalence of Micronutrient Deficiencies Prior to Bariatric Surgery: Tehran Obesity Treatment Study (TOTS)

BACKGROUND

Micronutrient deficiencies are major concerns after bariatric surgery, although these conditions often go undiagnosed pre-surgery.

OBJECTIVE

To assess pre-surgery micronutrient status of an Iranian population of morbidly obese candidates of bariatric surgery in a cross-sectional study.

METHODS

A cross-sectional analysis of 2008 candidates for bariatric surgery, aged 15-65 years, with either body mass index (BMI) ≥ 40 kg/m² or 30 < BMI < 35 kg/m² with a medical comorbidity was conducted. In order to determine the micronutrient status of participants, blood samples were collected to assess serum concentrations of vitamins (B12 and D), minerals (copper, calcium, phosphate, and zinc), and iron profiles (total iron binding capacity, iron concentration, ferritin, and iron saturation), according to standard protocol.

RESULTS

The mean age and BMI of patients (79.3% female) were 37.8 years and 44.8 kg/m², respectively. Deficiencies were found for 25(OH) D (53.6%), vitamin B12 (34.4%), serum iron (10.2%), and low levels of hemoglobin (16.6%). The prevalence of other deficiencies were all below 10%. Body mass index had a negative correlation with iron, calcium, vitamin B12, and 25(OH) D and was positively correlated with copper.

CONCLUSION

Micronutrient deficiencies, including vitamin D, vitamin B12, and iron, are commonly found among morbidly obese subjects who are potential candidates of bariatric surgery.

The alteration of ferritin and transferrin saturation under body mass index and blood pressure in first-time and regular male blood donors in Taiwan

Iron status, body mass index (BMI) and blood pressure (BP) are all important health indicators. In this study, ferritin and transferrin saturation levels and their correlations with BMI and BP were investigated in first-time and regular male blood donors in Taiwan. Serum ferritin and transferrin saturation values represented iron status of blood donors. Serum ferritin, serum iron, and total iron binding capacity (TIBC) were determined by chemiluminescent immunoassay sandwich method, timed-endpoint method, and turbidimetric method, respectively. Transferrin saturation was calculated as 100× serum iron/TIBC. Statistical analyses included 2-sample t test, chi-square test, Pearson correlation coefficient, and multiple linear regression. Comparisons of ferritin and transferrin saturation mean values with BMI, age, systolic blood pressure (SBP), diastolic blood pressure (DBP), and occupation were conducted. A total of 111 first-time donors and 1249 regular blood donors participated in this study. The ferritin and transferrin saturation mean values of regular male blood donors were lower than those of first-time male blood donors, but remained within the safe range. BMI was positively correlated with serum log ferritin, but not with transferrin saturation value in first-time and regular blood donors. First-time donors with BMI ≥24 kg/m and aged more than 40 years demonstrated 1.37-fold higher serum ferritin on average. Among regular donors, significant effects of BMI ≥24 kg/m and age >40 years were observed with 1.25- and 1.18-fold higher serum ferritin levels, respectively. First-time donors with SBP ≥120/DBP ≥80, ≥120/<80, and <120/≥80 mm Hg had on average 1.65-, 1.54-, and 2.59-fold higher serum ferritin levels than those with normal BP. Ferritin level was higher in BMI ≥24 kg/m subgroup than in BMI <24 kg/m subgroup among first time and regular male donors, but no difference was found in transferrin saturation values.Abnormal SBP/DBP was associated with increased ferritin level only in first-time male blood donors.

Folate and Vitamin B12 in Morbid Obesity: The Influence of Folate on Anti-Atherogenic Lipid Profile

Previous studies showed a high prevalence of micronutrient deficiencies in obese subjects, with low folate and vitamin B12 serum levels and intakes. Correlations between vitamins and lipids have been investigated both in animal and human studies. The aim of our study is to evaluate the influence of dietetic and serum levels of folate and vitamin B12 on lipid pattern in morbidly obese subjects. We also analysed the relationship between serum concentrations and dietary intake of these micronutrients, and compared the intakes to the Recommended Levels of Nutrients and Energy Intakes (LARN). In 122 morbidly obese patients, mean BMI 45 ± 7 kg/m², we evaluated anthropometric parameters, hepatic, glyco/lipid profile, total folate and vitamin B12, blood pressure, and finally nutritional intakes in a subgroup of 68 patients using a food frequency questionnaire about the frequency of food consumption and daily water intake. These values were determined in obese patients before and one year after sleeve gastrectomy. Both before and after surgery, levels of vitamins and minerals remained in normal range compared to LARN. According to univariate analysis, at baseline folate showed a significantly positive correlation with high-density lipoprotein cholesterol (p = 0.028, ρ = 0.204), apolipoprotein A-I (p = 0.006, ρ = 0.268) and vitamin B12 (p = 0.040, ρ = 0.192), and a significantly negative correlation with triglycerides (p = 0.049, ρ = -0.184). Folate and vitamin B12 levels do not correlate with their nutritional intakes, which remain within recommended range after surgery. In conclusion the correlation between folate and anti-atherogenic lipid profile is confirmed also in a large group of morbid obese patients.

Prevalence of Micronutrient Deficiency in Patients with Morbid Obesity Before Bariatric Surgery

BACKGROUND

Postoperative micronutrient deficiency is a known side effect of bariatric surgery. In this study, we examined the prevalence of micronutrient deficiency in patients with morbid obesity (MO) preoperatively.

METHODS

A total of 1732 patients with MO wishing to undergo bariatric surgery (age: 40 ± 12 years, mean BMI: 44 ± 9 kg/m², means ± SD, 77.3% female) were analyzed in this cross-sectional examination. Iron state, vitamin B12, folic acid, 25hydroxy(OH)-vitamin D, PTH, vitamin A, and vitamin E levels were determined. Subsequently, patients underwent nutritional counseling and were substituted accordingly.

RESULTS

A total of 63.2% (n = 1094) of the patients had a deficit in folic acid (< 5.3 ng/ml), 97.5% (n = 1689) in 25OHvitamin D (< 75 nmol/l), and 30.2% (n = 523) had a PTH elevation (> 56.9 pg/ml). A total of 5.1% (n = 88) of the patients presented with a deficit in vitamin B12 (< 188 pg/ml) and 6.2% (n = 107) in vitamin A (< 1.05 μmol/l). A total of 9.6% (n = 166) exhibited iron deficiency (ferritin < 15 μg/l). None of the patients had a deficit in vitamin E. There were no gender differences except for ferritin deficiency (women 11.8% vs. men 1.5%, p < 0.001). Patients in the highest BMI tertile had significantly more often a deficit in vitamin D (p = 0.033) and folic acid (p < 0.001). Patients in the lowest age tertile had significantly more often a deficit in folic acid (p < 0.001).

CONCLUSIONS

Our data show a high prevalence of micronutrient deficiency in patients with morbid obesity preoperatively and emphasize the importance of exact preoperative evaluation and adequate substitution as well as postoperative surveillance.