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Bretón I, Velasco C, Cuerda C, Motilla M, Serrano C, Morales Á, Carrascal ML, Lopez Lazareno N, Gonzalez-Estecha M, Ballesteros-Pomar MD, Rubio-Herrera MÁ. Minerals and trace elements in pregnancy in women with previous bariatric surgery consequences on maternal and foetal health. J Trace Elem Med Biol 2024; 85:127458. [PMID: 38772250 DOI: 10.1016/j.jtemb.2024.127458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 03/10/2024] [Accepted: 04/16/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Bariatric surgery (BS) may decrease the risk of these obesity-related complications; however, due to its effect on nutrient intake and absorption, it can also have adverse consequences on maternal and foetal health. The aim of this study is to describe the evolution of electrolytes and trace elements serum levels throughout pregnancy after BS, according to the surgical technique and to evaluate the effect of nutritional deficiencies on the risk of maternal-foetal complications. METHODS This is a retrospective observational study of the clinical evolution and maternal-foetal complications in a group of women with pregnancies that occurred after BS. Clinical evolution during pregnancy, body weight, and plasma electrolytes, vitamins, and trace elements, as well as their influence on maternal-foetal outcomes were evaluated. Composite neonatal variable (CNV) was defined to evaluate unfavourable foetal outcome. Published reference values for micronutrients during pregnancy have been used. RESULTS The study includes data on 164 singleton pregnancies in 91 women. A hundred and twenty-seven pregnancies got to full term. The average birth weight was 2966 (546) g., 26.8% < P10 and 13.8% < P3 of a reference population. New-born of gestations after malabsorptive bariatric surgery had a higher risk of having a percentile of birth weight < P3. Plasma electrolytes, trace elements and vitamins throughout pregnancy showed differences depending on the surgical technique, with lower haemoglobin, ferritin, calcium, zinc, copper, vitamin A and vitamin E in the malabsorptive techniques. A high percentage of deficiency was observed, especially in the third trimester (Hb < 11 g/dl: 31.8%; ferritin < 30 mg/ml: 85.7%; zinc < 50 μg/dl: 32.4%, vitamin D < 30 ng/ml: 75.5% and < 20 ng/ml: 53.3%). A decreased plasma copper in the first trimester or zinc in the third trimester were associated with a lower percentile of new-born birth weight. A higher risk of CNV was observed in predominant malabsorptive BS and in pregnancies that had presented at least one vitamin D level lower than 20 ng/ml throughout pregnancy (30.4% vs. 7.1%, p=0.018). CONCLUSIONS Trace elements and vitamin deficiencies are common in pregnant women after bariatric surgery, especially of iron, zinc, and vitamin D. These deficiencies might negatively affect foetal development. Further studies are needed to better define the role of micronutrients in maternal-foetal health after bariatric surgery.
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Affiliation(s)
- Irene Bretón
- Department of Endocrinology and Nutrition. Hospital General Universitario Gregorio Marañón. Madrid, IiSGGM, Calle del Dr. Esquerdo, 46, Madrid 28007, Spain; Faculty of Medicine. Department of Medicine, Universidad Complutense, Madrid, Spain.
| | - Cristina Velasco
- Department of Endocrinology and Nutrition. Hospital General Universitario Gregorio Marañón. Madrid, IiSGGM, Calle del Dr. Esquerdo, 46, Madrid 28007, Spain
| | - Cristina Cuerda
- Department of Endocrinology and Nutrition. Hospital General Universitario Gregorio Marañón. Madrid, IiSGGM, Calle del Dr. Esquerdo, 46, Madrid 28007, Spain; Faculty of Medicine. Department of Medicine, Universidad Complutense, Madrid, Spain
| | - Marta Motilla
- Department of Endocrinology and Nutrition. Hospital General Universitario Gregorio Marañón. Madrid, IiSGGM, Calle del Dr. Esquerdo, 46, Madrid 28007, Spain
| | - Clara Serrano
- Department of Endocrinology and Nutrition. Hospital General Universitario Gregorio Marañón. Madrid, IiSGGM, Calle del Dr. Esquerdo, 46, Madrid 28007, Spain
| | - Ángela Morales
- Department of Endocrinology and Nutrition. Hospital General Universitario Gregorio Marañón. Madrid, IiSGGM, Calle del Dr. Esquerdo, 46, Madrid 28007, Spain
| | - Maria Luisa Carrascal
- Department of Endocrinology and Nutrition. Hospital General Universitario Gregorio Marañón. Madrid, IiSGGM, Calle del Dr. Esquerdo, 46, Madrid 28007, Spain
| | - Nieves Lopez Lazareno
- Department of Laboratory Medicine, Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, Madrid 28007, Spain; Department of Endocrinology and Nutrition. Complejo Asistencial Universitario de León, Calle Altos de Nava, s/n, León 24008, Spain
| | - Montserrat Gonzalez-Estecha
- Department of Laboratory Medicine, Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, Madrid 28007, Spain; Department of Endocrinology and Nutrition. Complejo Asistencial Universitario de León, Calle Altos de Nava, s/n, León 24008, Spain
| | - Maria D Ballesteros-Pomar
- Department of Endocrinology and Nutrition. Hospital Universitario Clínico San Carlos, IdISSC, Calle del Prof. Martín Lagos s.n., Madrid 28040, Spain
| | - Miguel Ángel Rubio-Herrera
- Department of Endocrinology and Nutrition. Hospital Universitario Clínico San Carlos, IdISSC, Calle del Prof. Martín Lagos s.n., Madrid 28040, Spain
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Bretón I, Ballesteros-Pomar MD, Calle-Pascual A, Alvarez-Sala LA, Rubio-Herrera MA. Micronutrients in Pregnancy after Bariatric Surgery: A Narrative Review. J Clin Med 2023; 12:5429. [PMID: 37629473 PMCID: PMC10455502 DOI: 10.3390/jcm12165429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Bariatric surgery is increasingly used in women of childbearing age due to the rising prevalence of obesity and the effectiveness and availability of this treatment. Pregnancy in women with previous bariatric surgery deserves special attention. Weight loss induced by surgery reduces the risks that obesity poses to pregnancy. But on the other hand, decreased intake and malabsorption may increase the risk of malnutrition and micronutrient deficiency and negatively affect maternal and foetal health. The aim of this narrative review is to provide an updated analysis of the impact of different bariatric surgery techniques on mineral and micronutrient nutritional status during pregnancy and the possible effect on maternal-foetal health.
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Affiliation(s)
- Irene Bretón
- Department of Endocrinology and Nutrition, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
- Department of Medicine, Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain
| | - María D. Ballesteros-Pomar
- Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, 24008 León, Spain
| | - Alfonso Calle-Pascual
- Department of Medicine, Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain
- Department of Endocrinology and Nutrition, Hospital Clínico Universitario San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, 28040 Madrid, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), 28029 Madrid, Spain
| | - Luis Antonio Alvarez-Sala
- Department of Medicine, Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
| | - Miguel Angel Rubio-Herrera
- Department of Medicine, Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain
- Department of Endocrinology and Nutrition, Hospital Clínico Universitario San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, 28040 Madrid, Spain
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Talbot C, Kearns S, Mouser PJ. Treatment of Superficial Necrolytic Dermatitis with Copper Chelationina Dog with Copper-Associated Hepatitis. J Am Anim Hosp Assoc 2023; 59:1-6. [PMID: 36584317 DOI: 10.5326/jaaha-ms-7217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2021] [Indexed: 12/31/2022]
Abstract
A 7 yr old castrated male Cavalier King Charles spaniel presented for evaluation of liver enzyme elevations. Abdominal ultrasound revealed a small liver with mixed echogenicity, small hypoechoic nodules, and an irregular surface. Histologic examination and copper quantification of the liver obtained by laparoscopy diagnosed copper-associated hepatitis. One month later the dog developed hyperkeratosis of all four foot pads and ulcerations of feet, legs, and rectum. Punch biopsies confirmed superficial necrolytic dermatitis. After a total of 2 mo of chelation with no changes to medications, skin lesions began to improve, continuing over the following 6 wk to almost complete resolution. At this point the skin lesions returned and had minimal response to four amino acids infusions. The dog was switched from penicillamine to trientine. Zinc acetate was initiated 6 wk after the switch to trientine, and skin improvement was noted soon thereafter. At the time of death, skin lesions were improving and the dog was clinically comfortable. Copper-associated hepatitis should be considered as a possible etiology for superficial necrolytic dermatitis. Treatment of superficial necrolytic dermatitis is often unrewarding, and copper chelation, when copper-associated hepatitis has been confirmed, represents another therapeutic option.
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Affiliation(s)
- Cindy Talbot
- From Massachusetts Mobile Veterinary Ultrasound, Boston, Massachusetts (C.T.)
| | - Shawn Kearns
- From Angell Animal Medical Center, Boston, Massachusetts (S.K., P.J.M.)
| | - Pamela J Mouser
- From Angell Animal Medical Center, Boston, Massachusetts (S.K., P.J.M.)
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Relation of Serum Copper Status to Survival in COVID-19. Nutrients 2021; 13:nu13061898. [PMID: 34072977 PMCID: PMC8229409 DOI: 10.3390/nu13061898] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/28/2021] [Accepted: 05/30/2021] [Indexed: 12/12/2022] Open
Abstract
The trace element copper (Cu) is part of our nutrition and essentially needed for several cuproenzymes that control redox status and support the immune system. In blood, the ferroxidase ceruloplasmin (CP) accounts for the majority of circulating Cu and serves as transport protein. Both Cu and CP behave as positive, whereas serum selenium (Se) and its transporter selenoprotein P (SELENOP) behave as negative acute phase reactants. In view that coronavirus disease (COVID-19) causes systemic inflammation, we hypothesized that biomarkers of Cu and Se status are regulated inversely, in relation to disease severity and mortality risk. Serum samples from COVID-19 patients were analysed for Cu by total reflection X-ray fluorescence and CP was quantified by a validated sandwich ELISA. The two Cu biomarkers correlated positively in serum from patients with COVID-19 (R = 0.42, p < 0.001). Surviving patients showed higher mean serum Cu and CP concentrations in comparison to non-survivors ([mean+/−SEM], Cu; 1475.9+/−22.7 vs. 1317.9+/−43.9 µg/L; p < 0.001, CP; 547.2.5+/−19.5 vs. 438.8+/−32.9 mg/L, p = 0.086). In contrast to expectations, total serum Cu and Se concentrations displayed a positive linear correlation in the patient samples analysed (R = 0.23, p = 0.003). Serum CP and SELENOP levels were not interrelated. Applying receiver operating characteristics (ROC) curve analysis, the combination of Cu and SELENOP with age outperformed other combinations of parameters for predicting risk of death, yielding an AUC of 95.0%. We conclude that the alterations in serum biomarkers of Cu and Se status in COVID-19 are not compatible with a simple acute phase response, and that serum Cu and SELENOP levels contribute to a good prediction of survival. Adjuvant supplementation in patients with diagnostically proven deficits in Cu or Se may positively influence disease course, as both increase in survivors and are of crucial importance for the immune response and antioxidative defence systems.
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Abusabeib A, El Ansari W, Elhag W. First Case Report of Acquired Copper Deficiency Following Revisional Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) Leading to Severe Pancytopenia with Refractory Anemia. Obes Surg 2020; 30:5131-5134. [PMID: 32860129 PMCID: PMC7455096 DOI: 10.1007/s11695-020-04916-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 12/05/2022]
Affiliation(s)
- Alyaa Abusabeib
- Department of Bariatric Surgery/Bariatric Medicine, Hamad General Hospital, 3050, Doha, Qatar
| | - Walid El Ansari
- Department of Surgery, Hamad General Hospital, 3050, Doha, Qatar.
- College of Medicine, Qatar University, Doha, Qatar.
- Schools of Health and Education, University of Skovde, Skövde, Sweden.
| | - Wahiba Elhag
- Department of Bariatric Surgery/Bariatric Medicine, Hamad General Hospital, 3050, Doha, Qatar
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Asghar M, Khan U, Horvath E, Khan A. Not so Element-ary: A Copper Conundrum. Cureus 2020; 12:e9950. [PMID: 32983656 PMCID: PMC7510182 DOI: 10.7759/cureus.9950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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[Severe hypocupremia and familial amyloid polyneuropathy]. NUTR HOSP 2020; 37:223-227. [PMID: 31793325 DOI: 10.20960/nh.02771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Introduction: we report a patient with transthyretin familial amyloid polyneuropathy (TTR-FAP) and severe hypocupremia. Case report: a 79-year-old male with TTR-FAP and severe malnutrition. Laboratory tests showed low serum copper (Cu) and ceruloplasmin levels, as well as low urinary Cu levels. The patient reported neither digestive symptoms nor previous gastrointestinal surgery. Liver function tests, iron metabolism, hemoglobin, leukocytes and zinc were normal. Discussion: Cu is a trace element. It is part of the cuproenzymes involved in several physiological functions. Hypocupremia can be related to genetic or acquired etiologies, including low intake, bariatric surgery, increased losses, etc. Primary clinical manifestations include hematological (anemia and leukopenia) and neurological (myelopathy, peripheral neuropathy) features. Treatment is empirical. In severe cases it may be initiated with endovenose administration, followed by oral supplementation.
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Mouallem M, Margolin ML, Friedman YE, Blankenfeld H. Polyneuropathy, Myocardial Dysfunction and Pericardial Effusion Following Duodenal Switch. ACTA MEDICA (HRADEC KRÁLOVÉ) 2018; 61:111-113. [PMID: 30543517 DOI: 10.14712/18059694.2018.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Duodenal Switch procedure is a type of bariatric surgery that was reserved for severely morbid obese people. Patients undergoing this procedure are at high risk for nutrient deficiencies. In this report we present a case of a patient who had developed polyneuropathy, generalized muscle weakness, Wernicke encephalopathy, myocardial dysfunction and pericardial effusion six years following this operation. He was treated by multivitamins and trace elements with a complete resolution of all of these disturbances. The patient was fully rehabilitated.
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Affiliation(s)
- Meir Mouallem
- Department of Medicine E, Sheba Medical Center, Tel-Hashomer affiliated to Sackler Faculty of Medicine, Tel Aviv University, Israel.
| | - Moran Livne Margolin
- Department of Medicine E, Sheba Medical Center, Tel-Hashomer affiliated to Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yehudit Eden Friedman
- Department of Medicine E, Sheba Medical Center, Tel-Hashomer affiliated to Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Hadas Blankenfeld
- Department of Medicine E, Sheba Medical Center, Tel-Hashomer affiliated to Sackler Faculty of Medicine, Tel Aviv University, Israel
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Kumar P, Hamza N, Madhok B, De Alwis N, Sharma M, Miras AD, Mahawar KK. Copper Deficiency after Gastric Bypass for Morbid Obesity: a Systematic Review. Obes Surg 2018; 26:1335-42. [PMID: 27034062 DOI: 10.1007/s11695-016-2162-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A large number of patients undergoing bariatric surgery are deficient in copper, and Roux-en-Y gastric bypass can further aggravate it. Delays in diagnosis and treatment of copper deficiency can leave patients with residual neurological disability. This has led to recommendation from the British Obesity and Metabolic Surgery Society that copper levels should be monitored annually after gastric bypass. This review concludes that copper deficiency in adequately supplemented patients is rare and can be adequately treated if a related haematological or neurological disorder is diagnosed. The cost of routine monitoring may therefore not be justified for adequately supplemented, asymptomatic patients who have undergone Roux-en-Y gastric bypass. The screening may however be necessary for high-risk patient groups to prevent severe complications and permanent disability.
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Affiliation(s)
- Parveen Kumar
- Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Numan Hamza
- Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK
| | - Brijesh Madhok
- Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK
| | - Nimantha De Alwis
- Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK
| | - Manisha Sharma
- Department of Chemical Pathology, Homerton University Hospital NHS Trust, London, UK
| | | | - Kamal K Mahawar
- Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK.
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10
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Boullata J, Muthukumaran G, Piarulli A, Labarre J, Compher C. Oral copper absorption in men with morbid obesity. J Trace Elem Med Biol 2017; 44:146-150. [PMID: 28965570 DOI: 10.1016/j.jtemb.2017.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 07/11/2017] [Accepted: 07/21/2017] [Indexed: 12/23/2022]
Abstract
Copper deficiency has been reported in patients with severe obesity, both before and after bariatric surgery, the latter at increased rates. However, little is known about the absorption of copper. Because of differences in copper dynamics between men and women in the limited available data, we evaluated copper absorption in men who were candidates for bariatric surgery. All patients gave informed consent, approved by the University of Pennsylvania Institutional Review Board, to participate in a pharmacokinetics study. After a 12-h fast, body composition was measured using air displacement plethysmography and a single oral dose of 4mg copper gluconate was given followed by serial measures of serum copper over 10h. Meals and snacks very low in copper were provided. The seven participants had age 52±8years, BMI 44.87±9.01kg/m2 and fat free mass 77.92±14.45kg. Baseline serum copper was 36.1±19.5μg/dL and ceruloplasmin was 50.86±4.58mg/dL. Peak copper absorption occurred within 1-2h. The AUC for six subjects was 254.6±151.3μg/100mLh. The estimated volume of distribution (1.98±0.36L) was ∼25mL/kg fat free mass. In these severely obese men, copper absorption occurred early in spite of their normal copper status, suggesting no impairment of absorption due to obesity. Further studies of copper absorption after the significant weight loss and possible malabsorption derived from bariatric surgery are needed.
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Affiliation(s)
- Joseph Boullata
- Biobehavioral Research Laboratory, University of Pennsylvania, Philadelphia, PA, USA.
| | - Geetha Muthukumaran
- Biobehavioral Research Laboratory, University of Pennsylvania, Philadelphia, PA, USA.
| | - Amanda Piarulli
- Biobehavioral Research Laboratory, University of Pennsylvania, Philadelphia, PA, USA.
| | - John Labarre
- Biobehavioral Research Laboratory, University of Pennsylvania, Philadelphia, PA, USA.
| | - Charlene Compher
- Biobehavioral Research Laboratory, University of Pennsylvania, Philadelphia, PA, USA.
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11
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Sarker A, Meek CL, Park A. Biochemical consequences of bariatric surgery for extreme clinical obesity. Ann Clin Biochem 2015; 53:21-31. [DOI: 10.1177/0004563215588116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2015] [Indexed: 01/01/2023]
Abstract
Obesity, defined as a body mass index over 30 kg/m2 for adults, poses a major healthcare challenge with important economic, personal and social consequences. Although public health measures, lifestyle change and pharmacological therapies have an important role in the management of obesity, patients with established morbid obesity (body mass index over 40 kg/m2) may also require bariatric surgery. Bariatric or metabolic surgery is associated with effective and enduring weight loss but is also known to improve glucose homeostasis, blood pressure and dyslipidaemia. Patients who have bariatric surgery need lifelong clinical follow-up to identify and prevent nutritional deficiencies and other complications. Clinical biochemistry laboratories have an important role in the nutritional assessment of obese patients and in the identification of complications following bariatric surgery. The aim of this article is to review the different bariatric procedures available and to summarize their complications, especially nutrient deficiencies and those of particular relevance to clinical biochemistry laboratories.
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Affiliation(s)
- Anita Sarker
- Department of Clinical Biochemistry and Immunology, Cambridge Universities NHS foundation trust, Addenbrooke’s Hospital, Cambridge, UK
| | - Claire L Meek
- Department of Clinical Biochemistry and Immunology, Cambridge Universities NHS foundation trust, Addenbrooke’s Hospital, Cambridge, UK
- Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Adrian Park
- Department of Clinical Biochemistry and Immunology, Cambridge Universities NHS foundation trust, Addenbrooke’s Hospital, Cambridge, UK
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12
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Optic neuropathy, myelopathy, anemia, and neutropenia caused by acquired copper deficiency after gastric bypass surgery. J Clin Gastroenterol 2014; 48:862-5. [PMID: 24583748 DOI: 10.1097/mcg.0000000000000092] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Malabsorptive bariatric surgery is rapidly becoming a major cause of copper deficiency given the increasing prevalence of these procedures for morbid obesity. Acquired copper deficiency can present with clinically significant hematologic and neurological manifestations. Although hematologic manifestations of copper deficiency are rapidly reversible, significant neurological improvement after copper supplementation therapy is unusual and many patients remain debilitated and may only experience, at best, stabilization of the neurological manifestations. Here we present a case of an undiagnosed copper deficiency several years after bariatric gastric bypass surgery, in a patient who concomitantly used zinc-containing denture cream for several years, associated with anemia, neutropenia, myelopathy, respiratory failure, and bilateral optic neuropathy, which caused major vision loss. This patient was also a heterozygote carrier of the 5,10-methylenetetrahydrofolate reductase A1298C gene polymorphism, which may affect copper metabolism. Intravenous copper repletion resulted in rapid correction of hematologic indices. However, neurological manifestations, including vision loss responded only modestly to copper supplementation, despite achieving normal blood copper concentrations. Clinicians should consider copper deficiency in patients at risk, as in this case, as a delayed diagnosis can lead to irreversible disability due to neurological manifestations.
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Isom KA, Andromalos L, Ariagno M, Hartman K, Mogensen KM, Stephanides K, Shikora S. Nutrition and metabolic support recommendations for the bariatric patient. Nutr Clin Pract 2014; 29:718-39. [PMID: 25288251 DOI: 10.1177/0884533614552850] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Managing the metabolic needs of the patient with obesity is a challenge unto itself without the added demands of accounting for an altered gastrointestinal tract. Nevertheless, with about 200,000 bariatric procedures being performed annually in the United States, clinicians must be prepared to manage the critically ill bariatric surgery patient. This article reviews the recent literature relating to nutrient needs and metabolic support for the bariatric patient. Bariatric patients are at risk for several micronutrient deficiencies, including vitamins D and B₁₂, calcium, and iron; some bariatric procedures affect macronutrient needs as well. Literature on nutrition support guidelines for the bariatric population is limited. However, with an understanding of the anatomical and physiological effects of bariatric surgery, recent guidelines for critically ill patients with obesity can be applied to the bariatric surgery population. The unique needs of the bariatric population, such as susceptibility to micronutrient deficiencies and specialized access routes, must be considered to provide safe and efficacious nutrition support. Further research is necessary to develop specific nutrition support recommendations for the bariatric population.
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Affiliation(s)
- Kellene A Isom
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Laura Andromalos
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Meghan Ariagno
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Katy Hartman
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Kris M Mogensen
- Brigham and Women's Hospital Department of Nutrition, Boston, Massachusetts
| | - Katrina Stephanides
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Scott Shikora
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
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Freeland-Graves JH, Lee JJ, Mousa TY, Elizondo JJ. Patients at risk for trace element deficiencies: bariatric surgery. J Trace Elem Med Biol 2014; 28:495-503. [PMID: 25087156 DOI: 10.1016/j.jtemb.2014.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Obesity is a worldwide epidemic associated with diseases such as diabetes mellitus and cardiovascular disease. Current methods for weight loss are not very effective, particularly for those with morbid obesity. Surgical therapy may be recommended for those with a BMI≥40kg/m(2), or BMI≥35kg/m(2) with co-morbidities. This therapy can produce significant weight loss and improve/resolve co-morbidities including hypertension and hyperlipidemia. Yet successes may be tempered by adverse effects on trace element absorption and status. A PubMed literature search identified studies from January 1980 to February 2013 for inclusion in a meta-analysis. Publications that contained keywords 'bariatric surgery or gastric bypass,' 'trace element or mineral or zinc or iron or copper or iodine or manganese', and 'absorption or status or rate or level' were identified. Inclusion criteria were human markers that reflect changes in trace element status before and after bariatric surgery. The meta-analysis found a decrease in blood copper, zinc, hemoglobin, as well as an increase in iron, regardless of the type of surgery. The pooled effect sizes and 95% confidence intervals were 0.17 and -0.09 to 0.43 for plasma/serum iron (p=0.20); -0.49 and -0.67 to -0.31 for blood hemoglobin (p=0.00); -0.47 and -0.90 to -0.05 for plasma/serum copper (p=0.03); -0.77 and -1.20 to -0.35 for plasma/serum zinc (p=0.00). Differences in levels of these minerals pre- and post-surgery may have been influenced by the time period after surgery, a pre-existing deficiency, type and dose of vitamin-mineral supplements, and malabsorption due to elimination of parts of the gastrointestinal tract.
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Affiliation(s)
| | - Jane J Lee
- Department of Nutritional Sciences, University of Texas, Austin, TX, USA
| | - Tamara Y Mousa
- Department of Nutritional Sciences, University of Texas, Austin, TX, USA
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Hedberg J, Sundström J, Sundbom M. Duodenal switch versus Roux-en-Y gastric bypass for morbid obesity: systematic review and meta-analysis of weight results, diabetes resolution and early complications in single-centre comparisons. Obes Rev 2014; 15:555-63. [PMID: 24666623 DOI: 10.1111/obr.12169] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 02/10/2014] [Accepted: 02/25/2014] [Indexed: 01/06/2023]
Abstract
Long-term weight loss after Roux-en-Y gastric bypass (RYGB) in super-obese patients has not been ideal. Biliopancreatic diversion with duodenal switch (DS) is argued to be better; however, additional side effects are feared. The aim of the present study was to determine differences in results after DS and RYGB in publications from single-centre comparisons. A systematic review of studies containing DS and RYGB performed at the same centre was performed. Outcome data were weight results, resolution of comorbid conditions, perioperative results and complications. Main outcome was difference in weight loss after DS and RYGB. Secondary outcomes were difference in resolution of comorbidities, perioperative results and complications. The final analysis included 16 studies with in total 874 DS and 1,149 RYGB operations. When comparing weight results at the longest follow-up of each study, DS yielded 6.2 (95% confidence interval 5.0-7.5) body mass index units additional weight loss compared with RYGB, P < 0.001. Operative time and length of stay were significantly longer after DS, as well as the risk for post-operative leaks, P < 0.05. DS is more effective than RYGB as a weight-reducing procedure. However, this comes at the price of more early complications and might also yield slightly higher perioperative mortality.
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Affiliation(s)
- J Hedberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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16
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Chan LN, Mike LA. The science and practice of micronutrient supplementations in nutritional anemia: an evidence-based review. JPEN J Parenter Enteral Nutr 2014; 38:656-72. [PMID: 24847050 DOI: 10.1177/0148607114533726] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 04/03/2014] [Indexed: 12/14/2022]
Abstract
Nutritional anemia is the most common type of anemia, affecting millions of people in all age groups worldwide. While inadequate access to food and nutrients can lead to anemia, patients with certain health status or medical conditions are also at increased risk of developing nutritional anemia. Iron, cobalamin, and folate are the most recognized micronutrients that are vital for the generation of erythrocytes. Iron deficiency is associated with insufficient production of hemoglobin. Deficiency of cobalamin or folate leads to impaired synthesis of deoxyribonucleic acid, proteins, and cell division. Recent research has demonstrated that the status of copper and zinc in the body can significantly affect iron absorption and utilization. With an increasing number of patients undergoing bariatric surgical procedures, more cases of anemia associated with copper and zinc deficiencies have also emerged. The intestinal absorption of these 5 critical micronutrients are highly regulated and mediated by specific apical transport mechanisms in the enterocytes. Health conditions that persistently alter the histology of the upper intestinal architecture, expression, or function of these substrate-specific transporters, or the normal digestion and flow of these key micronutrients, can lead to nutritional anemia. The focus of this article is to review the science of intestinal micronutrient absorption, discuss the clinical assessment of micronutrient deficiencies in relation to anemia, and suggest an effective treatment plan and monitoring strategies using an evidence-based approach.
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17
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Squitti R, Siotto M, Polimanti R. Low-copper diet as a preventive strategy for Alzheimer's disease. Neurobiol Aging 2014; 35 Suppl 2:S40-50. [PMID: 24913894 DOI: 10.1016/j.neurobiolaging.2014.02.031] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 02/27/2014] [Accepted: 02/27/2014] [Indexed: 12/21/2022]
Abstract
Copper is an essential element, and either a copper deficiency or excess can be life threatening. Recent studies have indicated that alteration of copper metabolism is one of the pathogenetic mechanisms of Alzheimer's disease (AD). In light of these findings, many researchers have proposed preventive strategies to reduce AD risk. Because the general population comes in contact with copper mainly through dietary intake, that is, food 75% and drinking water 25%, a low-copper diet can reduce the risk of AD in individuals with an altered copper metabolism. We suggest that a diet-gene interplay is at the basis of the "copper phenotype" of sporadic AD. Herein, we describe the pathways regulating copper homeostasis, the adverse sequelae related to its derangements, the pathogenic mechanism of the AD copper phenotype, indications for a low-copper diet, and future perspectives to improve this preventive strategy.
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Affiliation(s)
- Rosanna Squitti
- Fatebenefratelli Foundation for Health Research and Education, AFaR Division, "San Giovanni Calibita" Fatebenefratelli Hospital, Rome, Italy; Laboratorio di Neurodegenerazione, IRCCS San Raffaele Pisana, Rome, Italy.
| | | | - Renato Polimanti
- Department of Biology, University of Rome "Tor Vergata", Rome, Italy
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18
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Vigorous periosteal reaction secondary to copper deficiency in an infant on total parenteral nutrition. Pediatr Radiol 2013; 43:1411-3. [PMID: 23893197 DOI: 10.1007/s00247-013-2759-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 05/02/2013] [Accepted: 07/01/2013] [Indexed: 12/24/2022]
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19
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Hematological disorders following gastric bypass surgery: emerging concepts of the interplay between nutritional deficiency and inflammation. BIOMED RESEARCH INTERNATIONAL 2013; 2013:205467. [PMID: 23984326 PMCID: PMC3741944 DOI: 10.1155/2013/205467] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/02/2013] [Accepted: 07/04/2013] [Indexed: 01/17/2023]
Abstract
Obesity and the associated metabolic syndrome are among the most common and detrimental metabolic diseases of the modern era, affecting over 50% of the adult population in the United States. Surgeries designed to promote weight loss, known as bariatric surgery, typically involve a gastric bypass procedure and have shown high success rates for treating morbid obesity. However, following gastric bypass surgery, many patients develop chronic anemia, most commonly due to iron deficiency. Deficiencies of vitamins B1, B12, folate, A, K, D, and E and copper have also been reported after surgery. Copper deficiency can cause hematological abnormalities with or without neurological complications. Despite oral supplementation and normal serum concentrations of iron, copper, folate, and vitamin B12, some patients present with persistent anemia after surgery. The evaluation of hematologic disorders after gastric bypass surgery must take into account issues unique to the postsurgery setting that influence the development of anemia and other cytopenias. In this paper, the clinical characteristics and differential diagnosis of the hematological disorders associated with gastric bypass surgery are reviewed, and the underlying molecular mechanisms are discussed.
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20
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Blackmer AB, Bailey E. Management of Copper Deficiency in Cholestatic Infants. Nutr Clin Pract 2012; 28:75-86. [DOI: 10.1177/0884533612461531] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Allison Beck Blackmer
- Department of Pharmacy Services/College of Pharmacy, University of Michigan, Ann Arbor
| | - Elizabeth Bailey
- Patient Food and Nutrition Services, University of Michigan, Ann Arbor
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21
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Dembinski K, Gargasz AE, Dabrow S, Rodriguez L. Three distinct cases of copper deficiency in hospitalized pediatric patients. Clin Pediatr (Phila) 2012; 51:759-62. [PMID: 22584540 DOI: 10.1177/0009922812446743] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Although copper deficiency is a rare occurrence in the developed world, attention should be given to the proper supplementation of minerals to at-risk pediatric patients. This study presents 3 distinct cases of copper deficiency in hospitalized patients aged 14 months, 6 years, and 12 years. Two patients had short bowel syndrome, requiring prolonged parenteral nutrition or complex intravenous fluid supplementation. The third patient was severely malnourished. Copper deficiency manifested in all of our patients as either microcytic anemia or pancytopenia with myelodysplastic syndrome. Copper deficiency is an important diagnosis to be considered in patients with prematurity, parenteral nutrition dependency, malabsorption, and/or those with malnutrition. More studies are needed to establish appropriate amounts of copper supplementation to replenish copper stores in deficient patients.
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Affiliation(s)
- Karolina Dembinski
- Department of Pediatrics, University of South Florida, Tampa, FL 33606, USA.
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22
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Kushner RF. Obesity medicine--the time has come. Nutr Clin Pract 2011; 26:510-1. [PMID: 21947633 DOI: 10.1177/0884533611418344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Robert F Kushner
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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