Mineral Malnutrition Following Bariatric Surgery1,2
Nana Gletsu-Miller3* and Breanne N. Wright3
3Department of Nutrition Science, Purdue University, West Lafayette, IN
Moderate/severe obesity is on the rise in the United States. Weight management includes bariatric surgery, which is effective and can alleviate
morbidity and mortality from obesity-associated diseases. However, many individuals are dealing with nutritional complications. Risk factors
include: 1) preoperative malnutrition (e.g., vitamin D, iron); 2) decreased food intake (due to reduced hunger and increased satiety, food
intolerances, frequent vomiting); 3) inadequate nutrient supplementation (due to poor compliance with multivitamin/multimineral regimen,
insufficient amounts of vitamins and/or minerals insupplements); 4) nutrient malabsorption; and 5) inadequate nutritional support (due to lack of
follow-up, insufficient monitoring, difficulty in recognizing symptoms of deficiency). For some nutrients (e.g., protein, vitamin B-12, vitamin D),
malnutrition issues are reasonably addressed through patient education, routine monitoring, and effective treatment strategies. However, there
is little attention paid to other nutrients (e.g., zinc, copper), which if left untreated may have devastating consequences (e.g., hair loss, poor
immunity, anemia, defects in neuro-muscular function). This review focuses on malnutrition in essential minerals, including calcium (and vitamin
D), iron, zinc, and copper, which commonly occur following popular bariatric procedures. There will be emphasis on the complexities, including
confounding factors, related to screening, recognition of symptoms, and, when available, current recommendations for treatment. There is an
exceptionally high risk of malnutrition in adolescents and pregnant women and their fetuses, who may be vulnerable to problems in growth and
development. More research is required to inform evidence-based recommendations for improving nutritional status following bariatric surgery
and optimizing weight loss, metabolic, and nutritional outcomes. Adv. Nutr. 4: 506–517, 2013.
Popularity and Benefits of Bariatric Surgery
Weight loss through bariatric surgery is a popular treatment
for moderate (BMI $35 kg/m2) and severe (BMI $40 kg/m2)
obesity across most higher income countries and in 2011,
>340,000 procedures were performed worldwide (1). In
the United States, a leading country for bariatric surgery, there
were ~160,000 bariatric procedures performed in 2010 (2).
Bariatric surgery was developed in the 1960s and 1970s (3,4),
rise in severe obesity (5,6), improved safety of the operations
(7), and a consensus statement by the NIH, which offered en-
dorsement and guidance (8). Since 1990, United States data
from the Nationwide Inpatient Sample and the American So-
1,426,268 persons have undergone bariatric surgery (1,9–12).
The burden of severe obesity and comorbid cardio-metabolic
disease, including type 2 diabetes (T2DM)4, atherosclerosis
and cancer, is lifted from most of these individuals (13–17).
Moreover, decreased prevalence of morbidity, including
athropathy, depression, poor quality of life (18–20), and mor-
tality (21–24), following bariatric surgery is well documented.
Drawbacks of Bariatric Surgery: Nutritional
Eligibility for bariatric surgery is described by a 1991 NIH
consensus statement and includes individuals who have a
BMI $40 kg/m2or a BMI $35 kg/m2and suffer from co-
morbid disease (8). In 2010, the US FDA expanded the cri-
teria for eligibility by approving the use of a device used in
the adjustable banding surgery (described below) for in-
dividuals who have a BMI $30 and have T2DM or other
comorbidities (25). Despite the demonstrated benefits of
bariatric surgery, it remains underutilized by eligible patients
[w1% have undergone surgery (2)] due to lack of accessi-
bility (26), high costs and questionable cost-effectiveness
(27,28), and adverse outcomes that limit acceptability among
patients, doctors, and third-party payers. The major adverse
events relate to the complications of gastrointestinal surgery
that typically occur within 30 d of the procedure and in-
clude wound infection, deep-vein thrombosis, small bowel
1Supported by NIH grants R03 DK067167 and R21 DK 075745 and the International Copper
2Author disclosures: N. Gletsu-Miller and B. N. Wright, no conflicts of interest.
4Abbreviations used: AGB, adjustable gastric banding; BPD, biliopancreatic diversion; RYGB,
roux-en-y gastric bypass; SG, sleeve gastrectomy; T2DM, type 2 diabetes.
*To whom correspondence should be addressed. E-mail: firstname.lastname@example.org.
ã2013 American Society for Nutrition. Adv. Nutr. 4: 506–517, 2013; doi:10.3945/an.113.004341.
by guest on November 5, 2015
obstructions, abdominal leaks, and death. Severely obese in-
dividuals undergoing major elective surgery are at a high risk
for complications due to preexisting medical conditions (29);
however, due to advances in laparoscopy, which is less inva-
sive and traumatic, the operative mortality and morbidity
has reduced to 0.1–0.3 and 4.5%, respectively, in recent years
(7,30). Despite improvement in perioperative safety, longer
term complicationsareanimportantissuefor patientsunder-
going bariatric surgery. These complications can be subdi-
vided into those that are general or gastrointestinal surgery
related (e.g., hernia, bowel obstruction, cholecystitis, slippage
of gastric band/pouch dilation, ulcer, nausea, vomiting, diar-
rhea) (30), nutritional (hypoglycemia, loss of lean body mass,
weight regain, vitamin and mineral deficiencies) (31,32), or
other (e.g., psychosocial issues, neisidioblastosis hyperinsuli-
nemia, bacterial overgrowth) (24,33,34). The frequency of
long-term complications following bariatric surgery is diffi-
cult to ascertain, because this has been mostly determined
through retrospectively obtained data with poor patient
follow-up and the various complications are specific to the
type of surgery performed (14,35). However, as evidenced
by a growing body of case reports, retrospective studies, and
a few prospective studies, poor nutritional outcomes are rel-
atively common after surgery and prevalence of upwards
of 82% has been reported (36–38). Some nutritional com-
plications are well known to the surgeons and other key
practitioners (dietitians, primary care doctors, and endocri-
nologists) who provide postoperative support as well as to
vitamin B-12, vitamin D, calcium, and iron. Thus, most clin-
ical practices provide adequate patient counseling for preven-
tion and routinely monitor patients for deficiency. However,
for many other nutrients, including B vitamins (thiamine,
pyridoxal phosphate, folate), fat-soluble vitamins (A, K), es-
sential fatty acids, and minerals (zinc, copper), awareness of
riskofdeficiency by patients and providers islow and prophy-
lactic protocols and monitoring are insufficient, leading to de-
bilitating consequences including long-term disability (39).
Moreover, as acknowledged by consensus guidelines from
experts within the American Society for Metabolic and
Bariatric Surgery, The Obesity Society and the American
Association of Clinical Endocrinologists, there is need for
more and better quality evidence behind recommendations
for the prevention and treatment for malnutrition after
bariatric surgery (35,40).
The issues of nutritional deficiency following bariatric
surgery were recently comprehensively reviewed (32,35).
However, this present review will focus on the problem of
essential mineral deficiencies following specific surgery pro-
cedures, especially highlighting the complexities involved
in monitoring and risk factors, as well as protocols for pre-
vention and treatment. The issues in recognizing nutritional
complications using clinical signs and symptoms as well as
sensitive biomarkers will be discussed. We discuss the con-
founding issues related to symptoms and biomarkers of defi-
ciency, including the masking of deficiency by other nutrients
and by inflammation. Information is provided regarding
strategies for prophylactic supplementation and interactions
between nutrients that affect absorption and bioavailability.
Finally, we discuss concerns of mineral malnutrition following
bariatric surgery in special populations, namely adolescents
and pregnant women.
Information in this review included published original
articles and review papers that were collected using PubMed
searches containing the subject headings bariatric surgery
(gastric bypass surgery, adjustable gastric banding (AGB),
sleeve gastrectomy (SG), bioliopancreatic diversion) and nu-
tritional deficiencies (malnutrition, micronutrients, nutri-
tional status) published between 1990 and May 2013. The
impact of bariatric surgery on magnesium, phosphorus,
electrolytes (e.g., potassium, sodium, chloride), and trace el-
ements (e.g., selenium, iodine) is important, but the data
were not sufficiently robust to be discussed in the review.
Current Status of Knowledge
Types of Bariatric Surgery Procedures
Bariatric surgeries are defined as procedures that alter the
gastrointestinal tract to reduce caloric intake or absorption
and can be classified by the mechanism of action for pro-
moting weight loss as restrictive or malabsorptive. Restrictive
procedures reduce the volume or capacity of the stomach
and thereby limit caloric intake by promoting early sati-
ety. Malabsorptive procedures reduce the amount of calo-
ries absorbed by altering the flow of food to limit contact
with pancreatic secretions and bile acids and/or bypass
the absorptive regions of the duodenum and proximal jeju-
num. Surgical alteration of the gastrointestine to restrict en-
ergy intake or promote malabsorption of macronutrients is
achieved but with varying effectiveness and durability for
sustained weight loss, as well as resulting nutritional side ef-
fects, depending on the extent of manipulation of the gastro-
intestinal system. The common bariatric surgery procedures
are described herein along with features that may impair nu-
The roux-en-y gastric bypass (RYGB) is the most popular
surgical procedure in the United States at 47% of annual
cases in 2011 (1). RYGB has a dual restrictive and malab-
sorptive mode of action as the stomach is reduced to a vol-
ume of 20–30 mL and stomach contents are rerouted to the
distal jejunum via an anastomosis connection (Fig. 1) (41).
The physiological mechanisms of RYGB for promoting
weight loss are under intense investigation given the acute
resolution of T2DM following surgery (42,43), and potential
mechanisms include caloric restriction and alterations in
secretion of incretins, satiety gastrointestinal hormones, and
bile acids and in the microbiome of the gut (44). Although
dietary intake plays a much larger role in the reduction of en-
ergy intake (45), and following RYGB, patients dramatically
reduce caloric intake to w1000 kcal/d (46,47). Studies have
shown decreased appetite and increased post-meal satiety
following RYGB, likely due to decreases in ghrelin, an orexi-
genic hormone, and increases in glucagon-like peptide 1 and
Weight loss surgery and deficiency507
by guest on November 5, 2015
102. Sánchez-Hernández J, Ybarra J, Gich I, de Leiva A, Ruis X, Rodriguez-
Espinosa J, Perez A. Effects of bariatric surgery on vitamin D status
and secondary hyperparathyroidism: a prospective study. Obes Surg.
103. Elliot K. Nutritional considerations after bariatric surgery. Crit Care
Nurs Q. 2003;26:133–8.
104. Bloomberg RD, Fleishman A, Nalle JE, Herron DM, Kini S. Nutri-
tional deficiencies following bariatric surgery: what have we learned?
Obes Surg. 2005;15:145–54.
105. Goode LR, Brolin RE, Chowdhury HA, Shapses SA. Bone and gastric
bypass surgery: effects of dietary calcium and vitamin D. Obes Res.
106. Stein EM, Carrelli A, Young P, Bucovsky M, Zhang C, Schrope B,
Bessler M, Zhou B, Wang J, Gou XE, et al. Bariatric surgery results
in cortical bone loss. J Clin Endocrinol Metab. 2013;98:541–9.
107. Casagrande DS, Repetto G, Mottin CC, Shah J, Pietrobon R, Worni M,
Schaan BD. Changes in bone mineral density in women following
1-year gastric bypass surgery. Obes Surg. 2012;22:1287–92.
108. Fleischer J, Stein EM, Bessler M, Della Badia M, Restuccia N, Olivero-
Rivera L, McMahon DJ, Silverberg SJ. The decline in hip bone density
after gastric bypass surgery is associated with extent of weight loss.
J Clin Endocrinol Metab. 2008;93:3735–40.
109. Vilarrasa N, San Jose P, Garcia I, Gomez-Vaquero C, Miras PM, de
Gordejuela AG, Masdevall C, Pujol J, Soler J, Gomez JM. Evaluation
of bone mineral density loss in morbidly obese women after gastric
bypass: 3-year follow-up. Obes Surg. 2011;21:465–72.
110. DiGiorgi M, Daud S, Inabnet WB, Schrope B, Urban-Skuro M,
Restuccia N, Bessler M. Markers of bone and calcium metabolism
following gastric bypass and laparoscopic adjustable banding. Obes
111. Mahdy T, Atia S, Farid M, Adulatif A. Effect of roux-en-y gastric by-
pass on bone metabolism in patients with morbid obesity: Mansoura
experiences. Obes Surg. 2008;18:1526–31.
112. McClung JP, Marchitelli LJ, Friedl KE, Young AJ. Prevalence of iron
deficiency and iron deficiency anemia among three populations
of female military personnel in the US Army. J Am Coll Nutr. 2006;
113. Gudzune KA, Huizinga MM, Chang HY, Asamoah V, Gadgil M, Clark
JM. Screening and diagnosis of micronutrient deficiencies before and
after bariatric surgery. Obes Surg. Epub 2013 Mar 21.
114. Vargas-Ruiz AG, Hernandez-Rivera G, Herrera MF. Prevalence of
iron, folate, and vitamin B12 deficiency anemia after laparoscopic
Roux-en-Y gastric bypass. Obes Surg. 2008;18:288–93.
115. Thurnheer M, Bisang P, Ernst B, Schultes B. A novel distal very long
roux-en-y gastric bypass (DVLRYGB) as a primary bariatric procedure:
complication rates, weight loss, and nutritional/metabolic changes in
the first 355 patients. Obes Surg. 2012;22:1427–36.
116. Naghshineh N, Coon DO, McTigue KM, Courcoulas A, Fernstrom M,
Rubin JP. Nutritional assessment of bariatric surgery patients present-
ing for plastic surgery: a prospective analysis. Plast Reconstr Surg.
117. Kushner RF, Gleason B, Shanta-Retelny V. Reemergence of pica fol-
lowing gastric bypass surgery for obesity: a new presentation of an
old problem. J Am Diet Assoc. 2004;104:1393–7.
118. Ruz M, Carrasco F, Rojas P, Codoceo J, Inostroza J, Basfi-fer K, Valencia
A, Csendes A, Papapietro K, Pizarro F, et al. Heme- and nonheme-iron
absorption and iron status 12 mo after sleeve gastrectomy and roux-
en-y gastric bypass in morbidly obese women. Am J Clin Nutr. 2012;
119. Ruz M, Carrasco F, Rojas P, Codoceo J, Inostroza J, Rebolledo A, Basfi-fer
K, Csendes A, Papapietro K, Pizarro F, et al. Iron absorption and iron
status are reduced after Roux-en-Y gastric bypass. Am J Clin Nutr.
120. Olivares M, Pizarro F, Ruz M, de Romana DL. Acute inhibition of iron
bioavailability by zinc: studies in humans. Biometals. 2012;25:657–64.
121. Solomons NW. Competitive interaction of iron and zinc in the diet:
Consequences for human nutrition. J Nutr. 1986;116:927–35.
122. Björn-Rasmussen E, Hallberg L. Iron absorption from maize. Effect of
ascorbic acid on iron absorption from maize supplemented with fer-
rous sulphate. Nutr Metab. 1974;16:94–100.
123. Failla ML, Johnson MA, Prohaska JR. Copper. In: Bowman BA, Russell
RM, editors. Present knowledge in nutrition. 8th ed. Washington, DC:
ILSI Press; 2001: 373–83.
124. Vulpe CD, Kuo YM, Murphy TL, Cowley L, Askwith C, Libina N,
Gitschier J, Anderson GJ. Hephaestin, a ceruloplasmin homologue
implicated in intestinal iron transport, is defective in the sla mouse.
Nat Genet. 1999;21:195–9.
125. Zimmermann MB, Hurrell RF. Nutritional iron deficiency. Lancet.
126. Malone M, Barish C, He A, Bregman D. Comparative review of the
safety and efficacy of ferric carboxymaltose versus standard medical
care for treatment of iron-deficiency anemia in bariatric and gastric
surgery patients. Obes Surg. Epub 2013 Apr 4.
127. Mason KE. A conspectus of research on copper metabolism and re-
quirements of man. J Nutr. 1979;109:1979–2066.
128. Gletsu-Miller N, Broderius M, Frediani JK, Zhao VM, Griffith DP,
Davis SS, Jr., Sweeney JF, Lin E, Prohaska JR, Ziegler TR. Incidence
and prevalence of copper deficiency following roux-en-y gastric by-
pass surgery. Int J Obes (Lond). 2012;36:328–35.
129. Balsa JA, Botella-Carretero JI, Gomez-Martin JM, Peromingo R,
Arrieta F, Santiuste C, Zamarron I, Vazquez C. Copper and zinc serum
levels after derivative bariatric surgery: Differences between roux-en-y
gastric bypass and biliopancreatic diversion. Obes Surg. 2011;21:
130. Atkinson RL, Dahms WT, Bray GA, Jacob R, Sandstead HH. Plasma
zinc and copper in obesity and after intestinal bypass. Ann Intern
131. O’Donnell KB, Simmons M. Early-onset copper deficiency following
roux-en-y gastric bypass. Nutr Clin Pract. 2011;26:66–9.
132. Griffith DP, Liff DA, Ziegler TR, Esper GJ, Winton EF. Acquired
copper deficiency: a potential serious and preventable complication
following gastric bypass surgery. Obesity (Silver Spring). 2009;17:
133. Prodan CI, Bottomley SS, Holland NR, Lind SE. Relapsing hypocu-
praemic myelopathy requiring high-dose oral copper replacement.
J Neurol Neurosurg Psychiatry. 2006;77:1092–3.
134. Ernst B, Thurnheer M, Schultes B. Copper deficiency after gastric by-
pass surgery. Obesity (Silver Spring). 2009;17:1980–1.
135. Hoffman HNI, Phyliky RL, Fleming CR. Zinc-induced copper defi-
ciency. Gastroenterology. 1988;94:508–12.
136. Prohaska JR, Wittmers LE, Haller EW. Influence of genetic obesity,
food intake and adrenalectomy in mice on selected trace element: de-
pendent protective enzymes. J Nutr. 1988;118:739–46.
137. Moyer TP, Mussmann GV, Nixon DE. Blood-collection device for
trace and ultra-trace metal specimens evaluated. Clin Chem. 1991;
138. Lassi KC, Prohaska JR. Erythrocyte copper chaperone for superoxide
dismutase is increased following marginal copper deficiency in adult
and postweanling mice. J Nutr. 2012;142:292–7.
139. Cousins RJ, Blanchard RK, Moore JB, Cui L, Green CL, Liuzzi JP,
Cao J, Bobo JA. Regulation of zinc metabolism and genomic outcomes.
J Nutr. 2003;133:S1521–6.
140. Ruz M, Carrasco F, Rojas P, Codoceo J, Inostroza J, Basfi-fer K,
Csendes A, Papapietro K, Pizarro F, Olivares M, et al. Zinc absorption
and zinc status are reduced after roux-en-y gastric bypass: a random-
ized study using 2 supplements. Am J Clin Nutr. 2011;94:1004–11.
141. Ruz M, Cavan KR, Bettger WJ, Thompson L, Berry M, Gibson RS. De-
velopment of a dietary model for the study of mild zinc deficiency in
humans and evaluation of some biochemical and functional indices of
zinc status. Am J Clin Nutr. 1991;53:1295–303.
142. Sallé A, Demarsy D, Poireir AL, Lelievre B, Guilloteau G, Becouarn G,
Rohmer V. Zinc deficiency: a frequent and underestimated complica-
tion after bariatric surgery. Obes Surg. 2010;20:1660–70.
143. Di Martino G, Matera MG, De Martino B, Vacca C, Di Martino S, Rossi
F. Relationship between zinc and obesity. J Med. 1993;24:177–83.
516Gletsu-Miller and Wright
by guest on November 5, 2015
144. Williams DM. Trace metal determinations in blood obtained in evac-
uated collection tubes. Clin Chim Acta. 1979;99:23–9.
145. Pech N, Meyer F, Lippert H, Manger T, Stroh C. Complications, reop-
erations, and nutrient deficiencies two years after sleeve gastrectomy.
BMC Surg. 2012;12:13.
146. le Roux CW, Bueter M, Theis N, Werling M, Ashrafian H, Lowenstein
C, Athanasiou T, Bloom SR, Spector AC, Olbers T, et al. Gastric bypass
reduces fat intake and preference. Am J Physiol Regul Integr Comp
147. U.S. Department of Health and Human Services and U.S. Department
of Agriculture. Dietary guidelines for Americans, 2010. USDA/HHS
ed. Washington, DC: U.S. Government Printing Office; 2010.
148. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence
of high body mass index in US children and adolescents, 2007–2008.
149. Tsai WS, Inge TH, Burd RS. Bariatric surgery in adolescents: recent
national trends in use and in-hospital outcome. Arch Pediatr Adolesc
150. Zeller MH, Reiter-Purtill J, Ratcliffe MB, Inge TH. Two-year trends in
psychosocial functioning after adolescent roux-en-y gastric bypass.
Surg Obes Relat Dis. 2011;7:727–32.
151. Nadler EP, Youn HA, Ren CJ, Fielding GA. An update on 73 US obese
pediatric patients treated with laparoscopic adjustable gastric banding:
comorbidity resolution and compliance data. J Pediatr Surg. 2008;43:
152. Kaulfers A-MD, Bean JA, Inge TH, Dolan LM, Kalkwarf HJ. Bone loss
in adolescents after bariatric surgery. Pediatrics. 2011;127:e956–61.
153. Jeffreys RM, Hrovat K, Woo JG, Schmidt M, Inge TH, Xanthakos SA.
Dietary assessment of adolescents undergoing laparoscopic roux-en-y
gastric bypass surgery: macro- and micronutrient, fiber and supple-
ment intake. Surg Obes Relat Dis. 2012;8:331–6.
154. Jen HC, Rickard DG, Shew SB, Maggard MA, Slusser WM, Dutson EP,
DeUgarte DA. Trends and outcomes of adolescent bariatric surgery in
California, 2005–2007. Pediatrics. 2010;126:e746–53.
155. Michalsky M, Reichard K, Inge TH, Pratt J, Lenders C. ASMBS pedi-
atric committee best practice guidelines. Surg Obes Relat Dis. 2012;8:
156. Censani M, Stein EM, Shane E, Oberfield SE, McMahon DJ, Lerner S,
Fennoy I. Vitamin D deficiency is prevalent in morbidly obese adoles-
cents prior to bariatric surgery. ISRN Obes. Epub 2013, June 1.
157. Sysko R, Zakarin EB, Devlin MJ, Bush J, Walsh BT. A latent class anal-
ysis of psychiatric symptoms among 125 adolescents in a bariatric sur-
gery program. Int J Pediatr Obes. 2011;6:289–97.
158. Rand CS, Macgregor AM. Adolescents having obesity surgery: a 6-year
follow-up. South Med J. 1994;87:1208–13.
159. Jackman LA, Millane SS, Martin BR, Wood OB, McCabe GP, Peacock M,
Weaver CM. Calcium retention in relation to calcium intake and postme-
narcheal age in adolescent females. Am J Clin Nutr. 1997;66:327–33.
160. Hill KM, Braun M, Kern M, Martin BR, Navalta JW, Sedlock DA,
McCabe L, McCabe GP, Peacock M, Weaver CM. Predictors of calci-
um retention in adolescent boys. J Clin Endocrinol Metab. 2008;93:
161. Fullmer MA, Abrams SH, Hrovat K, Mooney L, Scheimann AO,
Hillman JB, Suskind DL. Nutritional strategy for adolescents under-
going bariatric surgery: Report of a working group of the Nutrition
Committee of NASPGHAN/NACHRI. J Pediatr Gastroenterol Nutr.
162. Jamal M, Gunay Y, Capper A, Eid A, Heitshusen D, Samuel I. Roux-en-Y
gastric bypass ameliorates polycystic ovary syndrome and dramatically
improves conception rates: a 9-year analysis. Surg Obes Relat Dis. 2012;
163. Legro RS, Dodson WC, Gnatuk CL, Estes SJ, Kunselman AR,
Meadows JW, Kesner JS, Krieg EFJ, Rogers AM, Haluck RS, et al.
Effects of gastric bypass surgery on reproductive function. J Clin En-
docrinol Metab. 2012;97:4540–48.
164. Belogolovkin V, Salihu HM, Weldeselasse H, Biroscak BJ, August EM,
Mbah AK, Alio AP. Impact of prior bariatric surgery on maternal and
fetal outcomes among obese and non-obese mothers. Arch Gynecol
165. Lapolla A, Marangon M, Dalfra MG, Segato G, De Luca M, Fedele D,
Favretti F, Enzi G, Busetto L. Pregnancy outcome in morbidly obese
women before and after laparoscopic gastric banding. Obes Surg.
166. Hochner H, Friedlander Y, Calderon-Margalit R, Meiner V, Sagy Y,
Avgil-Tsadok M, Burger A, Savitsky B, Siscovick DS, Manor O. Asso-
ciations of maternal prepregnancy body mass index and gestational
weight gain with adult offspring cardiometabolic risk factors: the Jer-
usalem Perinatal Family Follow-up Study. Circulation. 2012;125:
167. Guénard F, Deshaies Y, Cianflone K, Kral JG, Marceau P, Vohl MC.
Differential methylation in glucoregulatory genes of offspring born
before vs. after maternal gastrointestinal bypass surgery. Proc Natl
Acad Sci U S A. 2013;110:11439–44.
168. Smith J, Cianflone K, Biron S, Hould FS, Lebel S, Marceau S, Lescelleur
O, Biertho L, Simard S, Kral JG, et al. Effects of maternal surgical weight
loss in mothers on intergenerational transmission of obesity. J Clin
Endocrinol Metab. 2009;94:4275–83.
169. Kjaer MM, Lauenborg J, Breum BM, Nilas L. The risk of adverse preg-
nancy outcome after bariatric surgery; a nationwide register-based
matched cohort study. Am J Obstet Gynecol. 2013;208:464.e1–5.
170. Lesko J, Peaceman A. Pregnancy outcomes in women after bariatric
surgery compared with obese and morbidly obese controls. Obstet
171. Josefsson A, Blomberg M, Bladh M, Fredricksen SG, Sydsjo G. Bariat-
ric surgery in a national cohort of women: sociodemographics and
obstetric outcomes. Am J Obstet Gynecol. 2011;205:e1–8.
172. Santulli P, Mandelbrot L, Facchiano E, Dussaux C, Ceccaldi PF,
Ledoux S, Msika S. Obstetrical and neonatal outcomes of pregnancies
following gastric bypass surgery: a retrospective cohort study in a
French referral centre. Obes Surg. 2010;20:1501–8.
173. Ducarme G, Parisio L, Santulli P, Carbillon L, Mandelbrot L, Luton D.
Neonatal outcomes in pregnancies after bariatric surgery: a retrospec-
tive multi-centric cohort study in three French referral centers. J Ma-
tern Fetal Neonatal Med. 2013;26:275–8.
174. Facchiano E, Iannelli A, Santulli P, Mandelbrot L, Msika S. Pregnancy
after laparoscopic bariatric surgery: comparative study of adjustable
gastric banding and Roux-en-Y gastric bypass. Surg Obes Relat Dis.
175. Sheiner E, Balaban E, Dreiher J, Levi I, Levy A. Pregnancy outcome in
patients following different types of bariatric surgeries. Obes Surg.
176. Bebber FE, Rizzolli J, Casagrande DS, Rodrigues MT, Padoin AV, Mottin
CC, Repetto G. Pregnancy after bariatric surgery: 39 pregnancies
follow-up in a multidisciplinary team. Obes Surg. 2011;21:1546–51.
177. Guelinckx I, Devlieger R, Donceel P, Bel S, Pauwels S, Bogaerts A,
Thijs I, Schurmans K, Deschilder P, Vansant G. Lifestyle after bariatric
surgery: a multicenter, prospective cohort study in pregnant women.
Obes Surg. 2012;22:1456–64.
178. New hope for women with morbid obesity trying to get pregnant
[cited 3 June 2013]. Available from: http://asmbs.org/2012/06/revers-
179. Martorell R, Zongrone A. Intergenerational influences on child
growth and undernutrition. Paediatr Perinat Epidemiol. 2012;26
Weight loss surgery and deficiency 517
by guest on November 5, 2015