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: email@example.com.
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
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