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Iron deficiency after bariatric surgery: what is the real problem?

  • Nele Steenackers (a1), Bart Van der Schueren (a1), Ann Mertens (a1), Matthias Lannoo (a1) (a2), Tara Grauwet (a3), Patrick Augustijns (a4) and Christophe Matthys (a1)...

Abstract

The growing prevalence of obesity explains the rising interest in bariatric surgery. Compared with non-surgical treatment options, bariatric surgery results in greater and sustained improvements in weight loss, obesity associated complications, all-cause mortality and quality of life. These encouraging metabolic and weight effects come with a downside, namely the risk of nutritional deficiencies. Particularly striking is the risk to develop iron deficiency. Postoperatively, the prevalence of iron deficiency varies between 18 and 53 % after Roux-en-Y gastric bypass and between 1 and 54 % after sleeve gastrectomy. Therefore, preventive strategies and effective treatment options for iron deficiency are crucial to successfully manage the iron status of patients after bariatric surgery. With this review, we discuss the risks and the contributing factors of developing iron deficiency after bariatric surgery. Furthermore, we highlight the discrepancy in the diagnosis of iron deficiency, iron deficiency anaemia and anaemia and highlight the evidence supporting the current nutritional recommendations in the field of bariatric research. In conclusion, we advocate for more nutrition-related research in patient populations in order to provide strong evidence-based guidelines after bariatric surgery.

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Corresponding author

*Corresponding author: C. Matthys, email christophe.matthys@uzleuven.be

References

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1.World Health Organization (2017) WHO Obesity and Overweight, Fact Sheet No 311. http://www.who.int/mediacentre/factsheets/fs311/en/ (accessed January 2018).
2.Collaboration GBM, Di Angelantonio, E, Bhupathiraju, ShN et al. (2016) Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents. Lancet 388, 776786.
3.MacMahon, S, Baigent, C, Duffy, S et al. (2009) Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet 373, 10831096.
4.Bray, GA, Frühbeck, G, Ryan, DH et al. (2016) Management of obesity. Lancet 387, 19471956.
5.Fried, M, Yumuk, V, Oppert, JM et al. (2014) Interdisciplinary European guidelines on metabolic and bariatric surgery. Obes Surg 24, 4255.
6.Mechanick, JI, Youdim, A, Jones, DB et al. (2013) Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 update: cosponsored by American association of clinical endocrinologists, the obesity society and American society for metabolic and bariatric surgery. Obesity (Silver Spring) 21, S1S27.
7.Sjöström, L, Narbro, K, Sjöström, CD et al. (2007) Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 357, 741752.
8.Sjöström, L. (2013) Review of the key results from the Swedish obese subjects (SOS) trial – a prospective controlled intervention study of bariatric surgery. J Intern Med 273, 219234.
9.Angrisani, L, Santonicola, A, Lovino, P et al. (2015) Bariatric surgery worldwide 2013. Obes Surg 25, 18221832.
10.DeMaria, EJ. (2007) Bariatric surgery for morbid obesity. N Engl J Med 356, 21762183.
11.Rubino, F & Cummings, DE (2012) Surgery: the coming of age of metabolic surgery. Nat Rev Endocrinol 8, 702704.
12.Rubino, F. (2013) From bariatric to metabolic surgery: definition of a new discipline and implications for clinical practice. Curr Atheroscler Rep 15, Epublication: 6 November 2013.
13.Buchwald, H. (2014) The evolution of metabolic/bariatric surgery. Obes Surg 24, 11261135.
14.Esteban Varela, J & Nguyen, NT (2015) Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers. Surg Obes Relat Dis 11, 987990.
15.Vidal, J, Corcelles, R, Jiménez, A et al. (2017) Metabolic and bariatric surgery for obesity. Gastroenterology 152, 17801790.
16.Lannoo, M & Dillemans, B (2014) Laparoscopy for primary and secondary bariatric procedures. Best Pract Res Clin Gastroenterol 28, 159173.
17.Ionut, V, Burch, M, Youdim, A et al. (2013) Gastrointestinal hormones and bariatric surgery-induced weight loss. Obesity 21, 10931103.
18.Decker, GA, Swain, JM, Crowell, MD et al. (2007) Gastrointestinal and nutritional complications after bariatric surgery. Am J Gastroenterol 102, 25712580.
19.Steenackers, N, Gesquiere, I & Matthys, C (2018) The relevance of dietary protein after bariatric surgery: what do we know? Curr Opin Clin Nutr Metab Care 21, 5863.
20.World Health Organization & Centers for Disease Control and Prevention (2007) Assessing the iron status of populations: report of a joint World Health Organization/Centers for Disease Control and Prevention technical consultation on the assessment of iron status at the population level. http://apps.who.int/iris/bitstream/10665/75368/1/9789241596107_eng.pdf?ua=1&ua=1 (accessed January 2018).
21.Gesquiere, I, Lannoo, M, Augustijns, P et al. (2014) Iron deficiency after Roux-en-Y gastric bypass: insufficient iron absorption from oral iron supplements. Obes Surg 24, 5661.
22.Aigner, E, Feldman, A & Datz, C (2014) Obesity as an emerging risk factor for iron deficiency. Nutrients 6, 35873600.
23.Colossi, FG, Casagrande, DS, Chatkin, R et al. (2008) Need for multivitamin use in the postoperative period of gastric bypass. Obes Surg 18, 187191.
24.De Torres Rossi, RG, Dos Santos, MTA, De Souza, FIS et al. (2012) Nutrient intake of women 3 years after Roux-en-Y gastric bypass surgery. Obes Surg 22, 15481553.
25.Mercachita, T, Santos, Z, Limão, J et al. (2014) Anthropometric evaluation and micronutrients intake in patients submitted to laparoscopic Roux-en-Y gastric bypass with a postoperative period of ≥1 year. Obes Surg 24, 102108.
26.Miller, GD, Norris, A & Fernandez, A (2014) Changes in nutrients and food groups intake following laparoscopic Roux-en-Y gastric bypass (RYGB). Obes Surg 24, 19261932.
27.Moizé, V, Andreu, A, Flores, L et al. (2013) Long-term dietary intake and nutritional deficiencies following sleeve gastrectomy or Roux-en-Y gastric bypass in a Mediterranean population. J Acad Nutr Diet 113, 400410.
28.Ruz, M, Carrasco, F & Rojas, P. (2009) Iron absorption and iron status are reduced after Roux-en-Y gastric bypass. Am J Clin Nutr 90, 527532.
29.Wardé-Kamar, J, Rogers, M, Flancbaum, L et al. (2004) Calorie intake and meal patterns up to 4 years after Roux-en-Y gastric bypass surgery. Obes Surg 14, 10701079.
30.Gesquiere, I, Foulon, V, Augustijns, P et al. (2017) Micronutrient intake, from diet and supplements, and association with status markers in pre- and post-RYGB patients. Clin Nutr 36, 11751181.
31.Aron-Wisnewsky, J, Verger, EO, Bounaix, C et al. (2016) Nutritional and protein deficiencies in the short term following both gastric bypass and gastric banding. Published online: 18 February 2016.
32.Bavaresco, M, Paganini, S, Lima, TP et al. (2010) Nutritional course of patients submitted to bariatric surgery. Obes Surg 20, 716721.
33.Menegati, GC, de Oliveira, LC, Santos, ALA et al. (2016) Nutritional status, body composition, and bone health in women after bariatric surgery at a university hospital in Rio de Janeiro. Obes Surg 26, 15171524.
34.McGrice, MA & Porter, JA (2014) The micronutrient intake profile of a multicentre cohort of Australian LAGB patients. Obes Surg 24, 400404.
35.Chou, J-J, Lee, W-J, Almalki, O et al. (2017) Dietary intake and weight changes 5 years after laparoscopic sleeve gastrectomy. Obes Surg 12, 32403246.
36.Nicoletti, CF, de Oliveira, BAP, Barbin, R et al. (2015) Red meat intolerance in patients submitted to gastric bypass: a 4-year follow-up study. Surg Obes Relat Dis 11, 842846.
37.Moize, V, Geliebter, A, Gluck, ME et al. (2003) Obese patients have inadequate protein intake related to protein intolerance up to 1 year following Roux-en-Y gastric bypass. Obes Surg 13, 2328.
38.Hood, MM, Corsica, J, Bradley, L et al. (2016) Managing severe obesity: understanding and improving treatment adherence in bariatric surgery. J Behav Med 39, 10921103.
39.Melissas, J, Torres, A, Yashkov, Y et al. (2016) International Federation for Surgical Obesity (IFSO) Center of Excellence Program for Bariatric Surgery. In Obesity, Bariatric and Metabolic Surgery. 1st ed., pp. 575580. [Agrawal, S, editor]. Heidelberg: Springer International Publishing.
40.Saber, AA, Bashah, MM & Zarabi, S (2016) Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) By American Society for Metabolic and Bariatric Surgery (ASMBS) and American College of Surgery (ACS). In Obesity, Bariatric and Metabolic Surgery. 1st ed., pp. 581584. [Agrawal, S, editor]. Heidelberg: Springer International Publishing.
41.Peacock, JC, Schmidt, CE & Barry, K (2016) A qualitative analysis of post-operative nutritional barriers and useful dietary services reported by bariatric surgical patients. Obes Surg 26, 23312339.
42.Ishida, RK, Faintuch, J, Paula, AMR et al. (2007) Microbial flora of the stomach after gastric bypass for morbid obesity. Obes Surg 17, 752758.
43.Behrns, KE, Smith, CD & Sarr, MG (1994) Prospective evaluation of gastric acid secretion and cobalamin absorption following gastric bypass for clinically severe obesity. Dig Dis Sci 39, 315320.
44.Spak, E, Björklund, P, Helander, HF et al. (2010) Changes in the mucosa of the Roux-limb after gastric bypass surgery. Histopathology 57, 680688.
45.Casselbrant, A, Elias, E, Fändriks, L et al. (2015) Expression of tight-junction proteins in human proximal small intestinal mucosa before and after Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 11, 4553.
46.Ruz, M, Carrasco, F, Rojas, P et al. (2012) 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 96, 810817.
47.Rhode, BM, Shustik, C, Christou, NV et al. (1999) Iron absorption and therapy after gastric bypass. Obes Surg 9, 1721.
48.Rosa, FT, De Oliveira-Penaforte, FR, De Arruda Leme, I et al. (2011) Altered plasma response to zinc and iron tolerance test after Roux-en-Y gastric bypass. Surg Obes Relat Dis 7, 309314.
49.Wienk, KJH, Marx, JJM & Beynen, AC (1999) The concept of iron bioavailability and its assessment. Eur J Nutr 38, 5175.
50.Salgado, W, Modotti, C, Nonino, CB et al. (2014) Anemia and iron deficiency before and after bariatric surgery. Surg Obes Relat Dis 10, 4954.
51.Kotkiewicz, A, Donaldson, K, Dye, C et al. (2015) Anemia and the need for intravenous iron infusion after Roux-en-Y gastric bypass. Clin Med Insights Blood Disord 8, 917.
52.Worm, D, Madsbad, S, Kristiansen, VB et al. (2015) Changes in hematology and calcium metabolism after gastric bypass surgery: a 2-year follow-up study. Obes Surg 25, 16471652.
53.Skroubis, G, Sakellaropoulos, G, Pouggouras, K et al. (2002) Comparison of nutritional deficiencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass. Obes Surg 12, 551558.
54.Kim, MK, Kim, W, Kwon, HS et al. (2014) Effects of bariatric surgery on metabolic and nutritional parameters in severely obese Korean patients with type 2 diabetes: a prospective 2-year follow up. J Diab Investig 5, 221227.
55.Avgerinos, DV, Llaguna, OH, Seigerman, M et al. (2010) Incidence and risk factors for the development of anemia following gastric bypass surgery. World J Gastroenterol 16, 18671870.
56.Obinwanne, KM, Fredrickson, KA, Mathiason, MA et al. (2014) Incidence, treatment, and outcomes of iron deficiency after laparoscopic Roux-en-Y gastric bypass: a 10-year analysis. J Am Coll Surg 218, 246252.
57.Yu, H, Du, R, Zhang, N et al. (2016) Iron-deficiency anemia after laparoscopic Roux-en-Y gastric bypass in Chinese obese patients with type 2 diabetes: a 2-year follow-up study. Obes Surg 26, 27052711.
58.Ledoux, S, Calabrese, D, Bogard, C et al. (2014) Long-term evolution of nutritional deficiencies after gastric bypass: an assessment according to compliance to medical care. Ann Surg 259, 11041110.
59.Dalcanale, L, Oliveira, CPMS, Faintuch, J et al. (2010) Long-term nutritional outcome after gastric bypass. Obes Surg 20, 181187.
60.Dogan, K, Homan, J, Aarts, EO et al. (2017) Long-term nutritional status in patients following Roux-en-Y gastric bypass surgery. Clin Nutr 37, 612617.
61.Skroubis, G, Kouri, N, Mead, N et al. (2014) Long-term results of a prospective comparison of Roux-en-Y gastric bypass versus a variant of biliopancreatic diversion in a non-superobese population (BMI 35–50 kg/m2). Obes Surg 24, 197204.
62.Coupaye, M, Puchaux, K, Bogard, C et al. (2009) Nutritional consequences of adjustable gastric banding and gastric bypass: a 1-year prospective study. Obes Surg 19, 5665.
63.Blume, CA, Boni, CC, Casagrande, DS et al. (2012) Nutritional profile of patients before and after Roux-en-Y gastric bypass: 3-year follow-up. Obes Surg 22, 16761685.
64.Cable, CT, Colbert, CY, Showalter, T et al. (2011) Prevalence of anemia after Roux-en-Y gastric bypass surgery: what is the right number? Surg Obes Relat Dis 7, 134139.
65.Karefylakis, C, Näslund, I, Edholm, D et al. (2015) Prevalence of anemia and related deficiencies 10 years after gastric bypass – a retrospective study. Obes Surg 25, 10191023.
66.Vargas-Ruiz, AG, Hernández-Rivera, G & Herrera, MF (2008) Prevalence of iron, folate, and vitamin B12 deficiency anemia after laparoscopic Roux-en-Y gastric bypass. Obes Surg 18, 288293.
67.Rojas, P, Carrasco, F, Codoceo, J et al. (2011) Trace element status and inflammation parameters after 6 months of Roux-en-Y gastric bypass. Obes Surg 21, 561568.
68.Von Drygalski, A, Andris, DAN, Nuttleman, PR et al. (2011) Anemia after bariatric surgery cannot be explained by iron deficiency alone: results of a large cohort study. SOARD 7, 151156.
69.Gjessing, HR, Nielsen, HJ, Mellgren, G et al. (2013) Energy intake, nutritional status and weight reduction in patients one year after laparoscopic sleeve gastrectomy. SpringerPlus 2, Epublication: 30 July 2013.
70.Al-Sabah, S, Al-Mutawa, A, Anderson, AK et al. (2017) Evaluation of Nutritional Status Post Laparoscopic Sleeve Gastrectomy – 5-Year Outcomes. [Epublication ahead of print version].
71.Hakeam, HA, O'Regan, PJ, Salem, AM et al. (2009) Impact of laparoscopic sleeve gastrectomy on iron indices: 1 year follow-up. Obes Surg 19, 14911496.
72.Zarshenas, N, Nacher, M, Loi, KW et al. (2016) Investigating nutritional deficiencies in a group of patients 3 years post laparoscopic sleeve gastrectomy. Obes Surg 26, 29362943.
73.Gillon, S, Jeanes, YM, Andersen, JR et al. (2017) Micronutrient status in morbidly obese patients prior to laparoscopic sleeve gastrectomy and micronutrient changes 5 years post-surgery. Obes Surg 27, 606612.
74.Van Rutte, PWJ, Aarts, EO, Smulders, JF et al. (2014) Nutrient deficiencies before and after sleeve gastrectomy. Obes Surg 24, 16391646.
75.Ben-Porat, T, Elazary, R, Yuval, JB et al. (2015) Nutritional deficiencies after sleeve gastrectomy: can they be predicted preoperatively? Surg Obes Relat Dis 11, 10291036.
76.Ben-Porat, T, Elazary, R, Goldenshluger, A et al. (2017) Nutritional deficiencies four years after laparoscopic sleeve gastrectomy – are supplements required for a lifetime? Surg Obes Relat Dis 13, 11381144.
77.Damms-Machado, A, Friedrich, A, Kramer, KM et al. (2012) Pre- and postoperative nutritional deficiencies in obese patients undergoing laparoscopic sleeve gastrectomy. Obes Surg 22, 881889.
78.Cepeda-Lopez, AC, Allende-Labastida, J, Melse-Boonstra, A et al. (2016) The effects of fat loss after bariatric surgery on inflammation, serum hepcidin, and iron absorption: a prospective 6-mo iron stable isotope study. Am J Clin Nutr 104, 10301038.
79.Aarts, EO, Janssen, IMC & Berends, FJ (2011) The gastric sleeve: losing weight as fast as micronutrients? Obes Surg 21, 207211.
80.Malone, M, Alger-Mayer, S, Lindstrom, J et al. (2013) Management of iron deficiency and anemia after Roux-en-Y gastric bypass surgery: an observational study. Surg Obes Relat Dis 9, 969974.
81.Auerbach, M & Adamson, JW (2015) How we diagnose and treat iron deficiency anemia. Am J Hematol 91, 3138.
82.World Health Organization (2011) Serum ferritin concentrations for the assessment of iron status and iron deficiency in populations. Vitamin and Mineral Nutrition Information System. http://www.who.int/vmnis/indicators/serum_ferritin.pdf (accessed January 2018).
83.Zimmermann, MB (2008) Methods to assess iron and iodine status. Br J Nutr 99, S29.
84.Ferguson, BJ, Skikne, BS, Simpson, KM et al. (1992) Serum transferrin receptor distinguishes the anemia of chronic disease from iron deficiency anemia. J Lab Clin Med 119, 385390.
85.Thomas, DW, Hinchliffe, RF, Briggs, C et al. (2013) Guideline for the laboratory diagnosis of functional iron deficiency. Br J Haematol 161, 639648.
86.Macdougall, IC, Malyszko, J, Hider, RC et al. (2010) Current status of the measurement of blood hepcidin levels in chronic kidney disease. Clin J Am Soc Nephrol 5, 16811689.
87.World Health Organization (2011) Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. http://www.who.int/vmnis/indicators/haemoglobin.pdf (accessed January 2018).
88.Beutler, E & Waalen, J (2006) The definition of anemia: what is the lower limit of normal of the blood hemoglobin concentration? Blood 107, 17471750.
89.Johnson-Spear, MA & Yip, R (1994) Hemoglobin difference between black and white women with comparable iron status: justification for race-specific anemia criteria. Am J Clin Nutr 60, 117121.
90.Cook, JD & Finch, CA (1979) Assessing iron status of a population. Am J Clin Nutr 32, 21152119.
91.Fried, M, Hainer, V, Basdevant, A et al. (2007) Inter-disciplinary European guidelines on surgery of severe obesity. Int J Obes 31, 569577.
92.Mechanick, J, Kushner, R, Sugerman, H et al. (2009) American association of clinical endocrinologists, the obesity society and American society for metabolic & bariatric surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric. Obesity S1, 170.
93.Thereaux, J, Lesuffleur, T, Paita, M et al. (2017) Long-term follow-up after bariatric surgery in a national cohort. Br J Surg 104, 13621371.
94.Parrott, J, Frank, L, Rabena, R et al. (2017) American society for metabolic and bariatric surgery integrated health nutritional guidelines for the surgical weight loss patient 2016 update: micronutrients. Surg Obes Relat Dis 13, 727741.
95.Sherf-Dagan, S, Hod, K, Buch, A et al. (2017) Health and nutritional status of vegetarian candidates for bariatric surgery and practical recommendations. Obes Surg 28, 152160.
96.Brethauer, SA, Kim, J, Chaar, M et al. (2015) Standardized outcomes reporting in metabolic and bariatric surgery. Obes Surg 25, 587606.

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