Current Obesity Reports

, Volume 6, Issue 3, pp 286–296 | Cite as

Nutritional and Micronutrient Care of Bariatric Surgery Patients: Current Evidence Update

  • Michael A. Via
  • Jeffrey I. Mechanick
Health Services and Programs (R Welbourn, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Health Services and Programs


Purpose of Review

The continued success of bariatric surgery to treat obesity and obesity-associated metabolic conditions creates a need for a strong understanding of clinical nutrition both before and after these procedures.

Recent Findings

Surgically induced alteration of gastrointestinal physiology can affect the nutrition of individuals, especially among those who have undergone malabsorptive procedures. While uncommon, a subset of patients may develop protein-calorie malnutrition. In these cases, nutrition support should be tailored to the severity of malnutrition.


Among all patients who undergo bariatric surgery, high rates of micronutrient deficiencies have been observed. To mitigate these deficiencies, empiric supplementation with multivitamins, calcium citrate, and vitamin D is generally recommended. Periodic surveillance should be performed for commonly deficient micronutrients, including thiamin (B1), folate (B9), cobalamin (B12), iron, and vitamin D. Following Roux-en-Y gastric bypass, serum levels of copper and zinc should also be monitored. In addition, lipid-soluble vitamins should be monitored following biliopancreatic diversion with/without duodenal switch.


Bariatric surgery Obesity Protein-calorie malnutrition Micronutrient deficiency Deficiency screening 


Compliance with Ethical Standards

Conflict of Interest

Michael A. Via and Jeffrey I. Mechanick declare they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Khorgami Z, Shoar S, Andalib A, Aminian A, Brethauer SA, Schauer PR. Trends in utilization of bariatric surgery, 2010–2014: sleeve gastrectomy dominates. Surg Obes Relat Dis. 2017;Google Scholar
  2. 2.
    Strohmayer E, Via MA, Yanagisawa R. Metabolic management following bariatric surgery. Mt. Sinai J Med. 2010;77(5):431–45.CrossRefPubMedGoogle Scholar
  3. 3.
    Fox SR. The use of the biliopancreatic diversion as a treatment for failed gastric partitioning in the morbidly obese. Obes Surg. 1991;1(1):89–93.CrossRefPubMedGoogle Scholar
  4. 4.
    Ledoux S, Msika S, Moussa F, Larger E, Boudou P, Salomon L, et al. Comparison of nutritional consequences of conventional therapy of obesity, adjustable gastric banding, and gastric bypass. Obes Surg. 2006;16(8):1041–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Perrone F, Bianciardi E, Ippoliti S, Nardella J, Fabi F, Gentileschi P. Long-term effects of laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass for the treatment of morbid obesity: a monocentric prospective study with minimum follow-up of 5 years. Updates Surg. 2017;Google Scholar
  6. 6.
    Laurenius A, Larsson I, Melanson KJ, Lindroos AK, Lonroth H, Bosaeus I, et al. Decreased energy density and changes in food selection following Roux-en-Y gastric bypass. Eur J Clin Nutr. 2013;67(2):168–73.CrossRefPubMedGoogle Scholar
  7. 7.
    Aron-Wisnewsky J, Verger EO, Bounaix C, Dao MC, Oppert JM, Bouillot JL, et al. Nutritional and protein deficiencies in the short term following both gastric bypass and gastric banding. PLoS One. 2016;11(2):e0149588.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Daniel H, Zietek T. Taste and move: glucose and peptide transporters in the gastrointestinal tract. Exp Physiol. 2015;100(12):1441–50.CrossRefPubMedGoogle Scholar
  9. 9.
    Mace OJ, Lister N, Morgan E, Shepherd E, Affleck J, Helliwell P, et al. An energy supply network of nutrient absorption coordinated by calcium and T1R taste receptors in rat small intestine. J Physiol. 2009;587(1):195–210.CrossRefPubMedGoogle Scholar
  10. 10.
    Mace OJ, Affleck J, Patel N, Kellett GL. Sweet taste receptors in rat small intestine stimulate glucose absorption through apical GLUT2. J Physiol. 2007;582(Pt 1):379–92.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Bhutta HY, Deelman TE, le Roux CW, Ashley SW, Rhoads DB, Tavakkoli A. Intestinal sweet-sensing pathways and metabolic changes after Roux-en-Y gastric bypass surgery. Am J Physiol Gastrointest Liver Physiol. 2014;307(5):G588–93.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351(26):2683–93.CrossRefPubMedGoogle Scholar
  13. 13.
    Suarez Llanos JP, Fuentes Ferrer M, Alvarez-Sala-Walther L, Garcia Bray B, Medina Gonzalez L, Breton Lesmes I, et al. Protein malnutrition incidence comparison after gastric bypass versus biliopancreatic diversion. Nutr Hosp. 2015;32(1):80–6.PubMedGoogle Scholar
  14. 14.
    • Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, et al. 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 & Bariatric Surgery. Endocr Pract. 2013;19(2):337–72.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Mala T. The gastric remnant in Roux-en-Y gastric bypass: challenges and possibilities. J Clin Gastroenterol. 2016;50(7):527–31.CrossRefPubMedGoogle Scholar
  16. 16.
    Pereira-da-Silva L, Pitta-Gros Dias M, Virella D, Serelha M. Osmolality of elemental and semi-elemental formulas supplemented with nonprotein energy supplements. J Hum Nutr Diet. 2008;21(6):584–90.CrossRefPubMedGoogle Scholar
  17. 17.
    Vilallonga R, van de Vrande S, Himpens J. Laparoscopic reversal of Roux-en-Y gastric bypass into normal anatomy with or without sleeve gastrectomy. Surg Endosc. 2013;27(12):4640–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Dyson JK, Thompson N. Adult parenteral nutrition in the North of England: a region-wide audit. BMJ Open. 2017;7(1):e012663.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Ezquerro S, Mendez-Gimenez L, Becerril S, Moncada R, Valenti V, Catalan V, et al. Acylated and desacyl ghrelin are associated with hepatic lipogenesis, beta-oxidation and autophagy: role in NAFLD amelioration after sleeve gastrectomy in obese rats. Sci Rep. 2016;6:39,942.CrossRefGoogle Scholar
  20. 20.
    Xu Z, Li Y, Wang J, Wu B, Li J. Effect of omega-3 polyunsaturated fatty acids to reverse biopsy-proven parenteral nutrition-associated liver disease in adults. Clin Nutr. 2012;31(2):217–23.CrossRefPubMedGoogle Scholar
  21. 21.
    Jones CJ, Calder PC. Influence of different intravenous lipid emulsions on fatty acid status and laboratory and clinical outcomes in adult patients receiving home parenteral nutrition: A systematic review. Clin Nutr. 2016;Google Scholar
  22. 22.
    Kim ES, Keam SJ. Teduglutide: a review in short bowel syndrome. Drugs. 2017;77(3):345–52.CrossRefPubMedGoogle Scholar
  23. 23.
    Segaran E. Provision of nutritional support to those experiencing complications following bariatric surgery. Proc Nutr Soc. 2010;69(4):536–42.CrossRefPubMedGoogle Scholar
  24. 24.
    van Gemert WG, Westerterp KR, Greve JW, Soeters PB. Reduction of sleeping metabolic rate after vertical banded gastroplasty. Int J Obes Relat Metab Disord. 1998;22(4):343–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Schneider J, Peterli R, Gass M, Slawik M, Peters T, Wolnerhanssen BK. Laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass lead to equal changes in body composition and energy metabolism 17 months postoperatively: a prospective randomized trial. Surg Obes Relat Dis. 2016;12(3):563–70.CrossRefPubMedGoogle Scholar
  26. 26.
    Hirsch KR, Smith-Ryan AE, Blue MN, Mock MG, Trexler ET. Influence of segmental body composition and adiposity hormones on resting metabolic rate and substrate utilization in overweight and obese adults. J Endocrinol Invest. 2017;Google Scholar
  27. 27.
    Alves VG, da Rocha EE, Gonzalez MC, da Fonseca RB, Silva MH, Chiesa CA. Assessement of resting energy expenditure of obese patients: comparison of indirect calorimetry with formulae. Clin Nutr. 2009;28(3):299–304.CrossRefPubMedGoogle Scholar
  28. 28.
    de Castro CM, de Lima Montebelo MI, Rasera I Jr, de Oliveira AV Jr, Gomes Gonelli PR, Aparecida Cardoso G. Effects of Roux-en-Y gastric bypass on resting energy expenditure in women. Obes Surg. 2008;18(11):1376–80.CrossRefGoogle Scholar
  29. 29.
    Choban P, Dickerson R, Malone A, Worthington P, Compher C. A.S.P.E.N. Clinical guidelines: nutrition support of hospitalized adult patients with obesity. JPEN J Parenter Enteral Nutr. 2013;37(6):714–44.CrossRefPubMedGoogle Scholar
  30. 30.
    MacLean LD, Rhode BM, Shizgal HM. Nutrition following gastric operations for morbid obesity. Ann Surg. 1983;198(3):347–55.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Schollenberger AE, Karschin J, Meile T, Kuper MA, Konigsrainer A, Bischoff SC. Impact of protein supplementation after bariatric surgery: a randomized controlled double-blind pilot study. Nutrition. 2015;32(2):186–92.CrossRefPubMedGoogle Scholar
  32. 32.
    Herring LY, Stevinson C, Carter P, Biddle SJ, Bowrey DJ, Sutton CD, et al. The effects of supervised exercise training 12–24 months after bariatric surgery on physical function and body composition: A randomised controlled trial. Int J Obes (Lond). 2017;Google Scholar
  33. 33.
    Campanha-Versiani L, Pereira DA, Ribeiro-Samora GA, Ramos AV, de Sander Diniz MF, De Marco LA, et al. The effect of a muscle weight-bearing and aerobic exercise program on the body composition, muscular strength, biochemical markers, and bone mass of obese patients who have undergone gastric bypass surgery. Obes Surg. 2017;Google Scholar
  34. 34.
    Bae J, Shade J, Abraham A, Abraham B, Peterson L, Schneider EB, et al. Effect of mandatory centers of excellence designation on demographic characteristics of patients who undergo bariatric surgery. JAMA Surg. 2015;150(7):644–8.CrossRefPubMedGoogle Scholar
  35. 35.
    Hutter MM, Schirmer BD, Jones DB, Ko CY, Cohen ME, Merkow RP, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011;254(3):410–20. discussion 420–412CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Gehrer S, Kern B, Peters T, Christoffel-Courtin C, Peterli R. Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux-Y-gastric bypass (LRYGB)—a prospective study. Obes Surg. 2010;20(4):447–53.CrossRefPubMedGoogle Scholar
  37. 37.
    Coupaye M, Puchaux K, Bogard C, Msika S, Jouet P, Clerici C, et al. Nutritional consequences of adjustable gastric banding and gastric bypass: a 1-year prospective study. Obes Surg. 2009;19(1):56–65.CrossRefPubMedGoogle Scholar
  38. 38.
    Marinari GM, Murelli F, Camerini G, Papadia F, Carlini F, Stabilini C, et al. A 15-year evaluation of biliopancreatic diversion according to the Bariatric Analysis Reporting Outcome System (BAROS). Obes Surg. 2004;14(3):325–8.CrossRefPubMedGoogle Scholar
  39. 39.
    Liu D, Ke Z, Luo J. Thiamine deficiency and neurodegeneration: the interplay among oxidative stress, endoplasmic reticulum stress, and autophagy. Mol Neurobiol. 2016;Google Scholar
  40. 40.
    Said HM. Intestinal absorption of water-soluble vitamins in health and disease. Biochem J. 2011;437(3):357–72.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Matrana MR, Vasireddy S, Davis WE. The skinny on a growing problem: dry beriberi after bariatric surgery. Ann Intern Med. 2008;149(11):842–4.CrossRefPubMedGoogle Scholar
  42. 42.
    Bhardwaj A, Watanabe M, Shah JR. A 46-yr.-old woman with ataxia and blurred vision 3 months after bariatric surgery. Am J Gastroenterol. 2008;103(6):1575–7.CrossRefPubMedGoogle Scholar
  43. 43.
    Moat SJ, Lang D, McDowell IF, Clarke ZL, Madhavan AK, Lewis MJ, et al. Folate, homocysteine, endothelial function and cardiovascular disease. J Nutr Biochem. 2004;15(2):64–79.CrossRefPubMedGoogle Scholar
  44. 44.
    Zhao R, Matherly LH, Goldman ID. Membrane transporters and folate homeostasis: intestinal absorption and transport into systemic compartments and tissues. Expert Rev. Mol Med. 2009;11:e4.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Reynolds EH. The neurology of folic acid deficiency. Handb Clin Neurol. 2014;120:927–43.CrossRefPubMedGoogle Scholar
  46. 46.
    • Pellitero S, Martinez E, Puig R, Leis A, Zavala R, Granada ML, et al. Evaluation of vitamin and trace element requirements after sleeve gastrectomy at long term. Obes Surg. 2017; A prospective cohort trial that demonstrates micronutrient deficiencies up to 5 years following LSG Google Scholar
  47. 47.
    Homan J, Betzel B, Aarts EO, Dogan K, van Laarhoven KJ, Janssen IM, et al. Vitamin and mineral deficiencies after biliopancreatic diversion and biliopancreatic diversion with duodenal switch—the rule rather than the exception. Obes Surg. 2015;25(9):1626–32.CrossRefPubMedGoogle Scholar
  48. 48.
    • Coupaye M, Riviere P, Breuil MC, Castel B, Bogard C, Dupre T, et al. Comparison of nutritional status during the first year after sleeve gastrectomy and Roux-en-Y gastric bypass. Obes Surg. 2014;24(2):276–83. A prospective trial comparing micronutrient deficiencies among patients that have undergone LSG or RYGB CrossRefPubMedGoogle Scholar
  49. 49.
    Baltaci D, Deler MH, Turker Y, Ermis F, Iliev D, Velioglu U. Evaluation of serum Vitamin B12 level and related nutritional status among apparently healthy obese female individuals. Niger J Clin Pract. 2017;20(1):99–105.CrossRefPubMedGoogle Scholar
  50. 50.
    Moore CE, Sherman V. Effectiveness of B vitamin supplementation following bariatric surgery: rapid increases of serum vitamin B12. Obes Surg. 2013;25(4):694–9.CrossRefGoogle Scholar
  51. 51.
    Grasbeck R. Hooked to vitamin B12 since 1955: a historical perspective. Biochimie. 2013;95(5):970–5.CrossRefPubMedGoogle Scholar
  52. 52.
    Punchai S, Hanipah ZN, Meister KM, Schauer PR, Brethauer SA, Aminian A. Neurologic manifestations of vitamin B deficiency after bariatric surgery. Obes Surg. 2017;Google Scholar
  53. 53.
    Aasheim ET, Bjorkman S, Sovik TT, Engstrom M, Hanvold SE, Mala T, et al. Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Am J Clin Nutr. 2009;90(1):15–22.CrossRefPubMedGoogle Scholar
  54. 54.
    Cupa N, Schulte DM, Ahrens M, Schreiber S, Laudes M. Vitamin B6 intoxication after inappropriate supplementation with micronutrients following bariatric surgery. Eur J Clin Nutr. 2015;69(7):862–3.CrossRefPubMedGoogle Scholar
  55. 55.
    Gobato RC, Seixas Chaves DF, Chaim EA. Micronutrient and physiologic parameters before and 6 months after RYGB. Surg Obes Relat Dis. 2014;10(5):944–51.CrossRefPubMedGoogle Scholar
  56. 56.
    Riess KP, Farnen JP, Lambert PJ, Mathiason MA, Kothari SN. Ascorbic acid deficiency in bariatric surgical population. Surg Obes Relat Dis. 2009;5(1):81–6.CrossRefPubMedGoogle Scholar
  57. 57.
    Hansen EP, Metzsche C, Henningsen E, Toft P. Severe scurvy after gastric bypass surgery and a poor postoperative diet. J Clin Med Res. 2012;4(2):135–7.PubMedPubMedCentralGoogle Scholar
  58. 58.
    Conrad ME, Cortell S, Williams HL, Foy AL. Polymerization and intraluminal factors in the absorption of hemoglobin-iron. J Lab Clin Med. 1966;68(4):659–68.PubMedGoogle Scholar
  59. 59.
    Han O. Molecular mechanism of intestinal iron absorption. Metallomics. 2011;3(2):103–9.CrossRefPubMedGoogle Scholar
  60. 60.
    van den Berghe PV, Klomp LW. New developments in the regulation of intestinal copper absorption. Nutr Rev. 2009;67(11):658–72.CrossRefPubMedGoogle Scholar
  61. 61.
    Kumar P, Hamza N, Madhok B, De Alwis N, Sharma M, Miras AD, et al. Copper deficiency after gastric bypass for morbid obesity: a systematic review. Obes Surg. 2016;26(6):1335–42.CrossRefPubMedGoogle Scholar
  62. 62.
    Livingstone C. Zinc: physiology, deficiency, and parenteral nutrition. Nutr Clin Pract. 2015;30(3):371–82.CrossRefPubMedGoogle Scholar
  63. 63.
    Ruz M, Carrasco F, Rojas P, Codoceo J, Inostroza J, Basfi-fer K, et al. Zinc absorption and zinc status are reduced after Roux-en-Y gastric bypass: a randomized study using 2 supplements. Am J Clin Nutr. 2011;94(4):1004–11.CrossRefPubMedGoogle Scholar
  64. 64.
    Jin J, Robinson AV, Hallowell PT, Jasper JJ, Stellato TA, Wilhem SM. Increases in parathyroid hormone (PTH) after gastric bypass surgery appear to be of a secondary nature. Surgery. 2007;142(6):914–20. discussion 914–920CrossRefPubMedGoogle Scholar
  65. 65.
    Youssef Y, Richards WO, Sekhar N, Kaiser J, Spagnoli A, Abumrad N, et al. Risk of secondary hyperparathyroidism after laparoscopic gastric bypass surgery in obese women. Surg Endosc. 2007;21(8):1393–6.CrossRefPubMedGoogle Scholar
  66. 66.
    Aarts E, van Groningen L, Horst R, Telting D, van Sorge A, Janssen I, et al. Vitamin D absorption: consequences of gastric bypass surgery. Eur J Endocrinol. 2011;164(5):827–32.CrossRefPubMedGoogle Scholar
  67. 67.
    Lieske JC, Mehta RA, Milliner DS, Rule AD, Bergstralh EJ, Sarr MG. Kidney stones are common after bariatric surgery. Kidney Int. 2015;87(4):839–45.CrossRefPubMedGoogle Scholar
  68. 68.
    Kumar R, Lieske JC, Collazo-Clavell ML, Sarr MG, Olson ER, Vrtiska TJ, et al. Fat malabsorption and increased intestinal oxalate absorption are common after Roux-en-Y gastric bypass surgery. Surgery. 2011;149(5):654–61.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Semins MJ, Matlaga BR, Shore AD, Steele K, Magnuson T, Johns R, et al. The effect of gastric banding on kidney stone disease. Urology. 2009;74(4):746–9.CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Switzer NJ, Marcil G, Prasad S, Debru E, Church N, Mitchell P, et al. Long-term hypovitaminosis D and secondary hyperparathyroidism outcomes of the Roux-en-Y gastric bypass: a systematic review. Obes Rev. 2017;Google Scholar
  71. 71.
    Alfonso B, Jacobson AS, Alon EE, Via MA. Previous gastric bypass surgery complicating total thyroidectomy. Ear Nose Throat J. 2015;94(3):E12–6.PubMedGoogle Scholar
  72. 72.
    Chen Y, Lubitz CC, Shikora SA, Hodin RA, Gaz RD, Moore FD Jr, et al. Primary hyperparathyroidism after Roux-en-Y gastric bypass. Obes Surg. 2015;25(4):700–4.CrossRefPubMedGoogle Scholar
  73. 73.
    Hatizifotis M, Dolan K, Newbury L, Fielding G. Symptomatic vitamin A deficiency following biliopancreatic diversion. Obes Surg. 2003;13(4):655–7.CrossRefPubMedGoogle Scholar
  74. 74.
    Espe KM, Raila J, Henze A, Krane V, Schweigert FJ, Hocher B, et al. Impact of vitamin A on clinical outcomes in haemodialysis patients. Nephrol Dial Transplant. 2011;26(12):4054–61.CrossRefPubMedGoogle Scholar
  75. 75.
    Kappus H, Diplock AT. Tolerance and safety of vitamin E: a toxicological position report. Free Radic Biol Med. 1992;13(1):55–74.CrossRefPubMedGoogle Scholar
  76. 76.
    Homan J, Ruinemans-Koerts J, Aarts EO, Janssen IM, Berends FJ, de Boer H. Management of vitamin K deficiency after biliopancreatic diversion with or without duodenal switch. Surg Obes Relat Dis. 2016;12(2):338–44.CrossRefPubMedGoogle Scholar
  77. 77.
    Norholk LM, Holst JJ, Jeppesen PB. Treatment of adult short bowel syndrome patients with teduglutide. Expert Opin Pharmacother. 2012;13(2):235–43.CrossRefPubMedGoogle Scholar
  78. 78.
    Somerville V, Bringans C, Braakhuis A. Polyphenols and Performance: A Systematic Review and Meta-Analysis. Sports Med. 2017;Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.Division of Endocrinology, Diabetes, and Bone DiseaseMount Sinai Beth Israel Medical CenterNew YorkUSA
  2. 2.Marie-Josee and Henry R. Kravis Center For Cardiovascular HealthMount Sinai HeartNew YorkUSA
  3. 3.Icahn School of Medicine at Mount SinaiNew YorkUSA
  4. 4.Division of CardiologyIcahn School of Medicine at Mount SinaiNew YorkUSA
  5. 5.Metabolic Support, Division of Endocrinology, Diabetes, and Bone DiseaseIcahn School of Medicine at Mount SinaiNew YorkUSA

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