Pharmacotherapy Prevention and Management of Nutritional Deficiencies Post Roux-en-Y Gastric Bypass


Roux-en-Y gastric bypass is the most commonly performed bariatric procedure. It is associated with nutritional deficiencies due to gastric reduction, intestinal bypass, reduced caloric intake, avoidance of nutrient-rich foods, noncompliance with supplementation and poor food tolerability. Although there are multiple publications on this topic, there is a lack of consistent guidance for the healthcare practitioner caring for the bariatric patient. This article will encompass literature reviewing the pharmacotherapy approach to prevention and management of nutritional deficiencies since the American Society of Metabolic and Bariatric Surgery guidelines were published in 2008.

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  1. 1.

    Mechanick JI, Kushner RF, Sugerman HJ, et al. 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 surgery patient. Surg Obes Relat Dis. 2008;4(5 Suppl):S109–84.

    PubMed  Article  Google Scholar 

  2. 2.

    Brethauer SA, Chand B, Schauer PR. Risks and benefits of bariatric surgery: current evidence. Cleve Clin J Med. 2006;73(11):993–1007.

    PubMed  Article  Google Scholar 

  3. 3.

    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–37.

    CAS  PubMed  Article  Google Scholar 

  4. 4.

    Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report. National Institutes of Health. Obesity Research. 1998;6 Suppl 2:51S–209S.

  5. 5.

    Dewey M, Heuberger R. Vitamin D and calcium status and appropriate recommendations in bariatric surgery patients. Gastroenterol Nurs. 2011;34(5):367–74.

    PubMed  Article  Google Scholar 

  6. 6.

    Bordalo LA, Teixeira TF, Bressan J, et al. Bariatric surgery: how and why to supplement. Rev Assoc Med Bras. 2011;57(1):113–20.

    PubMed  Article  Google Scholar 

  7. 7.

    Strohmayer E, Via MA, Yanagisawa R. Metabolic management following bariatric surgery. Mt Sinai J Med. 2010;77(5):431–45.

    PubMed  Article  Google Scholar 

  8. 8.

    Agha-Mohammadi S, Hurwitz DJ. Nutritional deficiency of post-bariatric surgery body contouring patients: what every plastic surgeon should know. Plast Reconstr Surg. 2008;122(2):604–13.

    CAS  PubMed  Article  Google Scholar 

  9. 9.

    Fernandez-Banares F, Monzon H, Forne M. A short review of malabsorption and anemia. World J Gastroenterol. 2009;15(37):4644–52.

    CAS  PubMed  Article  Google Scholar 

  10. 10.

    Gletsu-Miller N, Broderius M, Frediani JK, et al. Incidence and prevalence of copper deficiency following roux-en-y gastric bypass surgery. Int J Obes. 2012;36(3):328–35.

    CAS  Article  Google Scholar 

  11. 11.

    Avgerinos DV, Llaguna OH, Seigerman M, et al. Incidence and risk factors for the development of anemia following gastric bypass surgery. World J Gastroenterol. 2010;16(15):1867–70.

    CAS  PubMed  Article  Google Scholar 

  12. 12.

    Bloomberg RD, Fleishman A, Nalle JE, et al. Nutritional deficiencies following bariatric surgery: what have we learned? Obes Surg. 2005;15(2):145–54.

    PubMed  Article  Google Scholar 

  13. 13.

    Heber D, Greenway FL, Kaplan LM, et al. Endocrine and nutritional management of the post-bariatric surgery patient: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2010;95(11):4823–43.

    CAS  PubMed  Article  Google Scholar 

  14. 14.

    Aills L, Blankenship J, Buffington C, et al. ASMBS Allied Health Nutritional Guidelines for the surgical weight loss patient. Surg Obes Relat Dis. 2008;4(5 Suppl):S73–108.

    PubMed  Article  Google Scholar 

  15. 15.

    Williams SE. Metabolic bone disease in the bariatric surgery patient. J Obes. 2011;2011:634614.

    PubMed  Google Scholar 

  16. 16.

    Fujioka K. Follow-up of nutritional and metabolic problems after bariatric surgery. Diabetes Care. 2005;28(2):481–4.

    PubMed  Article  Google Scholar 

  17. 17.

    Vieira C, Cosmo C, Lucena R. The importance of methylmalonic acid dosage on the assessment of patients with neurological manifestations following bariatric surgery. Obes Surg. 2011;21(12):1971–4.

    PubMed  Article  Google Scholar 

  18. 18.

    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(3):288–93.

    PubMed  Article  Google Scholar 

  19. 19.

    Carmel R, Agrawal YP. Failures of cobalamin assays in pernicious anemia. N Engl J Med. 2012;367:385–6.

    CAS  PubMed  Article  Google Scholar 

  20. 20.

    Oh RC, Brown DL. Vitamin B12 deficiency. Am Fam Physician. 2003;67(5):979–86.

    PubMed  Google Scholar 

  21. 21.

    Langan RC, Zawistoski KJ. Update on vitamin B12 deficiency. Am Fam Physician. 2011;83(12):1425–30.

    PubMed  Google Scholar 

  22. 22.

    Sharabi A, Cohen E, Sulkes J, et al. Replacement therapy for vitamin B12 deficiency: comparison between the sublingual and oral route. Br J Clin Pharmacol. 2003;56(6):635–8.

    PubMed  Article  Google Scholar 

  23. 23.

    Shankar P, Boylan M, Sriram K. Micronutrient deficiencies after bariatric surgery. Nutrition. 2010;26(11–12):1031–7.

    CAS  PubMed  Article  Google Scholar 

  24. 24.

    Koch TR, Finelli FC. Postoperative metabolic and nutritional complications of bariatric surgery. Gastroenterol Clin North Am. 2010;39(1):109–24.

    PubMed  Article  Google Scholar 

  25. 25.

    Rudnicki SA. Prevention and treatment of peripheral neuropathy after bariatric surgery. Curr Treat Options Neurol. 2010;12(1):29–36.

    PubMed  Article  Google Scholar 

  26. 26.

    von Drygalski A, Andris DA. Anemia after bariatric surgery: more than just iron deficiency. Nutr Clin Pract. 2009;24(2):217–26.

    Article  Google Scholar 

  27. 27.

    Coupaye M, Puchaux K, Bogard C, et al. Nutritional consequences of adjustable gastric banding and gastric bypass: a 1-year prospective study. Obes Surg. 2009;19(1):56–65.

    PubMed  Article  Google Scholar 

  28. 28.

    Nomura RM, Dias MC, Igai AM, et al. Anemia during pregnancy after silastic ring Roux-en-Y gastric bypass: influence of time to conception. Obes Surg. 2011;21(4):479–84.

    PubMed  Article  Google Scholar 

  29. 29.

    Walker J, Kepner A. Wernicke’s encephalopathy presenting as acute psychosis after gastric bypass. J Emerg Med. 2012;43(5):811–4.

    PubMed  Article  Google Scholar 

  30. 30.

    Sechi G, Serra A. Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol. 2007;6(5):442–55.

    CAS  PubMed  Article  Google Scholar 

  31. 31.

    Goldner WS, Stoner JA, Lyden E, et al. Finding the optimal dose of vitamin D following Roux-en-Y gastric bypass: a prospective, randomized pilot clinical trial. Obes Surg. 2009;19(2):173–9.

    PubMed  Article  Google Scholar 

  32. 32.

    Fish E, Beverstein G, Olson D, et al. Vitamin D status of morbidly obese bariatric surgery patients. J Surg Res. 2010;164:198–202.

    CAS  PubMed  Article  Google Scholar 

  33. 33.

    Compston JE, Vedi S, Ledger JE, et al. Vitamin D status and bone histomorphometry in gross obesity. Am J Clin Nutr. 1981;34(11):2359–63.

    CAS  PubMed  Google Scholar 

  34. 34.

    Carlin AM, Rao DS, Meslemani AM, et al. Prevalence of vitamin D depletion among morbidly obese patients seeking gastric bypass surgery. Surg Obes Relat Dis. 2006;2(2):98–103.

    PubMed  Article  Google Scholar 

  35. 35.

    Minambres I, Chico A, Perez A. Severe hypocalcemia due to vitamin D deficiency after extended Roux-en-Y gastric bypass. J Obes. 2011;2011:141024.

    CAS  PubMed  Google Scholar 

  36. 36.

    Carlin AM, Rao DS, Yager KM, et al. Treatment of vitamin D depletion after Roux-en-Y gastric bypass: a randomized prospective clinical trial. Surg Obes Relat Dis. 2009;5(4):444–9.

    PubMed  Article  Google Scholar 

  37. 37.

    Bacci V, Silecchia G. Vitamin D status and supplementation in morbid obesity before and after bariatric surgery. Expert Rev Gastroenterol Hepatol. 2010;4(6):781–94.

    CAS  PubMed  Article  Google Scholar 

  38. 38.

    Mahlay NF, Verka LG, Thomsen K, et al. Vitamin D status before Roux-en-Y and efficacy of prophylactic and therapeutic doses of vitamin D in patients after Roux-en-Y gastric bypass surgery. Obes Surg. 2009;19(5):590–4.

    PubMed  Article  Google Scholar 

  39. 39.

    Holick MF, Biancuzzo RM, Chen TC, et al. Vitamin D2 is as effective as vitamin D3 in maintaining circulating concentrations of 25-hydroxyvitamin D. J Clin Endocrinol Metab. 2008;93(3):677–81.

    CAS  PubMed  Article  Google Scholar 

  40. 40.

    Clements RH, Katasani VG, Palepu R, et al. Incidence of vitamin deficiency after laparoscopic Roux-en-Y gastric bypass in a university hospital setting. Am Surg. 2006;72(12):1196–202.

    PubMed  Google Scholar 

  41. 41.

    Eckert MJ, Perry JT, Sohn VY, et al. Incidence of low vitamin A levels and ocular symptoms after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2010;6(6):653–7.

    PubMed  Article  Google Scholar 

  42. 42.

    Zalesin KC, Miller WM, Franklin BI, et al. Vitamin A deficiency after gastric bypass surgery: an underreported postoperative complication. Journal of Obesity. 2011. (2011): Article ID 760695, 4 page.

  43. 43.

    Brolin RE, Leung M. Survey of vitamin and mineral supplementation after gastric bypass and biliopancreatic diversion for morbid obesity. Obes Surg. 1999;9(2):150–4.

    CAS  PubMed  Article  Google Scholar 

  44. 44.

    Pereira S, Saboya C, Chaves G, et al. Class III obesity and its relationship with the nutritional status of vitamin A in pre- and postoperative gastric bypass. Obes Surg. 2009;19(6):738–44.

    PubMed  Article  Google Scholar 

  45. 45.

    Madan AK, Orth WS, Tichansky DS, et al. Vitamin and trace mineral levels after laproscopic gastric bypass. Obes Surg. 2006;16:603–6.

    PubMed  Article  Google Scholar 

  46. 46.

    Salle A, Demarsy D, Poirier AL, et al. Zinc deficiency: a frequent and underestimated complication after bariatric surgery. Obes Surg. 2010;20(12):1660–70.

    PubMed  Article  Google Scholar 

  47. 47.

    Ruz M, Carrasco F, Rojas P, 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.

    CAS  PubMed  Article  Google Scholar 

  48. 48.

    Xanthakos SA. Nutritional deficiencies in obesity and after bariatric surgery. Pediatr Clin North Am. 2009;56(5):1105–21.

    PubMed  Article  Google Scholar 

  49. 49.

    Gasteyger C, Suter M, Gaillard RC, et al. Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation. Am J Clin Nutr. 2008;87(5):1128–33.

    CAS  PubMed  Google Scholar 

  50. 50.

    Wu J, Ricker M, Muench J. Copper deficiency as cause of unexplained hematologic and neurologic deficits in patient with prior gastrointestinal surgery. J Am Board Fam Med. 2006;19(2):191–4.

    PubMed  Article  Google Scholar 

  51. 51.

    Kumar N, McEvoy KM, Ahlskog JE. Myelopathy due to copper deficiency following gastrointestinal surgery. Arch Neurol. 2003;60(12):1782–5.

    PubMed  Article  Google Scholar 

  52. 52.

    Griffith DP, Liff DA, Ziegler TR, et al. Acquired copper deficiency: a potentially serious and preventable complication following gastric bypass surgery. Obesity. 2009;17(4):827–31.

    CAS  PubMed  Article  Google Scholar 

  53. 53.

    Pineles SL, Wilson CA, Balcer LJ, et al. Combined optic neuropathy and myelopathy secondary to copper deficiency. Surv Ophthalmol. 2010;55(4):386–92.

    PubMed  Article  Google Scholar 

  54. 54.

    Matrana MR, Davis WE. Vitamin deficiency after gastric bypass surgery: a review. South Med J. 2009;102(10):1025–31.

    PubMed  Article  Google Scholar 

  55. 55.

    Tan JC, Burns DL, Jones HR. Severe ataxia, myelopathy, and peripheral neuropathy due to acquired copper deficiency in a patient with history of gastrectomy. J Parenter Enter Nutr. 2006;30(5):446–50.

    Article  Google Scholar 

  56. 56.

    Faure A, Mathon L, Poupelin JC, et al. Acute cupric sulfate intoxication: pathophysiology and therapy about a case report. Ann Fr Anesth Reanim. 2003;22(6):557–9.

    CAS  PubMed  Article  Google Scholar 

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Conflict of Interest Disclosure Statement

Radmila Levinson, PharmD, BCPS—no conflict of interest

Jennifer G. Catella, PharmD, BCPS—no conflict of interest

Jon B. Silverman, BS, PharmD—no conflict of interest

Hina Jolin, PharmD—no conflict of interest

Iwona Rybak, PharmD, BCPS—no conflict of interest

Kellene Isom, MS, RD, LDN—no conflict of interest

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Correspondence to Jon B. Silverman.

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Levinson, R., Silverman, J.B., Catella, J.G. et al. Pharmacotherapy Prevention and Management of Nutritional Deficiencies Post Roux-en-Y Gastric Bypass. OBES SURG 23, 992–1000 (2013).

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  • Bariatric surgery
  • Deficiency
  • Morbid obesity
  • Roux-en-Y gastric bypass
  • Malabsorption
  • Protein
  • Iron
  • Vitamin
  • Trace mineral