Skip to main content

Malnutrition in Bariatric Surgery Candidates: Multiple Micronutrient Deficiencies Prior to Surgery



Over 78 million American adults have obesity. Bariatric surgery is the leading means of durable weight loss. Nutritional deficiencies are commonly treated post-operatively but are often undiagnosed pre-operatively. Malnutrition is correlated with adverse surgical outcomes.


The aim of this study is to assess pre-operative nutritional status in our bariatric surgery candidates in a cross-sectional study.


We recruited 58 bariatric candidates approved to undergo the Roux-en Y gastric bypass. Nutritional status was determined for vitamins A, B12, D, E-α, and E-β/γ as well as thiamine, folate, and iron. We used clinical as well as frank deficiency cut-offs based on the Institute of Medicine and the World Health Organization guidelines.


This cohort was largely female (77.6 %) and white (63.8 %). Median age was 42.2 years. Median body mass index (BMI) was 46.3 kg/m2. Multiple comorbidities (MCM) were present in 41.4 %, 54.0 % hypertension, 42.0 % diabetic, 34.0 % sleep apnea. Men had more comorbidities, 69.2 % with MCM. Folate and iron saturation varied significantly by sex. Vitamins A, D, E-α, and thiamine significantly varied by race. Vitamin D negatively correlated with BMI (p = 0.003) and age (p = 0.030). Vitamin A negatively correlated with age (p = 0.001) and number of comorbidities (p = 0.003). These pre-operative bariatric candidates had significant malnutrition, particularly in vitamin D (92.9 %) and iron (36.2 to 56.9 %). Multiple micronutrient deficiency (MMND) was more common in blacks (50.0 versus 39.7 % overall). Number of comorbidities did not correlate with MMND.


Malnutrition in one or multiple micronutrients is pervasive in this pre-operative bariatric cohort. The effect of pre-operative supplementation, especially vitamin D and iron, should be explored.

This is a preview of subscription content, access via your institution.


  1. Baker MT. The history and evolution of bariatric surgical procedures. Surg Clin N Am. 2011;91:1181–201. viii.

    Article  PubMed  Google Scholar 

  2. Burden S, Todd C, Hill J, et al. Pre-operative nutrition support in patients undergoing gastrointestinal surgery. Cochrane Database Syst Rev. 2012;11:CD008879.

    PubMed  Google Scholar 

  3. Dempsey DT, Mullen JL, Buzby GP. The link between nutritional status and clinical outcome: can nutritional intervention modify it? Am J Clin Nutr. 1988;47:352–6.

    CAS  PubMed  Google Scholar 

  4. Evans DC, Martindale RG, Kiraly LN, et al. Nutrition optimization prior to surgery. Nutr Clin Pract. 2014;29:10–21.

    Article  PubMed  Google Scholar 

  5. 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. Obesity (Silver Spring). 2009;17(1):S1–70.

    Article  Google Scholar 

  6. Handelman GJ, Epstein WL, Peerson J, et al. Human adipose alpha-tocopherol and gamma-tocopherol kinetics during and after 1 y of alpha-tocopherol supplementation. Am J Clin Nutr. 1994;59:1025–32.

    CAS  PubMed  Google Scholar 

  7. Kirkness JP, Schwartz AR, Schneider H, et al. Contribution of male sex, age, and obesity to mechanical instability of the upper airway during sleep. J Appl Physiol (1985). 2008;104:1618–24.

    Article  Google Scholar 

  8. Kritikou I, Basta M, Tappouni R, et al. Sleep apnoea and visceral adiposity in middle-aged male and female subjects. Eur Respir J. 2013;41:601–9.

    Article  CAS  PubMed  Google Scholar 

  9. Schwartz AR, Patil SP, Laffan AM, et al. Obesity and obstructive sleep apnea: pathogenic mechanisms and therapeutic approaches. Proc Am Thorac Soc. 2008;5:185–92.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Schwartz AR, Patil SP, Squier S, et al. Obesity and upper airway control during sleep. J Appl Physiol (1985). 2010;108:430–5.

    Article  Google Scholar 

  11. Schwartz AR, Schneider H, Smith PL, et al. Physiologic phenotypes of sleep apnea pathogenesis. Am J Respir Crit Care Med. 2011;184:1105–6.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Iftikhar IH, Khan MF, Das A, et al. Meta-analysis: continuous positive airway pressure improves insulin resistance in patients with sleep apnea without diabetes. Ann Am Thorac Soc. 2013;10:115–20.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Lam JC, Mak JC, Ip MS. Obesity, obstructive sleep apnoea and metabolic syndrome. Respirology. 2012;17:223–36.

    Article  PubMed  Google Scholar 

  14. Pallayova M, Steele KE, Magnuson TH, et al. Sleep apnea predicts distinct alterations in glucose homeostasis and biomarkers in obese adults with normal and impaired glucose metabolism. Cardiovasc Diabetol. 2010;9:83.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Punjabi NM, Sorkin JD, Katzel LI, et al. Sleep-disordered breathing and insulin resistance in middle-aged and overweight men. Am J Respir Crit Care Med. 2002;165:677–82.

    Article  PubMed  Google Scholar 

  16. Tasali E, Ip MS. Obstructive sleep apnea and metabolic syndrome: alterations in glucose metabolism and inflammation. Proc Am Thorac Soc. 2008;5:207–17.

    Article  PubMed  Google Scholar 

  17. Spechler SJ, Sharma P, Souza RF, et al. American gastroenterological association medical position statement on the management of Barrett’s esophagus. Gastroenterology. 2011;140:1084–91.

    Article  PubMed  Google Scholar 

  18. Hirota WK, Zuckerman MJ, Adler DG, et al. ASGE guideline: the role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. Gastrointest Endosc. 2006;63:570–80.

    Article  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  20. McGill AT, Stewart JM, Lithander FE, et al. Relationships of low serum vitamin D3 with anthropometry and markers of the metabolic syndrome and diabetes in overweight and obesity. Nutr J. 2008;7:4.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Parikh SJ, Edelman M, Uwaifo GI, et al. The relationship between obesity and serum 1,25-dihydroxy vitamin D concentrations in healthy adults. J Clin Endocrinol Metab. 2004;89:1196–9.

    Article  CAS  PubMed  Google Scholar 

  22. Salehpour A, Hosseinpanah F, Shidfar F, et al. A 12-week double-blind randomized clinical trial of vitamin D(3) supplementation on body fat mass in healthy overweight and obese women. Nutr J. 2012;11:78.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Saneei P, Salehi-Abargouei A, Esmaillzadeh A. Serum 25-hydroxy vitamin D levels in relation to body mass index: a systematic review and meta-analysis. Obes Rev 2013

  24. Vimaleswaran KS, Berry DJ, Lu C, et al. Causal relationship between obesity and vitamin D status: bi-directional Mendelian randomization analysis of multiple cohorts. PLoS Med. 2013;10:e1001383.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Lee P, Greenfield JR, Seibel MJ, et al. Adequacy of vitamin D replacement in severe deficiency is dependent on body mass index. Am J Med. 2009;122:1056–60.

    Article  CAS  PubMed  Google Scholar 

  26. Centers for Disease Control and Prevention. FastStats—Anemia. . 7-14-2014. 12-22-2014.

  27. Institute of Medicine Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press; 2010.

  28. Liel Y, Ulmer E, Shary J, et al. Low circulating vitamin D in obesity. Calcif Tissue Int. 1988;43:199–201.

    Article  CAS  PubMed  Google Scholar 

  29. Wortsman J, Matsuoka LY, Chen TC, et al. Decreased bioavailability of vitamin D in obesity. Am J Clin Nutr. 2000;72:690–3.

    CAS  PubMed  Google Scholar 

  30. Earthman CP, Beckman LM, Masodkar K, et al. The link between obesity and low circulating 25-hydroxyvitamin D concentrations: considerations and implications. Int J Obes (Lond). 2012;36:387–96.

    Article  CAS  Google Scholar 

  31. Goldner WS, Stoner JA, Thompson J, et al. Prevalence of vitamin D insufficiency and deficiency in morbidly obese patients: a comparison with non-obese controls. Obes Surg. 2008;18:145–50.

    Article  PubMed  Google Scholar 

  32. Holick MF. Deficiency of sunlight and vitamin D. BMJ. 2008;336:1318–9.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96:1911–30.

    Article  CAS  PubMed  Google Scholar 

Download references

Conflicts of Interest Disclosure Statement

The authors declare that they have no competing interests.

Statement of Informed Consent

Informed consent was obtained from all individual participants included in the study.

Statement of Human and Animal Rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Author information

Authors and Affiliations


Corresponding authors

Correspondence to Leigh A. Peterson or Lawrence J. Cheskin.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Peterson, L.A., Cheskin, L.J., Furtado, M. et al. Malnutrition in Bariatric Surgery Candidates: Multiple Micronutrient Deficiencies Prior to Surgery. OBES SURG 26, 833–838 (2016).

Download citation

  • Published:

  • Issue Date:

  • DOI:


  • Bariatric surgery
  • Nutritional status
  • Multiple micronutrient deficiency
  • Malnutrition