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Managing Micronutrient Deficiencies in the Bariatric Surgical Patient

  • Robert F. Kushner
Part of the Contemporary Endocrinology book series (COE)

Abstract

Bariatric surgery is associated with development of several micronutrient deficiencies that are predictable based on the surgically altered anatomy and the imposed dietary changes. The three restrictive malabsorptive procedures—Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion (BPD), and biliopancreatic diversion with duodenal switch (BPD/DS) — pose a greater risk for micronutrient malabsorption and deficiency than the purely restrictive laparoscopic adjustable silicone gastric banding (LASGB). Metabolic and clinical deficiencies of two minerals (iron and calcium) and four vitamins (thiamine, folate, vitamin B12, vitamin D) have been well described in the literature. This chapter reviews the pathophysiology, clinical presentation, screening tests, and treatment for each micronutrient deficiency. With careful monitoring and adequate supplementation, these deficiencies are largely avoidable and treatable.

Key Words

Bariatric surgery micronutrient deficiency Wernicke’s encephalopathy irondeficiency anemia hypovitaminosis D metabolic bone disease 

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References

  1. 1.
    Gastrointestinal surgery for severe obesity. NIH Consens Dev Conf Consens Statement 1991 March 25–27. Am J Clin Nutr 1992;55:615S–619S.Google Scholar
  2. 2.
    National Heart, Lung, and Blood Institute (NHLBI) and National Institute for Diabetes and Digestive and Kidney Diseases (NIDDKD). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. The Evidence Report. Obes Res 1998;6(Suppl 2):51S–210S.Google Scholar
  3. 3.
    National Heart, Lung, and Blood Institute (NHLBI) and North American Association for the Study of Obesity (NAASO). Practical Guide on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH Publication number 00-4084. National Institutes of Health, Bethesda, MD: 2000.Google Scholar
  4. 4.
    Jones DB, Provost DA, De Maria EJ.et al. Optimal management of the morbidly obese patient. SAGES appropriateness conference statement. Surg Endosc 2004; 18:1029–1037.PubMedGoogle Scholar
  5. 5.
    Buchwald H. Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. J Am Coll Surg 2005;200:593–604.PubMedGoogle Scholar
  6. 6.
    Encinosa WE, Bernard DM, Steiner CA, et al. Use and costs of bariatric surgery and prescription weight-loss medications. Health Affairs 2005;24:1039–1046.PubMedGoogle Scholar
  7. 7.
    Steinbrook R. Surgery for severe obesity. N Engl J Med 2004;350:1075–1079.PubMedGoogle Scholar
  8. 8.
    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery. A systematic review and meta-analysis. JAMA 2004;292:1724–1737.PubMedGoogle Scholar
  9. 9.
    Sturm R. Increase in clinically severe obesity in the United States, 1998-2000. JAMA 2003;163:2146–2148.Google Scholar
  10. 10.
    Hedley AA, Ogden CL, Johnson CL, et al. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999–2002. JAMA 2004;291:2847–2850.PubMedGoogle Scholar
  11. 11.
    Avinoah E, Ovnat A, Charuzi I. Nutritional status seven years after Roux-en-Y gastric bypass surgery. Surgery 1992;111:137–142.PubMedGoogle Scholar
  12. 12.
    Amaral JE, Thompson WR, Caldwell MD, et al. Prospective hematologic evaluation of gastric exclusion surgery for morbid obesity. Ann Surg 1985;201:186–193.PubMedGoogle Scholar
  13. 13.
    Crowley LV, Seay J, Mullen G. Late effects of gastric bypass for obesity. Am J Gastroenterol 1984;79:850–860.PubMedGoogle Scholar
  14. 14.
    Halverson JD. Micronutrient deficiencies after gastric bypass for morbid obesity. Am Surg 1985;52:594–598.Google Scholar
  15. 15.
    Brolin RE, Gorman JH, Gorman RC, et al. Are vitamin B12 and folate deficiency clinically important after roux-en-y gastric bypass? J Gastrointest Surg 1998;2:436–442.PubMedGoogle Scholar
  16. 16.
    Brolin RE, Leung M. Survey of vitamin and mineral supplementation after gastric bypass and biliopancreatic diversion for morbid obesity. Obes Surg 1999;9:150–154.PubMedGoogle Scholar
  17. 17.
    Skroubis G, Sakellaropoulos G, Pouggouras K, et al. Comparison of nutritional deficiencies after roux-en-y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass. Obes Surg 2002;12:551–558.PubMedGoogle Scholar
  18. 18.
    Schilling RF, Gohdes PN, Hardie GH. Vitamin B12 deficiency after gastric bypass surgery for obesity. Ann Intern Med 1984;101:501–502.PubMedGoogle Scholar
  19. 19.
    Provenzale D, Reinhold RB, Golner B, et al. Evidence for diminished B12 absorption after gastric bypass: oral supplementation does not prevent low plasma B12 levels in bypass patients. J Am Coll Nutr 1992;11:29–35.PubMedGoogle Scholar
  20. 20.
    Belle S. The NIDDK bariatric surgery clinical research consortium (LABS). SOARDS 2005; 1:145–147.Google Scholar
  21. 21.
    Kushner R. Managing the obese patient after bariatric surgery: A case report of severe malnutrition and review of the literature. J Parental Enterai Nutr 2000;24:126–132.Google Scholar
  22. 22.
    Alvarez-Leite JI. Nutrient deficiencies secondary to bariatric surgery. Curr Opin Clin Nutr Metab Care 2004;7:569–575.PubMedGoogle Scholar
  23. 23.
    Mason ME, Jalagani H, Vinik AI. Metabolic complications of bariatric surgery: diagnosis and management issues. Gastroenterol Clin N Am 2005;34:25–33.Google Scholar
  24. 24.
    Fujioka K. Follow-up of nutritional and metabolic problems after bariatric surgery. Diab Care 2005;28:481–484.Google Scholar
  25. 25.
    Bloomberg RD, Fleishman A, Nalle JE, et al. Nutritional deficiencies following bariatric surgery: what have we learned? Obes Surg 2005; 15:145–154.PubMedGoogle Scholar
  26. 26.
    Shuster MH, Vazquez JA. Nutritional concerns related to Roux-en-Y gastric bypass. Crit Care Nurs Q 2005;28:227–260.PubMedGoogle Scholar
  27. 27.
    Dietary Reference Intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline. Institute of Medicine. National Academy Press, Washington, DC: 1998.Google Scholar
  28. 28.
    MacLean JB. Wernicke’s encephalopathy after gastric placation. JAMA 1982;248:1311.PubMedGoogle Scholar
  29. 29.
    Feit H, Glasberg M, Ireton C, et al. Peripheral neuropathy and starvation after gastric partitioning for morbid obesity. Ann Intern Med 1982;96:453–455.PubMedGoogle Scholar
  30. 30.
    Fawcett C, Young B, Holliday RL. Wernicke’s encephalopathy after gastric partitioning for morbid obesity. Can J Surg 1984;27:169–170.PubMedGoogle Scholar
  31. 31.
    Viller HV, Ranne RD. Neurologic deficit following gastric partitioning: possible role of thiamine. JPEN 1984;8:575–578.Google Scholar
  32. 32.
    Somer H, Bergstrom L, Mustajoki P, et al. Morbid obesity, gastric placation and a severe neurological deficit. Ada Med Scand 1985;217:575–576.Google Scholar
  33. 33.
    Paulson GW, Martin EW, Mojzisik C, et al. Neurologic complications of gastric partitioning. Arch Neurol 1985;42:675–677.PubMedGoogle Scholar
  34. 34.
    Oczkowski WJ, Kertesz A. Wernicke’s encephalopathy after gastroplasty for morbid obesity. Neurology 1985;35:99–101.PubMedGoogle Scholar
  35. 35.
    Salas-Salvado J, Garcia-Lorda P, Cuatrecasas G, et al. Wernicke’s syndrome after bariatric surgery. Clin Nutr 2000; 19:1356–1359.Google Scholar
  36. 36.
    Seehra H, MacDermott N, Lascelles RG, et al. Wernicke’s encephalopathy after vertical banded gastroplasty for morbid obesity. BMJ 1996;312:434.PubMedGoogle Scholar
  37. 37.
    Vlason EE. Starvation injury after gastric reduction for obesity. World J Surg 1998;22:1002–1007.Google Scholar
  38. 38.
    Cirignotta F, Manconi M, Mondini S, et al. Wernicke’s-Korsakoff encephalopathy and polyneuropathy after gastroplasty for morbid obesity. Arch Neurol 2000;57:1356–1359.PubMedGoogle Scholar
  39. 39.
    Bozbora A, Coskun H, Ozarmagan S, et al. A rare complication of adjustable gastric banding: Wernicke’s encephalopathy. Obes Surg 2000; 10:274–275.PubMedGoogle Scholar
  40. 40.
    Toth C, Volt C. Wernicke’s encephalopathy following gastroplasty for morbid obesity. Can J Neurol Sci 2001;28:89–92.PubMedGoogle Scholar
  41. 41.
    Chaves LC, Faintuch J, Kahwage S, et al. A cluster of polyneuropathy and Wernecke-Korsakoff syndrome in a bariatric unit. Obes Surg 2002;12:328–334.PubMedGoogle Scholar
  42. 42.
    Sola E, Morllas C, Garzon S, et al. Rapid onset of Wernicke’s encephalopathy following gastric restrictive surgery. Obes Res 2003;13:661–662.Google Scholar
  43. 43.
    Loh T, Watson WD, Verman A, et al. Acute Wernicke’s encephalopathy following bariatric surgery; clinical course and MRI correlation. Obes Surg 2004;14:129–132.PubMedGoogle Scholar
  44. 44.
    Nautiyal A, Singh S, Alaimo DJ. Wernicke’s encephalopathy — an emerging trend after bariatric surgery. Am J Med 2004; 117:804–805.PubMedGoogle Scholar
  45. 45.
    Towbin A, Inge TH, Garcia VF, et al. Beriberi after gastric bypass surgery in adolescence. J Pediatr 2004; 145:263–267.PubMedGoogle Scholar
  46. 46.
    Abarbanel JM, Berginer VM, Osimani A, et al. Neurologic complications after gastric restriction surgery for morbid obesity. Neurology 1987;37:196–200.PubMedGoogle Scholar
  47. 47.
    Thaisetthawatkul P, Collazo-Clavell ML, Sarr MG, et al. A controlled study of peripheral neuropathy after bariatric surgery. Neurology 2004;63:1462–1470.PubMedGoogle Scholar
  48. 48.
    Chang CG, Adams-Huet B, Provost DA. Acute post-gastric reduction surgery (APGARS) neuropathy. Obes Surg 2004; 14:182–189.PubMedGoogle Scholar
  49. 49.
    Antunwz E, Estruch R, Cardenal C, et al. Usefulness of CT and MR imaging in the diagnosis of acute Wernicke’s encephalopathy. Am J Roentegenol 1998;171:1131–1137.Google Scholar
  50. 50.
    Conrad ME, Umbreit JN. Iron absorption and transport’an update. Am J Hematol 2000;64:287–298.PubMedGoogle Scholar
  51. 51.
    Smith CD, Herkes SB, Behrns KE, et al. Gastric acid secretion and vitamin B12 absorption after vertical Roux-en-Y gastric bypass for morbid obesity. Ann Surg 1993;218:91–96.PubMedGoogle Scholar
  52. 52.
    Behrns KE, Smith CD, Sarr MG. Prospecti ve evaluation of gastric acid secretion and cobalmin absorption following gastric bypass for clinically severe obesity. Dig Dis Sci 1994;39:315–320.PubMedGoogle Scholar
  53. 53.
    Beard JL, Dawson H, Pinero DJ. Iron metabolism: a comprehensive review. Nutr Rev 1996;54:295–317.PubMedGoogle Scholar
  54. 54.
    Lash A, Saleem A. Iron metabolism and its regulation. A review. Ann Clin Lab Sci 1995;25:20–30.Google Scholar
  55. 55.
    Brolin RE, Robertson LB, Kenler FIA, et al. Weight loss and dietary intake after vertical banded gastroplasty and Roux-en-Y gastric bypass. Ann Surg 1994;220:782–790.PubMedGoogle Scholar
  56. 56. Dietary Reference Intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. A report of the panel on micronutrients, Dietary Reference Intakes. Food and Nutrition Board, Institute of Medicine. National Academy Press, Washington, DC: 2001.Google Scholar
  57. 57.
    Amaral JE, Thompson WR, Caldwell MD, et al. Prospective heniatologic evaluation of gastric exclusion surgery for morbid obesity. Ann Surg 1985;201:186–193.PubMedGoogle Scholar
  58. 58.
    Monsen ER, Cook JD. Food iron absorption in human subjects IV. The effects of calcium and phosphate salts on the absorption of nonheme iron. Am J Clin Nutr 1976;29:1142–1148.PubMedGoogle Scholar
  59. 59.
    Hallberg L, Brune M, Erlandsson M, et al. Calcium: effect of different amounts on nonheme-and heme-iron absorption in humans. Am J Clin Nutr 1991;53:112–119.PubMedGoogle Scholar
  60. 60.
    Cook JD, Dassenko SA, Whittaker P. Calcium supplementation: effect on iron absorption. Am J Clin Nutr 1991;53:106–111.PubMedGoogle Scholar
  61. 61.
    Hallberg L, Rossander-Hulthen L, Brune M, et al. Calcium and iron absorption: mechanism of action and nutritional importance. Euro J Clin Nutr 1992;46:317–327.Google Scholar
  62. 62.
    Gleerup A, Rossander-Hulthen L, Gramatkovski E, et al. Iron absorption from the whole diet: comparison of the effect of two different distributions of daily calcium intake. Am J Clin Nutr 1995;61:97–104.PubMedGoogle Scholar
  63. 63.
    Minihane AM, Fairweather-Tait SJ. Effect of calcium supplementation on daily nonheme-iron absorption and long-term iron status. Am J Clin Nutr 1998;68:96–102.PubMedGoogle Scholar
  64. 64.
    Reddy MB, Cook JD. Effect of calcium intake on nonheme-iron absorption from a complete diet. Am J Clin Nutr 1997;65:1820–1825.PubMedGoogle Scholar
  65. 65.
    Grinder-Pederson L, Bukhave K, Jensen M, et al. Calcium from milk or calcium-fortified foods does not inhibit nonheme-iron absorption from a whole diet consumed over a 4-day period. J Clin Nutr 2004;80:404–409.Google Scholar
  66. 66.
    Andrews NC. Disorders of iron metabolism. N Engl J Med 1999;341:1986–1995.PubMedGoogle Scholar
  67. 67.
    Ross EM. Evaluation and treatment of iron deficiency in adults. Nutr Clin Care 2002;5:220–224.PubMedGoogle Scholar
  68. 68.
    Rainville A J. Pica practices of pregnant women are associated with lower maternal hemoglobin level at delivery. J Am Diet Assoc 1998;98:293–296.PubMedGoogle Scholar
  69. 69.
    Simpson E, Mull JD, Longley E, et al. Pica during pregnancy in low-income women born in Mexico. West J Med 2000;173:20–24.PubMedGoogle Scholar
  70. 70.
    Rector WG. Pica: its frequency and signifi cance in patients with i ron-defi ciency anemia due to chronic gastrointestinal blood loss. J Gen Intern Med 1989;4:512–513.PubMedGoogle Scholar
  71. 71.
    Ivascu NS, Sarnaik S, McCrae J, et al. Characterization of pica prevalence among patients with sickle cell disease. Arch Peds Adolesc Med 2001; 155:1243–1247.Google Scholar
  72. 72.
    Kushner RF, Gleason B, Shanta-Retelny V. Reemergence of picafollowing gastric bypass surgery for obesity: a new presentation of an old problem. J Am Diet Assoc 2004;104:1393–1397.PubMedGoogle Scholar
  73. 73.
    Kushner RF, Shanta-Retelny V. Obes Surg 2005; 15:1491–1495.PubMedGoogle Scholar
  74. 74.
    Brolin RE, Gorman JH, Gorman RC, et al. Prophylatic iron supplementation after Roux-en-Y gastric bypass. A prospective, double-blind, randomized study. Arch Surg 1998;133:740–744.PubMedGoogle Scholar
  75. 75.
    Rhode BM, Shustik C, Christou NV, et al. Iron absorption and therapy after gastric bypass. Obes Surg 1999;9:17–21.PubMedGoogle Scholar
  76. 76.
    Balk HW, Russell RM. Vitamin B12 deficiency in the elderly. Annu Rev Nutr 1999;19:357–377.Google Scholar
  77. 77.
    Rhode BM, Arseneau P, Cooper BA, et al. Vitamin B12 deficiency after gastric surgery for obesity. Am J Clin Nutr 1996;63:103–109.PubMedGoogle Scholar
  78. 78.
    Eussen SJPM, DeGroot LCPM, Clarke R, et al. Oral cyanocobalamin supplementation in older people with vitamin B12 deficiency. A dose-finding trial. Arch Intern Med 2005; 165:1167–1172.PubMedGoogle Scholar
  79. 79.
    Kuzminski AM, Del Giacco EJ, Allen RH, et al. Effective treatment of cobalamin deficiency with oral cobalamin. Blood 1998;92:1191–1198.PubMedGoogle Scholar
  80. 80.
    Riedt C, Brolin R, Shapses S. True fractional calcium absorption is decreased after Roux-en-Y gastric bypass. Obes Res 2004;12(supp):A33.Google Scholar
  81. 81.
    Wasserman RH. Vitamin D and the dual processes of intestinal calcium absorption. J Nutr 2004;134:3137–3139.PubMedGoogle Scholar
  82. 82.
    Charles P. Calcium absorption and calcium bioavailability. J Intern Med 1992;231:161–168.PubMedGoogle Scholar
  83. 83.
    Dietary Reference Intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride. Institute of Medicine, National Academy Press, Washington, DC: 1997.Google Scholar
  84. 84.
    Looker AC. Body fat and vitamin D status in black versus white women. J Clin Endocrinol Metab 2005;90:635–640.PubMedGoogle Scholar
  85. 85.
    Wortsman J, Matsuika LY, Chen TC, et al. Decreased bioavailability of vitamin D in obesity. Am J Clin Nutr 2000;72:690–693.PubMedGoogle Scholar
  86. 86.
    Parikh SJ, Edelman VI, Uwaifo GI, et al. The relationship between obesity and serum 1.12-dihydroxy vitamin D concentrations in healthy adults. J Clin Endocrinol Metab 2004;89:1196–1199.PubMedGoogle Scholar
  87. 87.
    Kamycheva E, Sundsfjord J, Jorde R. Serum parathyroid hormone level is associated with body mass index. The 5th Tromso study. Eur J Endocrinol 2004; 151:167–172.PubMedGoogle Scholar
  88. 88.
    Arunabh S, Pollack S, Yeh J, et al. Body fat content and 25-hydroxyvitamin D levels in healthy women. J Clin Endocrinol Metab 2003;88:157–161.PubMedGoogle Scholar
  89. 89.
    Ahmad R, Hammond JM. Primary, secondary, and tertiary hyperparathyroidism. Otolaryngol Clin N Am 2004;37:701–713.Google Scholar
  90. 90.
    Whiting SJ, Calvo MS. Dietary recommendations for vitamin D: a critical need for functional end points to establish an estimated average requirement. J Nutr 2005; 135:304–309.PubMedGoogle Scholar
  91. 91.
    Hickey L, Gordon CM. Vitamin D deficiency: new perspectives on an old disease. Curr Opin Endocrinol Diabetes 2004; 11:18–25.Google Scholar
  92. 92.
    Hollis BW. Circulating 25-hydroxyvitamin D levels indicative of vitamin D sufficiency: implications for establishing a new effective dietary intake recommendation for vitamin D. J Nutr 2005; 135:317–322.PubMedGoogle Scholar
  93. 93.
    Chapuy MC, Preziosi P, Maamer M, et al. Prevalence of vitamin D insufficiency in an adult normal population. Osteoporos Int 1997;7:439–443.PubMedGoogle Scholar
  94. 94.
    Rosen HN. Biochemical markers of bone turnover: clinical utility. Curr Opin Endocrinol Diabetes 2003;10:387–393.Google Scholar
  95. 95.
    Burke MS. Current roles and realities of noninvasive assessment of osteoporosis. Curr Opin Endocrinol Diabetes 2004; 11:330–337.Google Scholar
  96. 96.
    Ott MT, Fanti P, Malluche HH, et al. Biochemical evidence of metabolic bone disease in women following Roux-en-Y gastric bypass for morbid obesity. Obes Surg 1992;2:341–348.PubMedGoogle Scholar
  97. 97.
    Newbury L, Dolan K, Hatzifotis M, et al. Calcium and vitamin D depletion and elevated parathyroid hormone following biliopancreatic diversion. Obes Surg 2003; 13:893–895.PubMedGoogle Scholar
  98. 98.
    Diniz FHS, Diniz MTC, Sanches SRA.et al. Elevates serum parahormone after Roux-en-Y gastric bypass. Obes Surg 2004; 14:1222–1226.PubMedGoogle Scholar
  99. 99.
    El-Kadre LJ, Rocha PR, de Almeida Tinoco AC, et al. Calcium metabolism in pre-and postmenopausal morbidly obese women at baseline and after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2004; 14:1062–1066.PubMedGoogle Scholar
  100. 100.
    Hamoui N, Anthone G, Crookes PF. Calcium metabolism in the morbidly obese. Obes Surg 2004; 14:9–12.PubMedGoogle Scholar
  101. 101.
    von Mach MA, Stoeckli R, Bilz S, et al. Changes in bone mineral content after surgical treatment of morbid obesity. Metabolism 2004;53:918–921.Google Scholar
  102. 102.
    Prisco CD, Levine SN. Metabolic bone disease after gastric bypass surgery for obesity. Am J Med Sci 2005;329:57–61.PubMedGoogle Scholar
  103. 103.
    Coates PS, Fernstrom JD, Fernstrom MH, et al. Gastric surgery for morbid obesity leasds to an increase in bone turnover and a decrease in bone mass. J Clin Endocrinol Metab 2004;89:1061–1065.PubMedGoogle Scholar
  104. 104.
    Johnson JM, Maher JW, Samuel I, et al. Effects of gastric bypass procedures on bone mineral density, calcium, parathyroid hormone, and vitamin D. J Gastrointest Surg 2005;9:1106–1111.PubMedGoogle Scholar
  105. 105.
    Ybarra J, Sanchez-Hernandez J, Gich I, et al Unchanged hypovitaminosis D and secondary hyperparathyroidism in morbid obesity after bariatric surgery. Obes Surg 2005;15:330–335.PubMedGoogle Scholar
  106. 106.
    Goldner WS, O’Dorisio TM, Dillon JS, et al. Severe metabolic bone disease as a long-term complication of obesity surgery. Obes Surg 2002; 12:685–692.PubMedGoogle Scholar
  107. 107.
    van Loan MD, Johnson FIL, Barbieri TF. Effect of weight loss on bone mineral content and bone mineral density in obese women. Am J Clin Nutr 1998;67:734–738.PubMedGoogle Scholar
  108. 108.
    Pugnale N, Giusti V, Suter M, et al. Bone metabolism and risk of secondary hyperparathyroidism 12 months after gastric banding in obese pre-menopausal women. Int J Obes Relat Metab Disord 2003;27:110–116.PubMedGoogle Scholar
  109. 109.
    Guney E, Kisakol G, Ozgen G, et al. Effect of weight loss on bone metabolism: comparison of vertical banded gastroplasty and medical intervention. Obes Surg 2003;13:383–388.PubMedGoogle Scholar
  110. 110.
    Thomas MK, Demay MB. Vitamin D deficiency and disorders of vitamin D metabolism. Endocrinol Metab Clin North Am 2000;29:611–627.PubMedGoogle Scholar
  111. 111.
    Slater GH, Ren CF, Siegel N, et al. Serum fat-soluble vitamin D deficiency and abnormal calcium metabolism after malbsorptive bariatric surgery. J Gastrointest Surg 2004;8:48–55.PubMedGoogle Scholar
  112. 112.
    Dolan K, Hatzfotis M, Newbury L, et al. A clinical and nutritional comparison of biliopancreatic diversion with and without duodenal switch. Ann Surg 2004;240:51–56.PubMedGoogle Scholar
  113. 113.
    Hatzifotis M, Dolan K, Newbury L, et al. Symptomatic vitamin A deficiency following biliopancreatic diversion. Obes Surg 2003; 13:655–657.Google Scholar
  114. 114.
    Lee WB, Hamilton SM, Harris JP, et al. Ocular complications of hypovitaminosis A after bariatric surgery. Ophthalmology 2005;112:1031–1034.PubMedGoogle Scholar

Copyright information

© Humana Press Inc., Totowa, NJ 2007

Authors and Affiliations

  • Robert F. Kushner
    • 1
  1. 1.Department of MedicineNorthwestern University Feinberg School of MedicineChicago

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