It is a fact that the amount of metabolic surgeries to treat (morbid) obesity has grown tremendously in the last decade1. This type of surgery has gained in popularity in both patients and healthcare professionals, due to its positive long-term results on both weight and comorbidities. Unfortunately, all types of metabolic surgery are also associated with several disadvantages, such as a high rate of micronutrient deficiencies, with up to 80% in the first year. Among the most common deficiencies in the first postoperative years are vitamin B12, vitamin D and iron. In the long term, patients can be at risk of developing deficiencies for almost all micronutrients. Another challenging aspect is that every type of metabolic procedure requires different doses of micronutrients to avoid deficiencies or hypervitaminosis2.
Pre- and postoperative deficiency risks
Preoperatively, many obese patients already have or are at risk of developing a micronutrient deficiency because of their poor eating pattern. Thus, it is more than logic and advised to screen and supplement patients before surgery. Another benefit of this approach is that it is much easier to correct most deficiencies at this timepoint than after metabolic surgery, because of the reduced oral uptake postoperatively.
Postoperatively, a further increase in the prevalence of deficiencies is induced by a combination of decreased intake, reduced absorption, lowered or absent gastric acid and intrinsic factor and bypassing of the main absorption sites in the gastrointestinal tract3. Depending on the type of metabolic surgery, one can predict which deficiencies might occur and in which period, but on average, after for example a Sleeve Gastrectomy procedure, 75% of patients show one or more new deficiencies already in the first years4.
Postoperative prevention and treatment
One can debate which micronutrients should be measured after surgery, but a lifelong follow-up including serum measurements of the most common deficiencies should be the standard. International literature provides advice on optimal prevention and treatment of various common micronutrient deficiencies5. However, these current advices are only based on the scarce literature available. Additionally, it is unknown how to follow-up these patients once they have finished their additional supplementation. Perhaps the most challenging objective for healthcare providers is to have their patients compliant to the lifelong use of multivitamins.
One of the factors that lead to a lowered compliance is the belief patients have that the costs of specialized multivitamins do not weigh up to the benefits. A recent publication has shown that the opposite is actually true. Because of the high likelihood of developing one or more deficiencies, the costs for the healthcare system are significantly higher for patients that use over-the-counter multivitamins, let alone compared to patients who do not use any form of supplementation6. Of course, this is not the case for the (rare) patients who were not appropriately screened, diagnosed and treated, or did not become deficient in the first few years.
To ensure the best outcome for patients, they should be advised on every follow-up moment to use vitamins and mineral supplements. A regular over-the-counter multivitamin should be considered a minimum, since they positively affect the risk of developing some deficiencies, especially compared to patients who do not use any supplements. However, specialized multivitamins have proven to further reduce micronutrient deficiency risks by two-third in the first postoperative years3. Additionally, requirements between procedures differ enormously and compared to standard multivitamins, specialized multivitamins contain micronutrients for that patients’ specific needs. Compliance is eminent and tends to be higher when specialized multivitamins are used, since these only have to be taken once a day.
1. Bariatric Surgery and Endoluminal Procedures: IFSO Worldwide Survey 2014. Angrisani L, Santonicola A, Iovino P, Vitiello A, Zundel N, Buchwald H, Scopinaro N. Obes Surg; 2017:2279-89
2. Long-term nutritional status in patients following Roux-en-Y gastric bypass surgery. Dogan K, Homan J, Aarts EO, de Boer H, van Laarhoven CJHM, Berends FJ. Clin Nutr; 2018:612-7
3. An optimized multivitamin supplement lowers the number of vitamin and mineral deficiencies three years after Roux-en-Y gastric bypass: a cohort study. Homan J, Schijns W, Aarts EO, van Laarhoven CJHM, Janssen IMC, Berends FJ. Surg Obes Relat Dis; 2016:659-67.
4. The true story on deficiencies after sleeve gastrectomy. Results of a double-blind RCT. Heusschen L, Schijns W, Ploeger N, Deden LN, Hazebroek EJ, Berends FJ, Aarts EO. In press april 2019
5. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients. Parrott J, Frank L, Rebecca Rabena R, Craggs-Dino L, Isom, Laura Greiman. Surg Obes Relat Dis; 2017: 727–41
6. Adequate Multivitamin Supplementation after Roux-En-Y Gastric Bypass Results in a Decrease of National Health Care Costs: a Cost-Effectiveness Analysis. Homan J, Schijns W, Janssen IMC, Berends FJ, Aarts EO. Obes Surg. 2019: In press