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2094-2. Article Text - Manuscript-18476-1-10-20220131
2094-2. Article Text - Manuscript-18476-1-10-20220131
2094-2. Article Text - Manuscript-18476-1-10-20220131
surgery, BS) [7]. Up to date, BS is considered to be the despite medical therapy [25].
most effective treatment of clinically severe obesity (BMI Although anti-obesity drugs and lifestyle changes
≥40 kg/m2 or BMI ranging between 35-40 kg/m2), leading do hold a role in obesity management [26], BS has been
to sustained weight loss and improvement of obesity- proven effective in inducing a more significant long-
associated comorbidities [8,9]. Although it has proven term weight reduction, as well as in decreasing obesity-
successful in treating obesity and its complications, BS associated comorbidities and improving the life quality
is known to predispose patients to a range of vitamin (QoL) and life expectancy of patients with severe obesity
and mineral deficiencies [10]. The importance of [27]. The Swedish Obese Subjects Study (SOS), a
nutritional consequences following BS correlates to the prospective, landmark controlled trial with an extended
type of procedure performed and, thus, to the specific follow-up period (between 10-20 years), found that BS
physiologic changes in digestion and absorption of food was related to clinically important weight loss (>15%)
[11]. Moreover, studies have shown that patients with after 10 years that markedly improved cardiovascular
clinically severe obesity planning to undergo BS are often risk factors in these patients; BS resulted in a lower long
malnourished prior to surgical treatment for weight loss term all-cause mortality rate compared with usual medical
[12-16]. Furthermore, micronutrient deficiencies remain treatment [adjusted hazard ratio (HR)=0.71], increased
undiagnosed in most cases [17]. In fact, less than 25% of T2DM remission rate (adjusted OR=3.45; p<0.001),
patients undergoing BS is subjected to a nutritional status improved QoL [8] and also in a prolonged survival
assessment [18]. (adjusted median for life expectancy was 3 years longer
The most common micronutritional deficiencies in the surgery group compared to the control group) [28].
reported in BS candidates are vitamin D, vitamin B12, The clinical benefits of BS explain the rapid
folate, and iron [18-22]. Baseline deficiencies are growth of bariatric procedures performed worldwide with
considered to be strong predictors of postoperative an estimated number of over 600,000 operations in 2016
nutritional deficiencies. Hence, it is important to identify [29]. The mechanisms underpinning weight loss and health
and correct the preoperative deficiencies as they might outcomes associated with BS are not fully elucidated and
exacerbate after the weight loss surgery and lead to include restriction and malabsorption, neuro-hormonal
long-term complications [23]. Although micronutrient and metabolic factors as well as postsurgical eating
deficiencies are the most common nutritional issues behavior modification. Currently, the most common
encountered in BS patients prior to surgical procedures, procedures performed worldwide are sleeve gastrectomy
some studies have also reported excess micronutrient (45.9%) and Roux-en-Y gastric bypass (39.6%) [30].
levels [13,16].
The purpose of this review is to describe the Preoperative evaluation of BS candidates
determinants of the preoperative nutritional status in Regardless of the type of planned surgery, all
obese patients planning to undergo BS as well as the most BS candidates should be submitted to a comprehensive
widespread micronutrient anomalies in terms of deficiency nutritional, medical and health-related behavior assessment
or excess and their deleterious health consequences. prior to surgery, followed by suitable counseling and
intervention. Patients planning to undergo BS must be also
Bariatric surgery: summary of indications, provided with appropriate knowledge about the surgical
outcomes, and most common procedures treatment for weight loss [31,32]. Preoperative screening
Most international guidelines still widely used, of baseline nutritional deficiencies should be performed
developed according to National Institute for Health (NIH) (Table I) [33] and adequate nutritional supplementation,
statement released in 1991, recommend BS as suitable based on micronutrient laboratory tests results, should be
for subjects whose BMI is greater than 40 kg/m2 without recommended [16].
comorbid conditions or 35 kg/m2 in the presence of at least
one or more comorbidities – such as heart disease, type Preoperative nutritional status of BS
2 diabetes (T2DM) or severe sleep apnea and who have candidates
reported unsuccessful attempts to lose weight or maintain Determinants of micronutrient deficiencies in
the weight loss obtained by non-surgical means [24]. The BS candidates
European Association for Endoscopic Surgery clinical Although it seems unlikely, obese patients present
guidelines issued in 2020, endorsed by the International various micronutrient deficiencies before undergoing
Federation Surgery of Obesity and Metabolic Disorders BS [23,34]. These disturbances generally occur due to
– European Chapter, recommend BS for patients with obesity per se, poor diet quality, preoperative weight loss,
an even lower BMI, respectively between 30–35 kg/m2, and altered nutrient metabolism and increased nutrients
and poor-controled T2DM and/or arterial hypertension requirements [35].
A major contributor to an altered nutritional status showed that a higher intake of UPFs is linked with an
in BS candidates is obesity itself [36]. Obesity is a chronic increased weight gain and may contribute to the rise
disease that causes a state of low-grade inflammation [37] of obesity rates. It is estimated that UPFs consumption
Inflammation may alter nutrient metabolism, synthesis of represents, in certain high income countries, up to 50-
nutrient transporters and induce oxidative stress, leading 60% of the total energy intake [42].
to an increased antioxidant utilization [35]. For example, Some studies evaluating the prevalence of
iron homeostasis may be dysregulated by adipose tissue micronutrient deficiencies among obese patients preparing
inflammation and by the increased level of hepcidin, the to undergo BS have also assessed food consumption
master iron regulatory hormone [38]. Another mechanism at baseline [14,15,43]. Sherf Dagan et al. conducted a
underpinning the obesity-impaired nutritional status cross-sectional study involving 100 BS candidates and
is attributed to the volume of distribution, which is reported a mean energy intake of 2710±1275.7 kcal/
greater in obese patients due to elevated adipose tissue day, providing 114.2±48.5 g protein/day (respectively
and total body water. Extracellular fluid is increased 1.0±0.4 g protein/kg body weight) (17%), 110.7±54.5
compared to the intracellular fluid, possibly leading to the g fat/day (36%) of which 35.0±17.3 g saturated fatty
dilution of the extracellular micronutrient concentration acids/day, 321.6±176.1 g carbohydrates/day (47%) and
[39]. Lastly, adipose tissue might be storage depot for 32.1±21.7 g fiber/day. Consumption levels of sweets
lipophilic compounds, such as vitamin D, which provides and sugar-sweetened beverages, sodium, and processed
an explanation for low plasma levels of 25(OH)D meats exceeded the dietary recommendations, while
documented in most obese patients [38]. intake of iron, calcium, folic acid, vitamin B12, and
The impaired nutritional status of BS candidates vitamin B1 did not meet the dietary reference intakes
is considered to be related to poor quality food choices (DRI) requirements for 46%, 48%, 58%, 14%, and 34%
that provide insufficient amounts of vitamins and minerals of the study population. Food intake analysis showed that,
in spite of a higher total caloric intake [23]. Low fruit regardless of calorie and macronutrient overload, most
and vegetables consumption combined with energy-dense vitamin and mineral levels were below the recommended
processed food intake have emerged main causes that lead levels of consumption, suggesting a poor diet quality.
to micronutrient deficiencies in extremely obese patients However, despite the nutritional inadequacy of the diet,
[40]. For example, excessive intake of simple sugars, milk the authors did not report a high prevalence of nutritional
products or fats might deplete thiamine stores [38]. Some deficiencies in baseline with one exception: 83% of the
authors hypothesized that, in turn, these deficiencies study population was vitamin D deficient. One possible
drive overconsumption in order to compensate for the explanation for this finding is that 59% of the study
scarcity of micronutrients in processed food [41]. A rapid participants were taking oral supplements preoperatively.
concomitant increase in ultra-processed foods (UPFs) In fact, study participants using multivitamins/minerals
consumption and obesity prevalence is seen worldwide. were found to have improved levels of folic acid and
UPFs possess unhealthy nutritional profiles, with lower vitamin B12. Nevertheless, the authors did not evaluate
vitamin and mineral content and higher fat, salt and sugar neither adherence, nor the type or the duration of the oral
levels. The French NutriNet-Santé cohort study, which supplement intake [14].
spanned 10 years and involved over 100.000 participants, Preoperative weight loss is often recommended as
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