Follow-up of Nutritional and Metabolic Problems After Bariatric Surgery (2022)

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Volume 28, Issue 2

1 February 2005

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Reviews/Commentaries/ADA Statement| February 01 2005

Ken Fujioka, MD

Ken Fujioka, MD

From the Department of Endocrinology, Scripps Clinic, San Diego, California

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Diabetes Care 2005;28(2):481–484

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October 12 2004


October 19 2004

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Ken Fujioka; Follow-up of Nutritional and Metabolic Problems After Bariatric Surgery. Diabetes Care 1 February 2005; 28 (2): 481–484.

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Over the next several years, the number of patients who will have had bariatric surgery for morbid obesity will reach close to a million. Several well-described nutritional problems such as B12 and iron deficiency will be noted in these patients. Many of these patients will be lost to the original surgeon and will now be in the care of the “other physicians.” These and other mineral and vitamin problems will need to be screened and treated. If these problems are left undiagnosed, severe and irreparable problems can result. Early problems, such as vomiting and dumping syndrome, will be easily recognized and treated, but other long-term problems, such as changes in bone metabolism, will need to be monitored. Again, if some of these long-term problems are not addressed in a timely fashion, then eventual treatment becomes much more difficult. This commentary will cover the common as well newer problems that are now developing in the patient who has had bariatric surgery. Patients who have undergone bariatric surgery require medical follow-up for reasons that are often determined by the type of surgical procedure performed. The majority of this review will deal with patients who have had the standard Roux-en-Y gastric bypass, which is a primarily restrictive procedure with a mild component of noncaloric malabsorption. At the end of this report, a short section will be devoted to the problems associated with the malabsorptive procedures.

Follow-up of the morbidly obese patient who has had gastric bypass can conveniently be divided into two areas: the issues of surgical complications and weight loss during the first year, and the nutritional and metabolic issues that arise after the first year.


The vast majority of weight loss after gastric bypass is accomplished at or around 1 year after surgery (1,2). Twelve to 18 months after surgery, some patients continue to lose a small amount of weight while others begin to maintain their lower weight. At eighteen to 24 months after surgery, almost all patients have stopped losing weight and most patients are maintaining or regaining weight.

Vomiting and dumping syndrome

Vomiting almost always occurs during the first few months after surgery and is often described as “spitting up food that is stuck.” It typically happens one to three times a week and is usually due to overeating or not chewing food adequately. Patients need to adjust to the much smaller gastric pouch that now receives food from the esophagus; bariatric surgery has diminished the stomach’s ability to grind food into small particles. Vomiting is well tolerated by most patients. If vomiting becomes more frequent, low potassium and/or low magnesium levels often occur, requiring oral replacement. Liquid forms of potassium are available but are not well tolerated by patients due to palatability; fortunately, by postoperative month 1, pills are usually able to pass through the anastomotic or restricted portion of the stomach. To ensure that the potassium can traverse the 1-cm anastomoses, smaller pills or capsules are often prescribed.

Vomiting can signal other problems and is associated with strictures and stomal stenosis. Intolerance for solid foods is a key symptom; if this develops, then endoscopic evaluation should be strongly considered. If intolerance to solid food develops 6 months after surgery, then the diagnosis of stenosis is very high. In one study, abnormal findings at endoscopy showed stomal stenosis in 39% of patients with nausea, vomiting, or dysphagia referred for endoscopy (3). Such stenosis can usually be treated by balloon dilation at the time of diagnosis. Many of these patients will require repeat dilations, determined by their ability to tolerate most solid foods.

Dumping syndrome is an extremely common, and somewhat intentional, problem after gastric bypass. High-osmolarity foods (e.g., foods high in sugar content), after bypassing much of the stomach undigested, cause an osmotic overload upon entering the small intestine. This osmotic overload brings fluid into the lumen of the small intestine, resulting in a vagal reaction. Patients will often complain about lightheadedness and sweating after eating a high-glucose meal or drinking fluid with a meal. This is a very uncomfortable feeling and is accompanied by impressive fatigue. Diarrhea may or may not occur, as there is usually sufficient distal bowel to absorb such food, and nutritional problems are rare. Foods that are identified in our clinic as causing dumping syndrome include ice cream and pastries.

Dehydration occurs frequently and is due to multiple factors. The very small surgically created gastric pouch makes it extremely difficult for patients to hold much fluid. Because dumping syndrome occurs if fluids are mixed with food, patients also must drink fluids separately from meals. (Fluid with a meal can solubilize food and increase osmolarity.) As a result, patients must constantly sip fluid throughout the day to meet their fluid requirements. Brief hospitalizations or urgent care visits for dehydration are very common during the first 6 months after surgery.

Water consumption is the best method to prevent dehydration. If rehydration is needed, salty broths or liquids containing salt work well. Many patients can tolerate sports fluid replacement drinks, either diluted 50% or occasionally full strength. Many gastric pouches after gastric bypass are ≤50 ml in size, and patients must learn to constantly sip fluid and not drink large gulps.

While protein malnutrition was very common with the truly malabsorptive surgical procedures of the past, it is rare after gastric bypass or any of the current restrictive surgeries. If protein malnutrition develops after gastric bypass, one needs to look at the total food intake of the patient and determine whether the patient is meeting his/her caloric and protein needs (4). Protein supplements are very helpful, and with the current trend of Americans eating high-protein diets, numerous high-protein low-carbohydrate supplements are readily available.

Hair loss, or telogen effluvium, is seen frequently 3–6 months after surgery. Patients note diffuse shedding of normal hair. Lasting as long as 6–12 months, it can be terribly distressing to the patient. The stress of weight loss disrupts the normal growth cycle of individual hairs, resulting in large numbers of growing hair simultaneously entering the dying (telogen) phase. Although there is no known treatment, it usually reverses without intervention (5).

Gallstone formation is very common during weight loss (6), and surgery-induced weight loss is no exception. In one study of bariatric surgery patients, 71% developed gallstones, despite the fact that two-thirds of the patients received preventative treatment (7). Of those patients who formed gallstones, 41% were symptomatic. Bariatric surgery patients presenting with right upper quadrant abdominal pain should thus be appropriately evaluated. At our own institution, all symptomatic patients undergo an ultrasound of the gallbladder before surgery. If patients have gallstones, these are removed either before or at the time of surgery. After surgery, all patients with an intact gallbladder will be placed on a gallstone-solubilizing agent for at least 6 months after surgery.


B12 deficiency

As weight loss begins to slow down, the risk of other nutritional problems increases. B12 and iron deficiency are two of the most common problems and often do not respond to typical multivitamin supplementation (8–10). Such nutrient issues are primarily seen with gastric bypass and any of the malabsorption procedures.

Because food now bypasses the lower stomach, B12 deficiency is frequently observed. If B12 is not supplemented above and beyond a multivitamin, 30% of patients will be unable to maintain normal levels of plasma B12 at 1 year (9). After 1 year, the prevalence of B12 deficiency appears to increase yearly and has been reported to be between 36 and 70% in the long term (11,12).

Over the counter oral and sublingual forms of vitamin B12 are available for use (13,14). Optimal dose and efficacy have not been well studied, but doses of 25,000 units sublingual B12 twice a week are usually sufficient to maintain normal plasma levels of B12. Some (up to 10%) patients will not respond to high-dose sublingual or oral B12 and will require monthly intramuscular B12 injections.

Iron deficiency

Iron deficiency after gastric bypass is usually only seen in menstruating women. Ferritin or iron levels and erythrocyte counts need to be monitored, as iron deficiency can develop early after surgery or years later; one study found that iron stores continuously declined up to 7 years after bypass surgery (15). Due to bypass of the lower stomach, it is very difficult for iron-deficient patients to absorb sufficient oral iron. Intramuscular iron can be impractical over the long run. At our institution, intravenous iron dextran or iron sucrose is used regularly; many patients require intravenous iron several times a year. This is done as an outpatient procedure and is well tolerated by patients.

Ulcers, NSAIDs, and abdominal pain

Patients with persistent iron loss should be evaluated for blood loss through the gastrointestinal tract. Ulcers at the margin of the anastomoses between the stomach pouch and the small intestine are a common cause of blood loss. All NSAIDs (nonsteroidal anti-inflammatory drugs), including aspirin, and COX-2 (cyclooxygenase-2) inhibitors, have the potential to cause ulcers; use of these drugs is to be avoided at all costs in gastric bypass patients. A study of gastric bypass patients referred for endoscopy found that marginal ulcers were present in 27% of patients (3). In our clinic, gastric bypass patients with abdominal pain are considered to have an ulcer until proven otherwise. Not all marginal ulcers will bleed significantly but most will have pain.


Several articles are starting to surface regarding problems with bone mineralization in gastric bypass patients (16–18). With increasing numbers of patients undergoing bariatric surgery (an estimated 100,000 procedures annually), long-term follow-up of this growing and aging population will need to monitor bone health and metabolism. While it is recommended that bone density be measured after bariatric surgery, there are no specific guidelines for treatment and follow-up (Table 1). In our clinic, we are currently following vitamin D, calcium, and parathyroid hormone levels, as well as bone densitometry.

Secondary hyperparathyroidism

One form of bone demineralization, secondary hyperparathyroidism, has been reported by several groups to occur in patients who have had gastric bypass (19–21). While the prevalence is unclear, it appears to be more common than previously thought. At our institution, we studied 65 consecutive patients seen for follow-up after gastric bypass. Time since surgery varied from 1 to 9 years; parathyroid hormone, calcium, and vitamin D levels were measured. Twenty-nine percent of patients were found to have elevated parathyroid hormone levels. Although the study group was small, patients at >4 years’ postsurgery had a much higher rate of secondary hyperparathyroidism. Average 25(OH)D level in patients with secondary hyperparathyroidism was 21 ng/ml, whereas patients with normal parathyroid hormone levels had an average 25(OH)D level of 30 ng/ml (normal 20–57 ng/ml). The majority of the patients with secondary hyperparathyroidism has responded to pharmacologic replacement of vitamin D, with normalization of parathyroid hormone levels. It should be noted that vitamin D and calcium supplementation at the usual recommended daily requirements did not normalize parathyroid hormone levels in at least one study (20).

Malabsorptive bariatric surgery

Currently, Roen-en-Y gastric bypass, which is a restrictive procedure with minimal to no malabsorption, comprises the vast majority of bariatric surgeries. Several decades ago, a bariatric procedure known as the biliopancreatic diversion or Scopinaro procedure was popular. It is still occasionally performed in morbidly obese patients and is intended to cause fat malabsorption to produce massive amounts of weight loss. The procedure involves a gastric restriction and diverts bile and pancreatic juice into the distal ileum (22). This leaves a very short segment of small bowel to absorb all the nutrients that require biliary and pancreatic juices. Variations of this procedure (biliopancreatic diversion with duodenal switch) causing malabsorption are still performed. In addition to the above-mentioned nutritional issues, patients who have this procedure often have other more severe problems related to protein and fat malabsorption.

Protein deficiency is easy to recognize by following albumin. Fat malabsorption manifests its presence by loss of fat-soluble vitamins. Patients can present with a number of problems after this procedure. In our clinic, the most common presenting complaint is fractured bones or a bone density study showing “severe bone loss.” Due to fat malabsorption, severe vitamin D deficiency will develop along with an already reduced ability to absorb calcium (23).

In general, fat-soluble vitamins A, D, and K will be deficient in two-thirds of these patients within 4 years after surgery. Up to 50% will have hypocalcemia, and all of these patients with low vitamin D levels will have secondary hyperparathyroidism (24,25).

Manifestations of all the different fat-soluble vitamins can be seen, ranging from unusual rashes, to osteomalacia, to easy bruising. Fortunately, there is a rather simple solution: pancreatic enzyme replacement. When pancreatic enzymes are replaced, there is some weight regain, and physicians often observe patient noncompliance as a result. The hyperparathyroidism may be difficult to treat and may require separate treatment or even surgery.

Other problems associated with this type of procedure include severe hair loss, liver disease (usually transient), kidney disease, and unusual body odors (26). The lifestyle after this procedure can be difficult due to the frequent bowel movements (over 10 times a day) and the foul-smelling stool that the fat malabsorption causes.


Despite billions of dollars spent on weight loss treatment, the number of morbidly obese patients continues to increase. The only treatment option shown to have any type of success in this population is bariatric surgery. Over 100,000 bariatric surgeries are performed annually, with gastric bypass being the most common surgery. Compliance with long-term follow-up is vital, as nutritional and metabolic problems can be easily treated or avoided. With increasing numbers of patients undergoing bariatric surgery, physicians other than the initial surgeon will need to become involved in the follow-up of such patients (27).

Table 1—

Recommended follow-up of the bariatric surgery patient by the nonsurgeon*

1 month3 months6 months12 months18 months24 monthsAnnually
Chemistry panelXXXXXXX
Complete blood countXXXXXXX
Iron studiesXXXXXXX
Vitamin DXXXX
Parathyroid hormoneXXXX
Bone densityXXX
1 month3 months6 months12 months18 months24 monthsAnnually
Chemistry panelXXXXXXX
Complete blood countXXXXXXX
Iron studiesXXXXXXX
Vitamin DXXXX
Parathyroid hormoneXXXX
Bone densityXXX

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(Video) Long-term nutritional consequences of bariatric surgery


What is the recommended follow up after bariatric surgery? ›

How many follow-up visits are necessary after surgery? Typically, you'll attend four to six follow-up meetings during your first post-surgery year. Then visits are scheduled at six to twelve month intervals for an indefinite period of time. First visit: Scheduled 2-3 weeks after bariatric surgery.

What are the nutritional concerns that occur after bariatric surgery? ›

The most common clinically relevant micronutrient deficiencies after gastric bypass include thiamine, vitamin B₁₂, vitamin D, iron, and copper. Reports of deficiencies of many other nutrients, some with severe clinical manifestations, are relatively sporadic.

What are the metabolic effects of bariatric surgery? ›

Increase in the fat mass associated with obesity results in adipocyte and adipose tissue dysfunction, termed adiposopathy. Metabolic surgery improves adipocyte dysfunction associated with improvements in metabolic parameters (e.g., glucose concentrations and blood pressure), dyslipidemia, and cardiovascular risk (30).

What labs should be checked after bariatric surgery? ›

Postoperative laboratory monitoring should include 25-hydroxyvitamin D, calcium, albumin, phosphorus, and PTH levels. The vitamin D supplement dose can be titrated to achieve and maintain a 25-hydroxyvitamin D level of at least 30 ng/mL.

What is the most common complication of bariatric surgery? ›

An anastomotic leak is the most dreaded complication of any bariatric procedure because it increases overall morbidity to 61% and mortality to 15%.

What vitamins do you need after bariatric surgery? ›

Vitamin Recommendations for Patients

Gastric Bypass: Doctors recommend that gastric bypass surgery patients take a complete multivitamin, calcium with Vitamin D, iron and Vitamin C, Vitamin D, and Vitamin B12. Others may be recommended.

What is the most important nutrient after bariatric surgery? ›

Protein is one of the most important nutrients of concern for bariatric surgery patients. Since bariatric surgery reduces the capacity of the stomach to a very small volume, high-protein foods should always be eaten FIRST or you may become too full to eat them.

What is a negative nutritional consequence of bariatric bypass surgeries? ›

Bariatric surgery could impact bone metabolism and induce significant changes, such as decreased mechanical loading, calcium/vitamin D malabsorption with secondary hyperparathyroidism, nutritional deprivations, changes in fat mass and alterations in fat- and gut-derived hormones[25-27].

How does bariatric surgery affect nutrient absorption? ›

Malabsorptive procedures can lead to nutrient deficiency through changes in biliary and pancreatic functions, alterations in GI transit time/gastric acid secretion, bypass of the duodenum (a primary site of absorption), and promotion of small intestinal bacterial overgrowth (SIBO).

How does bariatric surgery reset metabolism? ›

Bariatric surgery may reset your set point

By altering the anatomy of the stomach and/or intestine, these surgeries affect hormonal signals, resulting in decreased appetite, increased feelings of fullness, increased metabolism, and healthier food preferences.

How can I boost my metabolism after bariatric surgery? ›


It is absolutely vital to start and stay consistent with an exercise program after your obesity surgery. Exercising regularly will allow you to maintain your lean muscle mass, bone density, and boost your metabolism.

What is metabolic syndrome? ›

Metabolic syndrome is the medical term for a combination of diabetes, high blood pressure (hypertension) and obesity. It puts you at greater risk of getting coronary heart disease, stroke and other conditions that affect the blood vessels.

What is VSG test? ›

What is VSG Surgery? A vertical sleeve gastrectomy (VSG) is a minimally invasive procedure during which the size of your stomach is reduced to three or four ounces. This limits the amount of food you can eat to help you lose weight.

Why do you have to pee before bariatric surgery? ›

Testing can also help to ensure that a person is not using any drugs which may impair their lung function and put them at higher risk for complications while under anesthesia. It can also help to determine if a person is likely to abuse medications or painkillers that they are prescribed during recovery.

What medications can you take after gastric bypass? ›

After bariatric surgery, your daily regimen will include short- and long-term medications.
  • Omeprazole, which reduces the risk of developing ulcers in the digestive tract. ...
  • Ursodiol, which reduces the risk of developing gallstones during the postsurgical period of rapid weight loss.

What are 3 common long term complications of gastric bypass? ›

Longer term risks and complications of gastric bypass can include: Bowel obstruction. Dumping syndrome, causing diarrhea, nausea or vomiting. Gallstones.
  • Excessive bleeding.
  • Infection.
  • Adverse reactions to anesthesia.
  • Blood clots.
  • Lung or breathing problems.
  • Leaks in your gastrointestinal system.
Jun 25, 2022

What are the long term side effects of bariatric surgery? ›

Long-term risks associated with bariatric surgery

Dumping syndrome, a condition where food from the stomach is dumped into the large intestine without proper digestion. Low blood sugar. Malnutrition. Vomiting.

What is the life expectancy after gastric bypass? ›

The adjusted median life expectancy in the surgery group was 3.0 years (95% CI, 1.8 to 4.2) longer than in the control group but 5.5 years shorter than in the general population. The 90-day postoperative mortality was 0.2%, and 2.9% of the patients in the surgery group underwent repeat surgery.

Which multivitamin is best after gastric sleeve? ›

What vitamins are typically recommended after weight loss surgery?
  • Bariatric Advantage Ultra Solo with Iron.
  • Celebrate Bariatric Multivitamin.
  • Opurity Bariatric Multi Chewable with Iron.
  • ProCare Health Once Daily Bariatric Multivitamin Capsule.
  • TwinLab Bariatric Support Chewable Multivitamin.
Jan 5, 2022

How do you prevent dumping syndrome after gastric bypass? ›

Generally, you can help prevent dumping syndrome by changing your diet after surgery. Changes might include eating smaller meals and limiting high-sugar foods. In more-serious cases of dumping syndrome, you may need medications or surgery.

How much B12 do you need after gastric bypass? ›

CONCLUSION: At least 350 µg per day is the appropriate oral dose of crystalline vitamin B12 after gastric surgery for obesity to correct low serum vitamin B12 levels in 95% of patients.

What happens if I don't eat enough protein after gastric sleeve? ›

If your diet doesn't include enough protein, you might notice thinning hair about 6 months to a year after weight loss surgery. That's because the human body can't make protein without food – and also has no way to store protein – making it important to consume enough daily.

Can you have too much protein after bariatric surgery? ›

Try not to exceed the range of recommended daily protein, unless instructed to do so by your physician or dietitian. Excess protein intake will result in excess caloric intake, and any excess calories that are not burned are stored as FAT.

How much can you eat 2 years after gastric bypass? ›

Planning meals. After surgery, your stomach can only hold 2 to 4 tablespoons of food or drink. After about a year, it will expand to hold up to 16 tablespoons of food or drink. Because of its small size, you will need to eat and drink much less at any 1 meal than you did before surgery.

What is malabsorption after gastric bypass? ›

Bypass of the duodenum impairs mixing of ingested nutrients with bile acids and pancreatic enzymes leading to maldigestion. The combination of malabsorption and maldigestion, while resulting in significant weight loss, predisposes to malnutrition.

How many calories are not absorbed after gastric bypass? ›

Fourteen months after bypass, malabsorption reduced energy absorption by 172 ± 60 kcal/d compared with 1418 ± 171 kcal/d caused by restricted food intake.

What is bariatric beriberi? ›

Beriberi is a nutritional complication of gastric surgery, caused by deficiency of vitamin B1, or thiamine. Thiamine deficiency leads to impaired glucose metabolism, decreased delivery of oxygen by red blood cells, cardiac dysfunction, failure of neurotransmission, and neuronal death.

What happens if you don't take multivitamins after bariatric surgery? ›

Calcium & Vitamin D

This includes our teeth and bones. For bariatric patients, we are already concerned with loss of bone density. Inadequate calcium levels lead to degenerative conditions like osteoporosis as well as increased risk of bone fractures.

Does bariatric surgery cause malabsorption? ›

Types of Bariatric Surgeries

These procedures are commonly referred to as restrictive. A second mechanism is by inducing malabsorption by surgically bypassing regions of the small intestine and diverting biliopancreatic secretions, which limit nutrient absorption. These are known as malabsorptive.

How much Vitamin D should a bariatric patient take? ›

Vitamin D Recommendations:

Take 3,000 International Units (IU) of Vitamin D3 per day. If included in your bariatric brand multivitamin, you do not need to take a separate supplement.

Can I reset my gastric sleeve after 5 years? ›

The answer is yes, you can! Whether you are trying to stop weight regain, shed the excess pounds that have shown back up, or are trying to get past a weight plateau after gastric sleeve surgery, there are a few different options available to help you restart your weight loss after gastric sleeve surgery.

Does your metabolism slow down after bariatric surgery? ›

“After bariatric surgery, your metabolism decreases, and your need for calories drops as you lose weight. You can't eat the same number of calories at 150 pounds that you did at 300 pounds, or you'll gain weight.” Binge eating.

Can your stomach go back to normal after gastric sleeve? ›

As such the answer to can your stomach grow back after weight loss surgery is NO, it will not grow back to its original size, but rather hold a capacity that allows the patient to have a long term normal life once they achieve their weight loss success.

When should I call the doctor after gastric bypass? ›

Redness, swelling, and bleeding around the incision, or if it appears larger/deeper. Redness, pain, or swelling in legs or arms. You experience continuous nausea and vomiting after eating, cramps and bloating. You cannot keep liquids down or tolerate any food.

What is the priority for the immediate post operative care of the patient undergoing bariatric surgery? ›

For the first 24 h after the bariatric surgery, the postoperative priorities include pain management, leakage, nausea and vomiting, intravenous fluid management, pulmonary hygiene, and ambulation.

Which measure of body fat is recommended by NICE for use in adults with BMI under 35 kg/m2 not in children? ›

1.2. 3 Think about using waist circumference, in addition to BMI, in people with a BMI less than 35 kg/m2.

What is bariatric surgery? ›

Overview. Gastric bypass and other weight-loss surgeries — known collectively as bariatric surgery — involve making changes to your digestive system to help you lose weight. Bariatric surgery is done when diet and exercise haven't worked or when you have serious health problems because of your weight.


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