anemia occurs in what up to percentage of patients after bariatric surgery?
6-hundred million adults around the world are suffering from obesity, defined as an aberrant or excessive fatty accumulation that may impair health( 1 ). Worldwide, different prospective studies and meta-analyses observed that both overweight, defined as a BMI ≥25·0 kg/m2, and obesity, defined equally a BMI ≥30·0 kg/mii, are associated with increased all-cause mortality( Reference Di Angelantonio and Bhupathiraju 2 ). More than specific, every 5 kg/mtwo increase in BMI above 25 kg/m2 is associated with an average increment in mortality of thirty %. Predominantly, the excess mortality is mainly the event of vascular diseases (e.g. IHD, stroke and other vascular diseases) and diabetes( Reference MacMahon, Baigent and Duffy iii ). These factors, including the growing prevalence of obesity, the severity of associated comorbidities and the associated economic costs, explain the rising interest in preventive strategies with limited results so far( Reference Bray, Frühbeck and Ryan iv ). Treatment of obesity is therefore imperative with lifestyle changes, dietary adjustments and increased physical activity as cornerstone( Reference Fried, Yumuk and Oppert five , Reference Mechanick, Youdim and Jones vi ). Despite the ease of lifestyle modification, whether or non combined with pharmacological treatment, bariatric surgery results in greater and sustained improvements in weight loss, obesity-associated complications, all-cause bloodshed and quality of life compared with non-surgical treatment options( Reference Sjöström, Narbro and Sjöström vii , Reference Sjöström 8 ). These encouraging results explain the worldwide ascension number of bariatric procedures as roughly half a million bariatric procedures were performed in 2013( Reference Angrisani, Santonicola and Lovino 9 ).
Metabolic and bariatric surgery
Bariatric procedures are intended for patients suffering from morbid obesity where cornerstone treatment (east.g. lifestyle changes, dietary adjustments and increased concrete activity) and/or pharmacological treatment produces insufficient weight loss. European and American guidelines recommend bariatric surgery for patients with a BMI ≥40 kg/10002 or for patients with a BMI ≥35 kg/thouii in combination with at least one obesity-associated comorbidity (e.thousand. blazon two diabetes, hypertension or obstructive slumber apnoea)( Reference Fried, Yumuk and Oppert five , Reference Mechanick, Youdim and Jones six ). Traditionally, bariatric surgery procedures are classified as restrictive, malabsorptive or a combination thereof. Restrictive procedures reduce the size of the stomach, which limits the energetic intake and triggers satiety, while malabsorptive procedures featherbed a specific part of the intestine, which impedes the absorption of the ingested nutrients in the gastrointestinal tract. Combined procedures include both the aspects of restriction and malabsorption( Reference DeMaria 10 ). The positive effects of bariatric surgery extend beyond weight loss every bit the metabolic status of the patients is drastically improved afterwards surgery. Accordingly, the concept of metabolic and bariatric surgery has emerged and gained acceptance over the years( Reference Rubino and Cummings xi , Reference Rubino 12 ). For the remainder of the review, metabolic and bariatric surgery will be referred to every bit bariatric surgery.
While bariatric surgery is established to induce weight loss and/or better the metabolic contour, several evolutions accept occurred within the anatomical procedures( Reference Buchwald thirteen ). Worldwide, the combined Roux-en-Y gastric bypass (RYGB) procedure is considered the gold standard of all bariatric procedures in view of its benign balance between the long-term efficacy and complication rate. However, the more recent, restrictive sleeve gastrectomy (SG) procedure is rapidly gaining popularity and has exceeded RYGB as the almost commonly performed process within bookish medical centres of the USA( Reference Esteban Varela and Nguyen 14 ). The alterations in the gastrointestinal anatomical architecture after RYGB and SG are visualised in Fig. 1. Briefly, the laparoscopic RYGB procedure involves the formation of a small gastric pouch and a gastric remnant using surgical staples. Afterwards, the small intestine is rearranged into a Y-configuration through the segmentation of the proximal part of the small intestine distal to the ligament of Treitz. The distal office of the pocket-size intestine is reconnected to the pocket-size gastric pouch through a gastrojejunostomy with the germination of the Roux limb, while the proximal part of the small-scale intestine is reconnected to the Roux limb through a jejunojejunal anastomosis to facilitate the passage of secreted digestive enzymes and bile salts. The laparoscopic SG process involves the resection of the greater curvature of the stomach starting at the antrum betwixt the pylorus and the end of the nervus of Latarjet up to the angle of His. A sleeve-like pouch is formed that connects the oesophagus to the small intestine( Reference Vidal, Corcelles and Jiménez 15 , Reference Lannoo and Dillemans xvi ). These restrictive and malabsorptive alterations in the gastrointestinal anatomical architecture accept a direct effect on the intake, digestion and assimilation of nutrients, while additionally inducing changes in the levels of several gut peptides involved in the regulation of appetite and satiety. Taken together, both anatomical and physiological alterations contribute to the desired beneficial weight and metabolic effects( Reference Ionut, Burch and Youdim 17 ).
Fig. 1. (Colour online) Alterations in the gastrointestinal anatomical architecture after Roux-en-Y gastric bypass (a) and sleeve gastrectomy (b).
Iron deficiency after bariatric surgery
The benign results of bariatric surgery with respect to weight loss and comorbidities come at a cost, namely the risk for postoperative complications. Among all complications, the frequency of nutritional complications is a worrying trend and clearly demands extra attention( Reference Decker, Boyfriend and Crowell 18 ). These deficiencies develop as a consequence of the alterations in the gastrointestinal anatomical architecture and the associated changes in the physiology of the alimentary canal( Reference Steenackers, Gesquiere and Matthys 19 ). Peculiarly striking is the take chances of developing iron deficiency every bit it impairs the normal physiological function of tissues such as blood, brain and muscles( 20 ). Unlike factors contribute to the development of iron deficiency after bariatric surgery including reduced iron intake, reduced secretion of hydrochloric acid and a reduction in the surface area for absorption (Fig. 2). Taken together, these factors contribute to the development of iron deficiency after bariatric surgery and volition be further discussed in the review( Reference Steenackers, Gesquiere and Matthys nineteen , Reference Gesquiere, Lannoo and Augustijns 21 ). Furthermore, it should be emphasised that obese patients are already predisposed to develop atomic number 26 deficiency. Inadequate iron intake, greater requirements due to a higher blood book and the presence of low-grade chronic inflammation inhibits the absorption of fe, which may lead to atomic number 26 deficiency in obese patients and can then persist or even worsen after bariatric surgery( Reference Aigner, Feldman and Datz 22 ).
Fig. 2. (Color online) Factors contributing to the development of atomic number 26 deficiency after Roux-en-Y gastric bypass and sleeve gastrectomy.
Iron intake after bariatric surgery
The contribution of iron intake to iron deficiency after bariatric surgery has been the topic of investigation in several studies. Tables 1 and two provide an overview of the studies to date that have evaluated fe intake later on RYGB and SG. After surgery, iron intake was mostly lower or even inadequate compared with the bachelor estimated average requirements or dietary reference intake for good for you individuals( Reference Colossi, Casagrande and Chatkin 23 – Reference Chou, Lee and Almalki 35 ). Postoperatively, the restricted dietary intake, increased satiety and reduced appetite contribute to the lower fe intake by means of a reduced intake of micronutrients( Reference Moizé, Andreu and Flores 27 ). Furthermore, the lower atomic number 26 intake is partially the result of the low tolerance for red meat. Recent studies report a charge per unit of intolerance ranging from 23 to 50 % after bariatric surgery. Differences in reporting methodology explain the variety in the reported prevalence. For instance, disparity inside the definition for blood-red meat intolerance is observed between the different studies. Nicoletti et al. defined cherry-red meat intolerance 'equally an abnormal physiologic response (nausea and vomiting) later eating red meat', while Moize et al. defined red meat intolerance as 'nausea, airsickness, diarrhoea or abdominal discomfort following the ingestion of red meat'. Despite this variance, the tolerance for red meat improves as fourth dimension passes further from the bariatric procedure( Reference Nicoletti, de Oliveira and Barbin 36 , Reference Moize, Geliebter and Gluck 37 ). Finally, poor adherence to dietary guidelines provided by professionals, non-adherence to recommended supplementation or bereft professional guidance further contribute to depression iron intake. Adherence to the postoperative dietary recommendations has been reported to be inadequate, which tends to increase over fourth dimension. Supplementation adherence tends to be lower in the belatedly postoperative period compared with the early postoperative flow( Reference Hood, Corsica and Bradley 38 ). Concerning professional guidance, accreditation standards from the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) recommend that patients receive postoperative follow-up( Reference Melissas, Torres, Yashkov and Agrawal 39 , Reference Saber, Bashah, Zarabi and Agrawal 40 ). Nonetheless, information technology has been reported that 47–90 % of patients do not receive nutritional advice after surgery( Reference Peacock, Schmidt and Barry 41 ).
Tabular array one. Overview of studies reporting iron intake after Roux-en-Y gastric bypass
Table 2. Overview of studies reporting iron intake later sleeve gastrectomy
Iron assimilation after bariatric surgery
Depression iron intake later surgery is not an exclusive explanation for the development of iron deficiency. The digestion and assimilation of fe are affected past alterations in the gastrointestinal anatomical architecture as illustrated in Fig. two. Get-go, the reduced secretion of hydrochloric acid hinders the reduction of ferric iron into the absorbable ferrous form( Reference Ishida, Faintuch and Paula 42 , Reference Behrns, Smith and Sarr 43 ). Secondly, the bypass of the duodenum and proximal part of the jejunum later on RYGB reduces the intestinal absorption area for iron, which is mainly absorbed in the duodenum. Thirdly, the villi of the gastrointestinal tract are affected and potentially further contribute to the reduction of the intestinal absorption surface area for iron after surgery. Spak et al. and Casselbrant et al. found a decrease in villi height in the Roux limb after RYGB, while no studies have investigated potential changes in villi pinnacle afterward SG( Reference Spak, Björklund and Helander 44 , Reference Casselbrant, Elias and Fändriks 45 ). Taken together, bariatric surgery impedes the power to absorb iron from both dietary sources and nutritional supplementation. To the all-time of our cognition, five studies investigated the impact of bariatric surgery on fe absorption by comparing pre- and postoperative data( Reference Gesquiere, Lannoo and Augustijns 21 , Reference Ruz, Carrasco and Rojas 28 , Reference Ruz, Carrasco and Rojas 46 – Reference Rosa, De Oliveira-Penaforte and De Arruda Leme 48 ). Ruz et al. investigated the absorption of dietary iron later on RYGB (n 36). Iron absorption tests were performed before and at 6, 12 and xviii months after RYGB using a standard nutrition containing 3 mg labelled iron. At each follow-upwards, atomic number 26 absorption was significantly decreased to approximately 30 % of the preoperative baseline value( Reference Ruz, Carrasco and Rojas 28 ). To distinguish between haem- and non-haem iron, iron absorption tests were performed earlier and 12 months after RYGB (n 20) and SG (n 20) using a standard diet containing labelled ferric chloride and labelled haem iron. Fe assimilation from both haem and non-haem iron decreased significantly after RYGB and SG, only the magnitude of reduced absorption for haem atomic number 26 was greater compared with not-haem iron (haem assimilation: 23·nine (sem 22·two–25·viii)% 5. 6·two (sem 5·3–vii·1)%; non-haem absorption: 11·ane (sem 9·8–12·v)% v. iv·vii (sem 3·i–5·5)%)( Reference Ruz, Carrasco and Rojas 46 ).
In add-on to the assimilation of dietary iron, the alterations in the gastrointestinal anatomical compages potentially interfere with the dissolution and assimilation of iron supplements. In 1999, Rhode et al. investigated the absorption of 50 mg ferrous gluconate 3·ii years after RYGB (northward 55). Subsequently surgery, 65 % of the included patients appeared to have normal iron absorption, defined as more than than 100 % modify in serum fe concentration over iii h after administration. In the patients with normal assimilation, a college incidence of anaemia and lower levels of ferritin concentration were observed( Reference Rhode, Shustik and Christou 47 ). Additionally, two studies investigated the response to iron sulphate. Rosa et al. performed iron tolerance tests with fifteen mg elemental iron originating from ferrous sulphate before and at 3 months later on RYGB (n ix). Despite a delayed response in the first hour, no pregnant differences were observed in iron response afterward surgery, although six of the ix patients demonstrated a mean decrease of l % in area under the curve( Reference Rosa, De Oliveira-Penaforte and De Arruda Leme 48 ). Nonetheless, Gesquiere et al. performed fe challenges with 100 mg ferrous sulphate in iron-deficient patients subsequently RYGB (due north 23). I patient had sufficient absorption, divers as an increment in serum iron concentration larger than 80 µg/dl( Reference Gesquiere, Lannoo and Augustijns 21 ). Based on these iii studies, information technology is impossible to compare the level of iron assimilation due to differences in study design, type of iron, dosage and formulation of the supplement. Iron assimilation studies assessing the erythrocyte incorporation using stable iron isotopes would provide more than convincing data on the effectiveness of iron supplementation subsequently bariatric surgery( Reference Wienk, Marx and Beynen 49 ).
Iron condition after bariatric surgery
In light of the risk to develop atomic number 26 deficiency, unlike studies take examined the preoperative and postoperative nutritional status of iron after RYGB and SG. Postoperatively, the prevalence of fe deficiency varies between 18·0 and 53·3 % during a follow-up of maximal 11·six years afterward RYGB, while the prevalence of anaemia ranges betwixt 6·0 and 63·vi %( Reference Gesquiere, Foulon and Augustijns 30 , Reference Aron-Wisnewsky, Verger and Bounaix 31 , Reference Salgado, Modotti and Nonino 50 – Reference Von Drygalski, Andris and Nuttleman 68 ). To elucidate the contribution of iron deficiency to the development of anaemia, two studies evaluated the prevalence of iron deficiency anaemia during a follow-up of maximal 10 years after RYGB. Within these studies, the prevalence of iron deficiency anaemia ranged between half dozen·6 and 22·7 % later RYGB( Reference Obinwanne, Fredrickson and Mathiason 56 , Reference Rojas, Carrasco and Codoceo 67 ). In comparison, the prevalence of atomic number 26 deficiency varies between one and 54·ane % during a follow-upward of maximal 5 years after SG. Additionally, the prevalence of anaemia ranges between 3·six and 52·7 % after SG( Reference Gjessing, Nielsen and Mellgren 69 – Reference Aarts, Janssen and Berends 79 ). According to a prospective cohort study of Hakeam et al., iron deficiency anaemia occurred in 1·half-dozen % of the patients ane year subsequently SG( Reference Hakeam, O'Regan and Salem 71 ). Remarkably, the prevalence of iron deficiency, anaemia and fe deficiency anaemia varies widely both after RYGB and SG. Inconsistency inside the definition of deficiencies and differences in bariatric procedure, follow-upward, dietary guidance and nutritional supplementation analyze the extent of variation.
Diagnosis of atomic number 26 deficiency, anaemia and iron deficiency after bariatric surgery
I of the major challenges to diagnose patients every bit iron scarce concerns the definition of iron deficiency. The proportion of patients affected by fe deficiency depends on the proposed iron status markers and their reference ranges. Malone et al. investigated the proportion of patients affected by fe deficiency subsequently RYGB using three different definitions (north 125). First, iron deficiency was defined every bit serum ferritin <15 ng/ml (male) or <12 ng/ml (female) or as transferrin saturation (TSAT) <20 % (male person) or <16 % (female). Secondly, iron deficiency was based on a combination of serum fe <40 µg/dl and serum ferritin <35 ng/ml. Thirdly, fe deficiency was based on serum ferritin <twenty ng/ml. Based on the offset definition, 28·3 % of the ferritin values and 47·8 % of the TSAT values fulfilled the criteria for iron deficiency. Based on the combination of serum atomic number 26 and ferritin, 57·five % of the patients were suffering from iron deficiency, while 43·4 % of the patients were suffering from iron deficiency, based on the 3rd definition( Reference Malone, Alger-Mayer and Lindstrom 80 ). These information strengthen the clinical significance of combining different iron status markers to appraise the prevalence of iron deficiency.
In Table three, an overview of the iron condition markers and cut-off values used in the afore-mentioned studies is given for iron deficiency, anaemia and iron deficiency anaemia( Reference Gesquiere, Foulon and Augustijns 30 , Reference Aron-Wisnewsky, Verger and Bounaix 31 , Reference Salgado, Modotti and Nonino 50 – Reference Aarts, Janssen and Berends 79 ). Low levels of serum iron concentration are frequently used to diagnose iron deficiency later on surgery( Reference Skroubis, Kouri and Mead 61 , Reference Hakeam, O'Regan and Salem 71 , Reference Zarshenas, Nacher and Loi 72 , Reference Ben-Porat, Elazary and Goldenshluger 76 , Reference Damms-Machado, Friedrich and Kramer 77 , Reference Aarts, Janssen and Berends 79 ). However, serum iron concentration is not an absolute diagnostic marker for fe deficiency due to its diurnal variation and external influences( Reference Auerbach and Adamson 81 ). Additionally, diagnosis of iron deficiency is sometimes only based on serum ferritin concentration( Reference Aron-Wisnewsky, Verger and Bounaix 31 , Reference Kotkiewicz, Donaldson and Dye 51 , Reference Kim, Kim and Kwon 54 , Reference Obinwanne, Fredrickson and Mathiason 56 , Reference Dogan, Homan and Aarts 60 ). Low levels of serum ferritin imply the presence of depleted iron stores. Yet, concentration of ferritin might be increased as inflammation increases the product of this acute phase poly peptide. As a result, measuring inflammatory markers (east.g. C-reactive protein or α1-acid glycoprotein) could assistance to translate ferritin measurements( 82 , Reference Zimmermann 83 ). Another marker regularly used as a standalone determinant of iron deficiency is TSAT, which is calculated by dividing serum iron concentration with serum transferrin concentration( Reference Ledoux, Calabrese and Bogard 58 , Reference Coupaye, Puchaux and Bogard 62 , Reference Karefylakis, Näslund and Edholm 65 , Reference Vargas-Ruiz, Hernández-Rivera and Herrera 66 , Reference Al-Sabah, Al-Mutawa and Anderson seventy ). Again, low TSAT is not an absolute marker, simply is characteristic for atomic number 26 deficiency( Reference Auerbach and Adamson 81 ). Which iron status markers should and then be used to diagnose iron deficiency later bariatric surgery? Equally no single fe status mark is an absolute determinant of iron deficiency, the preferred screening approach is a combination of markers. These markers should include at least ferritin concentration, which is relevant in the absence of underlying inflammation, and TSAT, which provides more reliable information in the presence of underlying information. Furthermore, assessing hepcidin and/or the soluble transferrin receptor concentration would provide boosted important data regarding fe homeostasis. Nonetheless, the utility of these markers may somehow exist limited in clinical exercise due to associated costs and availability issues( Reference Ferguson, Skikne and Simpson 84 – Reference Macdougall, Malyszko and Hider 86 ).
Table 3. Iron condition markers and cut-off values used to diagnose fe deficiency, anaemia or fe deficiency anaemia
In contrast to diagnosing iron deficiency, one marking is sufficient to observe the presence of anaemia. According to the WHO, Hb concentration below 130 yard/l for men aged 15 years or above and a concentration below 120 grand/l for non-pregnant females aged 15 years or above is representative for anaemia( 87 ). Although the credibility of these cut-off values has been discussed in literature in light of differences in ethnicity. Therefore, new age, sexual activity and ethnic-specific cut-off values take been proposed( Reference Beutler and Waalen 88 , Reference Johnson-Spear and Yip 89 ). The disparity in cutting-off values for diagnosing anaemia could explain the diversity in reference ranges used within the afore-mentioned studies as illustrated in Table 3( Reference Gesquiere, Foulon and Augustijns 30 , Reference Aron-Wisnewsky, Verger and Bounaix 31 , Reference Salgado, Modotti and Nonino 50 – Reference Aarts, Janssen and Berends 79 ). As stated earlier, the prevalence of anaemia reaches an upper limit of approximately 50 % after SG and 65 % after RYGB. These high rates of anaemia may reflect a variety of vitamin or mineral deficiencies, but are predominantly the upshot of iron deficiency. To distinguish betwixt the different causes, the mean corpuscular book of erythrocytes can be measured. Microcytic and hypochromic erythrocytes are considered the authentication finding of iron deficiency anaemia( Reference Zimmermann 83 , Reference Melt and Finch 90 ). Clearly, there is a demand to standardise the definition of iron deficiency, anaemia and iron deficiency anaemia based on the nearly relevant iron condition markers and their reference range.
Nutritional recommendations after bariatric surgery
Throughout the years, different organisations have published guidelines on clinical and nutritional guidance of patients earlier and subsequently bariatric surgery. Table 4 summarises the bachelor guidelines and updates proposed by the ASMBS and the IFSO apropos nutritional screening for deficiencies, preventive postoperative vitamin and mineral supplementation and postoperative supplementation for the treatment of fe deficiency. To prevent atomic number 26 deficiency, pre- and postoperative nutritional screening in combination with multivitamin and mineral supplementation is recommended. In case of iron deficiency, oral or parenteral iron administration is required. To charge per unit the quality of their recommendations, both organisations adopted grading systems (IFSO: Oxford centre for evidence-based medicine classification organization; ASMBS: the protocol for standardised production of clinical do guidelines provided by the American Association of Clinical Endocrinologists). Still, these grading systems illustrate the lack of strong evidence supporting the preventive postoperative vitamin and mineral supplementation guidelines. In Tabular array 4, the quality of bear witness supporting the current recommendations for nutritional screening for deficiencies, preventive postoperative vitamin and mineral supplementation and postoperative supplementation for the handling of iron deficiency is provided( Reference Fried, Yumuk and Oppert 5 , Reference Mechanick, Youdim and Jones 6 , Reference Fried, Hainer and Basdevant 91 , Reference Mechanick, Kushner and Sugerman 92 ). The absence of strong evidence might also explicate the difficulty of patients to adhere to the proposed guidelines as patients feel clinical burden despite preventive strategies. According to a recent written report in 16 620 French post-bariatric patients, the number of patients that received reimbursement for a nutritional iron supplement decreased significantly in the first 5 years after surgery( Reference Thereaux, Lesuffleur and Paita 93 ). These data confirm the poor adherence to the international guidelines and abet for more nutritional enquiry in order to provide strong evidence-based guidelines after bariatric surgery.
Table 4. Nutritional guidelines afterward bariatric surgery
Autonomously from the guidelines of international organisations, some researchers accept provided updates or even proposed new guidelines. For instance, Parrott et al. updated the recommendations of the ASMBS past providing additional guidelines to prevent iron deficiency for patients at low take chances, menstruating females and patients afterwards RYGB, SG or biliopancreatic diversion with duodenal switch and by providing treatment guidelines for patients suffering from iron deficiency later bariatric surgery. Furthermore, the authors made recommendations for the dosing of supplements and recommendation on how to avoid potential interactions with other nutrients or medication( Reference Parrott, Frank and Rabena 94 ). Additionally, Dagan et al. proposed nutritional guidelines for vegetarian and vegan patients undergoing bariatric surgery based on their clinical experience and the current knowledge in the field of nutrition in bariatric, vegetarian and vegan patients( Reference Sherf-Dagan, Hod and Buch 95 ). All these different guidelines highlight the heterogeneity in the reporting of bariatric research. Therefore, the ASMBS published outcome reporting standards in 2015. In addition to improving the quality of reporting, these standards are proposed to lower the heterogeneity in upshot reporting within the field of metabolic and bariatric surgery literature. These reporting standards provide consistency and uniformity for authors on how to report the following outcomes: follow-upwardly, diabetes, hypertension, dyslipidaemia, obstructive slumber apnoea, gastroesophageal reflux disease, complications, weight loss and quality of life( Reference Brethauer, Kim and Chaar 96 ). Still, reporting standards are missing for the diagnosis and treatment of nutritional deficiencies after bariatric surgery.
Future perspectives
To improve futurity testify, a standardised reporting methodology should be included for various important aspects of bariatric research. For instance, clinical outcomes of patients regarding nutritional deficiencies have been compared in review papers and meta-analyses without accounting for differences in screening and treatment approaches. This matter leads to heterogeneity in the interpretation of similar studies. Therefore, a standardised reporting methodology for nutritional deficiencies would allow a more meaningful comparing among previously published and futurity studies, but will definitely provide leverage for the overall field of bariatric surgery research. In the context of the present paper, we propose to standardise the definition of iron deficiency based on a combination of iron status markers. These markers should include at least ferritin concentration, which is relevant in the absence of underlying inflammation, and TSAT, which provides more than reliable data in the presence of underlying data. Notwithstanding, future studies in bariatric patients are needed to assess the most optimal cut-off of values for ferritin concentration and TSAT to assess the prevalence of iron deficiency and to assess how to prevent and treat iron deficiency after bariatric surgery. Therefore, we advocate for more nutritional research in order to provide strong prove-based guidelines after bariatric surgery.
Source: https://www.cambridge.org/core/journals/proceedings-of-the-nutrition-society/article/iron-deficiency-after-bariatric-surgery-what-is-the-real-problem/112DBE4620D6AA6A485FEDDA1C174818
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