Running head: AN INTEGRATIVE REVIEW: BARIATRIC SURGICAL PATIENTS 1

An Integrative Review: Bariatric Surgical Patients and Iron Deficiency

Angela Wetli

Bon Secours Memorial College of Nursing

4222

Spann

April 24, 2016

I pledge

Abstract

The goal of the integrative review is to evaluate the literature

regarding iron deficiency in patients that have undergone weight-loss

surgery over a one-year period postoperatively. Weight loss surgery is

becoming more popular for patients that exceed a body mass index of 36.

The surgery is an effective weight loss tool, along with diet and exercise, to

help obese patients lose the excess weight. However, after the surgery, the
AN INTEGRATIVE REVIEW: BARIATRIC SURGICAL PATIENTS 2

patient is at an increased risk for nutrient deficiencies due to the lowered

absorption of nutrients and the decreased amount of food intake. The

research design is an integrative review. The search for literature was

conducted using Google Scholar and the Pubmed database. There were

studies regarding laparoscopic sleeve gastrectomy surgery and iron

deficiencies as a result of the decreased absorption of nutrients following

surgery. There were more studies available regarding the Roux-en-Y gastric

bypass surgery and the resulting decreased iron levels.

An Integrative Review: Bariatric Surgical Patients and Iron Deficiency

Introduction

Obesity has become an epidemic in America. These patients can

develop comorbidities, or other health problems, that affect their overall

health and quality of life. An option for these patients is to undergo bariatric

surgery. There are two common types of surgery done in order to facilitate

weight loss. One being the laparoscopic gastric sleeve, and the other being

the Roux-en-y gastric bypass surgery. Over the last few decades, bariatric

surgery has been demonstrated to be an effective treatment for obesity

(Love & Billett, 2007, p. 403). The purpose of this integrative review is to

examine multiple studies and review the results regarding the patients iron

levels for at least one year following surgery. The bariatric surgeries are

found to be very effective for weight loss, however, bypass surgery itself

may be associated with both short-term and long-term adverse events

(Love & Billett, 2007, p. 403). The PICOT question used for the basis of the
AN INTEGRATIVE REVIEW: BARIATRIC SURGICAL PATIENTS 3

research for this integrative review was, are bariatric patients undergoing

bariatric surgery likely develop iron deficiency in the first year following

surgery?

Design and search methods

The research design is an integrative review done in order to research

the prevalence of iron deficiencies following bariatric surgery. The search was

done using both Google Scholar and Pubmed database internet search

databases. The search was conducted using the terms bariatric surgery and

iron deficiencies, qualitative research, and qualitative studies of bariatric

surgery and nutrient deficiencies. Multiple research articles were available.

Many were not available without payment, so these were discarded. The

articles were then narrowed down to within the last ten years in order to use

the most recent research. There were no quantitative studies available. The

5 studies that were chosen were qualitative research studies containing

patients who have undergone bariatric surgery and the follow-up regarding

their iron levels postoperatively.

Findings/ Results

The results are shown in Table 1. As shown in Table 1, there are 5

articles that were found to be the most useful during the search. All 5 articles

are qualitative research design studies.

The study done by Ruz, Carrasco, Rojas et al. was done to study the

effects of the Roux-en-Y on the subjects iron levels following surgery. It was
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hypothesized that iron absorption would be markedly impaired immediately

after surgery and would not improve after such a procedure (Ruz et al.,

2009, p. 527). The iron levels were tested up to 18 months following the

surgery. The percentage of anemic subjects changed from 1.5% at the

beginning of the surgery to 38.8% at 18 months (Ruz et al., 2009, p. 527).

The study done by Dalcanale, Olivera et al. was looking at the long-

term nutritional outcome after a gastric bypass surgery. There 75 patients

that were monitored after their surgery for weight loss and any nutritional

abnormalities. The conclusion of this study was that the patients had good

initial weight loss with moderate late regain, anemia, and multiple nutrient

deficits was the common pattern (Dalcanale et al., 2010, p. 181).

The objective of the present study was to assess the metabolic and

nutritional profile of grade III obese individuals for 12 months after Roux-en-Y

gastric bypass (RYGBP) (Bavaresco et al., 2010, p. 716). This study showed

that RYGBP surgery was effective for these patients weight loss and reduced

many of their comorbidities such as diabetes, heart disease, hyperlipidemia,

and even some types of cancers. Iron deficiencies were present in 14.6%

after 12 months postop.

Only one research article was found that studied the effects of the

Laparoscopic sleeve gastrectomy on patients iron levels following surgery.

This study was done from January 2005 to October 2008. 60 patients under

LSG. All patients were instructed to take daily vitamin supplements. Patients

were tested for micronutrient deficiencies 6 and 12 months after surgery

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(Aarts, Janssen, & Berends, 2010, p. 207). The results of the study showed

that iron deficiency was found in 43% of the patients at the end of the 12

month period.

The last study that was used for this review was regarding Incidence,

treatment, and outcomes of iron deficiency after laparoscopic Roux-en-y

gastric bypass: a 10-year analysis. This study included 959 patients. 492 of

these patients were iron deficient, which is 51.3%. The conclusion of this

study stated that given the incidence of iron deficiency after LRYGB

observed in our series, patients should have iron status monitored carefully

by all providers and appropriately referred (Obinwanne et al., 2014, p. 246).

Female patients are especially prone to iron deficiency due to menses.

Discussion and Implications

Throughout all 5 of the studies, a significant percentage of patients

developed anemia following their bariatric surgery. A nutritional supplement

and postoperative diet was recommended for all of the patients, but

compliance was an issue following the surgery. Future research could include

compliance regarding supplementation and which supplements were

effective. Iron supplementation should be in the range of 40-65mg per day,

especially for women of reproductive age, substantially more than most

commercial multivitamins (Dalcanale et al., 2010, p. 186). A portion of the

patients required IV iron infusions in order to increase their iron levels.

Limitations
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There are limited studies regarding the laparoscopic gastric sleeve

surgery and the postoperative nutrient deficiencies. Deficiencies in

micronutrients after bariatric procedures are a known threat if not corrected

appropriately. Surprisingly, reports on anemia and micronutrient deficiencies

specifically in patients who underwent LSG are scarce (Aarts et al., 2010, p.

207). There are more studies regarding the gastric bypass surgery and iron

deficiencies. The limitations are also due to patient compliance with follow-

up appointments and lab work. Some of the patients also do not continue to

adhere to the diet and exercise recommendations given to them. Also, it was

shown that patients did not adequately follow the multivitamin prescription

despite careful instructions. The problem was more serious in males

(Dalcanale et al., 2010, p. 185).

Conclusion

The population of obese patients in America is on the rise. One option

that these patients have is bariatric surgery. However, both laparoscopic

Roux-en-Y, and gastric sleeve surgery is not without long term risk. The

research done in this integrative review is valuable because it shows the

patients that have undergone these surgeries and the lab work

postoperatively. There is a significant risk of developing micronutrient

deficiencies. The largest percentage of patients develop iron deficiencies.

Supplementing patients is a very important part of patient care after every

bariatric procedure. Balancing between low and high levels of micronutrients

is a challenging part of postoperative care (Aarts et al., 2010, p. 211). Each

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of the studies in this review have shown the percentages of patients that

developed iron deficiencies, which are significant, within at least one year

following surgery.
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References

Aarts, E., Janssen, I., & Berends, F. (2010). The gastric sleeve: Losing weight

as fast as micronutrients. Obesity Surgery, 21, 207-211.

http://dx.doi.org/10.1007/s11695-010-0316-7

Bavaresco, M., Paganini, S., Lima, T. P., Salgado , Jr., W., Ceneviva, R., Dos

Santos, J. E., & Nonino-Borges, C. B. (2010). Nutritional course of

patients submitted to bariatric surgery. Obesity Surgery, 20, 716-721.

http://dx.doi.org/10.1007/s11695-008-9721-6

Dalcanale, L., Oliveria, C., Faintuch, J., Nogueira, M., Rondo, P., Lima, V., ...

Carrilho, F. (2010, February). Long-term nutritional outcome after

gastric bypass. Obesity Surgery, 20, 181-187.

http://dx.doi.org/10.1007/s11695-009-9916-5

Love, A., & Billett, H. (2007, September 27). Obesity, bariatric surgery, and

iron deficiency: True, true, true and related. American Journal of

Hematology, 403-409. http://dx.doi.org/10.1002/ajh.21106

Obinwanne, K. M., Fredrickson, K. A., Mathiason, M. A., Kallies, K. J., Farnen, J.

P., & Kothari, S. N. (2014, February). Incidence, treatment, and

outcomes of iron deficiency after laparoscopic Roux-en-Y gastric

bypass: a 10 year analysis. Journal of the American College of

Surgeons, 218, 246-252.

http://dx.doi.org/10.1016/j.jamcollsurg.2013.10.023

Ruz, M., Currasco, F., Rojas, P., Codoceo, J., Inostroza, J., Rebolledo, A., ...

Krebs, N. (2009). Iron absorption and iron status reduced after Roux-en-
AN INTEGRATIVE REVIEW: BARIATRIC SURGICAL PATIENTS 9

Y gastric bypass. The American Journal of Clinical Nutrition, 90, 527-

532. http://dx.doi.org/10.3945/ajcn.2009.27699