The world is facing a global pandemic of overweight and obesity. The percentage of overweight and obese individuals has increased from 23% to 36% worldwide from 1980 to 2013. The percentage of adults with a body mass index (BMI) above 25 kg/m2 increased from 28.8 to 36.9 % for men and from 29.8 to 38 % for women between 1980 and 2013. Obesity increases your chances of developing conditions like type 2 diabetes, high blood pressure, and dyslipidemia, which are all risk factors for heart disease and stroke. It has also been linked to certain types of cancer and overall death rates. Having excess weight is thought to have caused 3 to 4 million deaths globally in 2010. It is the 6th most common cause of health problems worldwide.

There are various non-surgical treatments and bariatric surgery available to treat obesity. Bariatric surgery leads to more weight loss and an increase in the remission rate of type 2 diabetes and metabolic syndrome than non-surgical treatment. Even though patients undergoing bariatric surgery are successful in losing weight, 96% of them end up with a number of deformities caused by excess skin and residual fat deposits.

Skin deformities can have a negative impact on a person’s body image, self-esteem, and quality of life. In addition to causing intertrigo and difficulties with hygiene and mobility, skin deformities can make a person feel self-conscious and unhappy. While there are many different areas of the body that can develop deformities, patients often complain the most about deformities in the abdomen. A majority of female patients who have lost a significant amount of weight wish to have body-contouring surgery.

However, bariatric patients are 60-87% more likely to experience complications from body-contouring surgery as opposed to non-bariatric patients. Dietary deficiencies are common, with 51.3 % of patients developing iron deficiency and a 36 % prevalence of anemia. The main reasons for these conditions are lack of iron in the diet, low stomach acid, and stomach surgery preventing food from reaching the part of the intestines where iron is absorbed.

This type of surgery, which contours the body, such as post-bariatric abdominoplasty, typically involves removing large areas of subcutaneous tissue and highly vascularised skin, which can result in significant blood loss. It typically takes two months for patients to see an increase in their hemoglobin levels post-surgery, and 45% of patients develop severe iron deficiency.

Patients who have undergone bariatric surgery are at risk for developing anemia, which can lead to the need for a blood transfusion. Although blood transfusions are often necessary, they have been associated with increased comorbidity and mortality rates in observational studies. In addition, transfusions are associated with a two-fold higher complication rate, and longer hospital stays in patients undergoing post-bariatric abdominoplasty.

Even a small amount of anemia can cause problems for people who are having surgery. Hb levels are an important part of postoperative recovery for patients, especially post-bariatric patients who may have additional procedures to correct deformities in a short period of time. There have been several studies that have found iron deficiency can cause fatigue, even in patients who are not anemic. Correcting this deficiency helps improve the symptom.

Although iron can be given either orally or through a vein, giving it through a vein is five times more effective at increasing the level of red blood cells after someone has lost a lot of blood. Oral iron can cause side effects such as gastrointestinal symptoms, making it hard to stick to the treatment. The use of intravenously administered iron rarely has adverse effects, with the exception of high-molecular-weight iron dextran. In several observational studies, it has been shown that intravenously administered iron can be effective in optimizing the recovery of hemoglobin levels in patients who have undergone orthopedic surgery, surgery of the digestive tract, postpartum hemorrhage, or anyone who has received a renal transplant.

However, a different type of review that analyzed the results of four randomized controlled trials found that there were no benefits to using intravenously administered iron in the recovery of Hb levels or reductions in the number of blood transfusions for cardiac and orthopedic surgical patients. A systematic review looked at the effects of iron in people who are anemic but don’t have chronic kidney disease. They found that giving iron intravenously (into a vein) raised the level of hemoglobin (Hb) more than giving it orally (by mouth), but there was no clinical benefit in terms of reducing the need for blood transfusions or improving quality of life. None of these reviews included patients undergoing post-bariatric surgery. Intravenous iron supplementation may improve hemoglobin levels, reduce iron deficiency, and improve quality of life.

IRON’S ROLE

Iron is very important for the metabolism of all living organisms and is a big part of many proteins and enzymes. Some of the key functions of iron are as follows: -It is a vital component of hemoglobin, which carries oxygen in the blood. – It is also essential for the metabolism of energy. – It helps to maintain a healthy immune system.

• Heme is the iron-containing compound found in molecules.
• Hemoglobin and myoglobin are heme-containing proteins that help to transport and store oxygen.
• Hemoglobin is the primary protein in red blood cells and makes up two-thirds of the body’s iron. It helps to transport oxygen from the lungs to the rest of the body.
• Myoglobin transports and stores oxygen (short-term) for muscle cells. This is extremely important when the muscles are working (such as in a physical activity session).
• Iron is involved in electron transport (synthesizes a compound called ATP, which is the primary energy storage compound in cells) and energy metabolism.
• Iron acts as an antioxidant.
• Iron assists with DNA synthesis.

SYMPTOMS OF IRON DEFICIENCY.

There are many symptoms of iron deficiency, including fatigue, increased heart rate during physical activity, heart palpitations during physical activity, rapid breathing on exertion, decreased athletic and physical work capacity, inability to maintain a normal body temperature, brittle and spoon-shaped nails, sores at the corners of the mouth, taste buds diminish, sore tongue, some form of hair loss, pica, and lower immune status. Other symptoms of iron deficiency anemia include skin that is dry, scaly, and cracked; itchy skin; confusion; headaches; decreased mental capacity; amnesia; irritability; restless leg syndrome; dizziness; and depression. If iron deficiency is not treated, it can cause difficulty swallowing, because webs of tissue form in the throat and esophagus.

HOW MUCH IRON?

The RDA is not always applicable to bariatric surgery patients. Men and women who have gone through menopause need 8 milligrams of iron each day. Menstruating females require 18 mg of iron per day. However, bariatric surgery patients have varied needs. The amount of medication required varies from person to person, with some people only needing 18 mg per day while others may require up to 100 mg or more. It is very important to get your iron levels checked via blood work so your bariatric surgeon or primary care physician can determine your individual iron requirements.

WHY DO BARIATRIC PATIENTS REQUIRE MORE IRON?

The main reason is that following bariatric surgery; the body doesn’t absorb nutrients as well as it did before. Another reason is that bariatric surgery can cause bleeding in the gastrointestinal tract, which can lead to iron deficiency.

• As many as 35-44% of pre-op bariatric patients have low iron levels prior to their bariatric surgery.
• There is less stomach acid following bariatric surgery, and iron needs acid to aid in its absorption.
• Post-operatively, about 20-50% of patients experience an iron deficiency, and the risk increases over time. One study reported half of the patients were getting the recommended amount of iron and were still deficient, which further explains the need for individualized recommendations and continued blood work.
• A daily multivitamin may not prevent an iron deficiency since so many patients require above and beyond what is included in their daily multivitamin.
• Keep in mind the risk of iron deficiency increases over time as the body eventually runs out of iron stores.
• If you chose gastric bypass, then the primary area of absorption for iron was bypassed, and this further increases your need for iron supplementation. This same area is also bypassed in the duodenal switch.
• Post-operatively, there may be incomplete digestion of protein, and many patients have an aversion to iron-rich foods, such as red meat. Red meat tends to be one of the top five foods that bariatric patients do not tolerate very well (although every patient is different in what they do and do not tolerate following their bariatric surgery).
• There is decreased absorption of iron in gastric bypass and biliopancreatic diversion with or without duodenal switch.

Around half of the bariatric surgery patients can expect to develop an iron deficiency within a few years of having the surgery. The risk is highest in the first 6-9 months after the operation, but it can take up to four years for the deficiency to occur.

HOW TO INCREASE THE ABSORPTION OF IRON.

When taking iron supplements, there are ways to make sure you are getting the most benefit for your money. It is recommended that you take an iron supplement that also contains vitamin C to improve absorption or that you add vitamin C to the iron supplement you are already taking. Before making any changes to your supplement regimen, talk to your bariatric surgeon and/or dietitian.

• Do not take calcium at the same time as your iron or a multivitamin containing iron. Separate calcium and iron for at least two hours.
• Do not take your iron product with calcium-rich foods, such as with a glass of milk.
• Do not consume a high amount of tannin-rich products (tea, wine, chocolate, coffee) throughout the day. This is especially important for those trying to increase their iron levels.
• Avoid black tea or black coffee 1 hour before and 1 hour after taking your iron (this is especially important for those trying to increase their iron levels).
• Consider checking your vitamin A status if you are having trouble correcting your iron levels. Sometimes once you get your vitamin A levels within normal limits, iron is better absorbed.
• Adequate copper status is also important for normal iron metabolism.

There are also a few interactions between drugs and nutrients when it comes to iron. Although you may not be able to prevent these side effects if you are taking these medications, it is important to keep in mind that this increases the need to get your iron levels checked as recommended by your bariatric surgeon. If you take proton pump inhibitors or H2 receptor antagonists, it will decrease your absorption of iron. PPIs and H2 receptor antagonists are both types of medications that are commonly used to treat heartburn or esophageal reflux (GERD). If you take thyroid medication, it is important to speak to your bariatric surgeon and/or pharmacist about the timing of your bariatric vitamins, as you may need to adjust the dosing schedule.

If your recommended iron dose is high, talk to your bariatric program about starting with a lower dose and slowly increasing it to the recommended level to reduce the risk of side effects. You may be able to reduce stomach upset from taking your recommended iron by talking to your surgeon and/or dietitian about taking your iron with food. Ensure you do not take it with calcium-rich foods.

Conclusion

Anemia is a common complication following post-bariatric surgery, where the stomach is reduced in size. Two months after surgery, these patients have still not recovered their preoperative Hb levels. 45% of them develop severe iron deficiency. Hemoglobin levels are thought to be an important part of postoperative patient recovery. This becomes more relevant for post-bariatric patients as they often have to have more surgery to treat deformities in different parts of their bodies. This leaves them with little time to recover their hematological parameters.

A review of existing studies concluded that iron supplementation can effectively increase hemoglobin levels. It has been suggested that intravenous administration of iron supplements may be more effective than oral administration for post-bariatric surgery patients. This is because patients may have difficulty absorbing iron orally. This clinical trial protocol was designed to test the hypothesis that iron supplementation can help patients who have undergone bariatric surgery. This is because there are no studies in the literature that evaluate the effect of iron supplementation in this population.