Factors Associated with Dietary Intake and Changes in Nutritional Status Following Bariatric Surgery Among Saudi Adults

Abstract

Background:

This study aimed to assess the nutritional status of Saudi individuals postbariatric surgery and associated factors.

Methods:

A cross-sectional study included 146 Saudis, aged 20–50 years, who underwent laparoscopic sleeve gastrectomy. An online survey was distributed to collect demographic data and consent for participation. Weight history, anthropometrics, and dietary data were collected from each participant during a phone interview. Data regarding dietitian visit(s) and supplement use were also collected.

Results:

Participants who underwent the surgery >5 years ago had the most weight loss, whereas weight of the participants started to stabilize at 2-years postprocedure. Only 22% of study participants reached a body mass index of <25 kg/m² after the surgery. Energy-adjusted intakes of vitamin B₁₂ and vitamin D were significantly higher among supplement users. Dietitian visit was not associated with dietary intake or weight reduction. Energy-adjusted intake of vitamin B₁₂ was significantly associated with the time of procedure (p = 0.001).

Conclusions:

Our findings indicated poor dietary intake of some nutrients and weight stabilization in the long term following bariatric surgeries. Future research must be established to investigate the prevalence of malnutrition among individuals who underwent bariatric surgeries and to develop evidence-based interventions to improve patients' nutritional status.

Introduction

Obesity prevalence is increasing globally especially in high-income developing countries, including Saudi Arabia. According to data reported by the Saudi Health Interview Survey, the prevalence of obesity, assessed by body mass index (BMI) >30 kg/m², among adult females and males was estimated to be 34% and 24%, respectively.¹ Obesity is a significant health concern as it contributes to several diseases, such as type 2 diabetes mellitus and coronary heart disease.² In addition, obesity is an important cause of morbidity that may affect the quality of life.³

Bariatric surgery is an effective weight loss procedure that aims to reduce weight and improve overall health status. Bariatric surgery may reduce the risk of obesity-related diseases, such as hypertension, type 2 diabetes mellitus, sleep apnea, and lipid abnormalities.⁴ Due to the high prevalence of obesity reported in Saudi Arabia, a large number of bariatric surgical procedures are performed annually in the country (about 15,000 surgeries).⁵

Many studies were conducted to assess weight reduction and factors associated with bariatric surgeries. In 2016, an 18 months retrospective study compared the outcomes of the laparoscopic sleeve gastrectomy (LSG) with that of the laparoscopic Roux-en-Y gastric bypass (LRYGB) in Dammam, Saudi Arabia. This study reported a weight reduction of 10 and 6 BMI units for LRYGB and LSG, respectively, with no reported complications postprocedure.⁶

A more recent prospective study was conducted among 100 individuals who were recruited from two hospitals in Aseer region, Saudi Arabia. The study concluded that LSG was an effective approach to lose weight drastically (32% weight reduction), to normalize the inflammatory biomarkers in the blood and hepatic enzymes, and to reduce levels of fasting blood glucose, total cholesterol, triglyceride, and low-density lipoprotein.⁷ However, no data on the nutritional status of the participants following bariatric surgery were reported.

Micronutrient deficiency is a common complication of bariatric surgery, specifically iron, zinc, vitamin B₁₂, folic acid, calcium, and vitamin D. The severity of micronutrient deficiencies is linked to a number of factors, including preoperative nutritional status, degree of malabsorption associated with the procedure, dietary intake, and postoperative adherence to recommended supplementation.^8–10 In addition to micronutrient deficiency, weight regain after bariatric surgeries is a concern,^9,10 as it may lead to the re-emergence of obesity-related comorbidities and impaired quality of life.¹¹ Weight regain after bariatric surgeries may occur due to metabolic adaptation or it could be the result of increased food intake due to decreased levels of leptin that results from the decreased fat-free mass.^12,13

Given that studies assessing the nutritional status of individuals who underwent bariatric surgeries in Saudi Arabia are lacking, this study aimed to assess the nutritional status of Saudi individuals postbariatric surgery. In addition, associated factors, including dietitian visit(s) and supplement use, and nutrient intake postprocedure were investigated.

Materials and Methods

Sample

This cross-sectional study was conducted between January and April 2018. The study included 186 Saudi adults living in different regions within Saudi Arabia, aged between 20 and 50 years, who underwent one of the four common bariatric surgeries: LSG, LRYGB, laparoscopic adjustable gastric banding (LAGB), or biliopancreatic diversion. Individuals with any health issues or those on medications that may influence weight reduction, such as type 1 diabetes, hypertension, or thyroid diseases, were not included in this study. Individuals with missing data were also excluded; see Figure 1. The majority of individuals recruited for this study underwent an LSG (97%, n = 146), 2% of the participants (n = 3) underwent LRYGB, and 1.3% of the participants (n = 2) underwent LAGB. Therefore, only individuals who underwent LSG and completed 3 weeks at minimum postsurgery were eligible to be included in this study.

FIG. 1.

Flowchart of participant selection. BPD, biliopancreatic diversion; LAGB, laparoscopic adjustable gastric banding; LRYGB, laparoscopic Roux-en-Y gastric bypass.

Participants were recruited through social media, with the assistance of bariatric surgeons, as well as social media activists who underwent bariatric surgery. The number of participants included in the present study met the sample size requirement with a 95% confidence level; the standardized width of the confidence interval was 0.35.¹⁴ The Ethics Committee of the College of Applied Medical Sciences at Taibah University provided the ethical approval for this study (certificate number: CLN 201709). Consents were obtained from all participants using the online questionnaire.

Sociodemographic, dietitian visit, and supplement use

Initially, an online questionnaire was administered to describe the purpose of the study, the process of data collection, and to collect demographic data, including age, sex, monthly income in Saudi Riyals (SRs) (<6000 SRs, 6000–10,000 SRs, >10,000 SRs), education level (≥university degree, ≤high school/diploma), region (Central region, Western region, Other regions), contact information, and consent for participation. Individuals who matched the study criteria were contacted through phone or email (based on information provided in the online survey) to arrange for a 15-min phone interview. In addition, a text message reminder was sent to each participant 2 days before the interview. Data concerning frequency of dietitian visit(s) and supplement use were collected during phone interviews.

Dietary data

The dietary data were collected using a single 24-h dietary recall from 106 participants (70%), while three 24-h dietary recalls were collected from a subsample of 45 participants (30%) to determine the usual intake of the group and to adjust for within-person variation.

Portion sizes of food were determined based on commonly used measurements, including hand measurements (pictures of fist, palm, and fingers) and average size measurement tools (pictures of measuring cups and spoons). Pictures were sent to participants through text messages to determine the quantity of food consumed. Dietary data from the 24-h dietary recall were entered on the “Diet Organizer” software to prepare the dietary data for analysis. Supplement intake was not included in the dietary analysis as participants were unable to recognize types, brands, and/or doses of supplements used. Energy adjustment was done to all nutrients included in this study to calculate nutrient densities; data of macronutrients were expressed as proportions of energy, whereas data of micronutrients were expressed as intakes per units/1000 kcal.

Anthropometric measurements

The participants reported their height and weight during the phone interviews. The World Health Organization (WHO) criteria were used to define the weight status of each participant: underweight if BMI <18.5 kg/m²; normal weight if BMI 18.5–24.9 kg/m²; overweight if 25–29.9 kg/m²; obese I if BMI 30–34.9 kg/m²; obese II if BMI 35–39.9 kg/m²; and obese III if BMI ≥40 kg/m².¹⁵ Participants were requested to report their weight postprocedure and to provide weight loss/gain records through text messages if available. Amount of weight loss was calculated as presurgery weight minus the current weight, while the percentage of weight loss was calculated as weight divided by presurgery weight multiplied by 100.

Statistical analysis

Categorization of groups was adapted based on findings of previous studies.¹⁰ Descriptive data were presented as mean ± standard deviation and frequency (percentages). Descriptive data were analyzed using univariate analysis, correlation, and Fisher's exact test. Independent t-test and analysis of variance were used to compare means for the different groups (log or square root functions were taken to normalize distributions before tests were performed), whereas Kruskal–Wallis and Wilcoxon Rank sum tests were performed for vitamin D, as data were not normally distributed even after taking the log and square root functions. Fisher's exact test was used to analyze the data with two categorical variables.

Multiple regression analysis was performed to examine the association between weight reduction related to the time of the procedure, adjusted for age, gender, income, education, and energy intake. All tests were two-tailed with a significance level of p < 0.05. The Bonferroni method was used to correct for multiple comparisons (dietary intake of 12 nutrients by the time of procedure and supplement use: p < 0.004). The analysis of this study was performed using SAS^®, version 9.4 (2013; SAS Institute, Cary, NC).

Results

A total of 146 participants who underwent LSG with complete dietary data were included in this study. Thirty-six percent (n = 52) of the sample were females. The mean age of the sample was 32.3 ± 6.87 years. Thirty-two percent of the study sample underwent the surgery within the last 6 months, followed by 18.5% (6–11 months ago), 28% (1–2 years ago), 17% (3–5 years ago), and 4.1% underwent the surgery more than 5 years ago. The demographic characteristics of participants included in this study were similar across the different groups based on the time since the surgical procedure was performed (Table 1).

Table 1.

Demographic Characteristics of Saudi Adults Postbariatric Surgery Stratified by Time of Surgery (n = 146)

	<6 months (n = 47)	6–11 months (n = 27)	1–2 years (n = 41)	3–5 years (n = 25)	>5 years (n = 6)	Total (n = 146)	p^*
Age, years, mean ± SD	33.0 ± 7.12	30.1 ± 6.25	32.2 ± 7.14	33.6 ± 6.03	31.7 ± 8.89	32.3 ± 6.87	0.379
Sex, n (%)
Female	19 (40.4)	11 (40.7)	11 (26.8)	8 (32.0)	3 (50.0)	52 (35.6)	0.609
Male	28 (59.6)	16 (59.3)	30 (73.2)	17 (68.0)	3 (50.0)	94 (64.4)	0.609
Income, SR, n (%)
<6000	12 (25.5)	10 (37.0)	6 (14.6)	5 (20.0)	0 (0.00)	33 (22.6)	0.253
6000–10,000	15 (31.9)	6 (22.2)	20 (48.8)	12 (48.0)	2 (33.3)	55 (37.7)
>10,000	20 (42.6)	11 (40.7)	15 (36.6)	8 (32.0)	4 (66.7)	58 (39.7)
Region, n (%)
Central region	15 (31.9)	11 (40.7)	17 (41.5)	5 (20.0)	1 (16.7)	49 (33.6)	0.164
Western region	17 (36.2)	7 (25.9)	14 (34.1)	16 (64.0)	4 (66.7)	58 (39.7)
Other regions	15 (31.9)	9 (33.3)	10 (24.4)	4 (16.0)	1 (16.7)	39 (26.7)
Education, n (%)
≥University degree	34 (72.3)	20 (74.1)	28 (68.3)	19 (76.0)	6 (100)	107 (73.3)	0.725
≤High school/diploma	13 (27.7)	7 (25.9)	13 (31.7)	6 (24.0)	0 (0.00)	39 (26.7)	0.725

Alpha was set at 0.05 to denote significance.

SD, standard deviation; SR, Saudi Riyal.

Weight status of the participants and weight loss

Seventy-nine percent (n = 114) of the study sample were morbidly obese (Obesity III) before the surgery compared to 13.1% (n = 19) postsurgery. The mean BMI before the procedure was 46.1 ± 8.33 kg/m², while the mean BMI postprocedure was 30.4 ± 7.26 kg/m², with a mean weight loss of 45.3 ± 22.0 kg (34.8% weight loss of initial body weight). Description of weight status and weight loss stratified by time of procedure is shown in Table 2. Data of the present study indicated that participants who underwent bariatric surgery had the most weight loss >5 years postsurgery compared to participants in the other groups (p < 0.001). No significant weight reduction was reported after 2 years postprocedure (p = 0.167).

Table 2.

Anthropometrics, Dietitian Visit, and Supplement Use of Participants Postbariatric Surgery Stratified by Time of Surgery (n = 146)

	<6 months (n = 47)	6–11 months (n = 27)	1–2 years (n = 41)	3–5 years (n = 25)	>5 years (n = 6)	Total (n = 146)	P
Normal weight, n (%)	2 (4.26)	5 (18.5)	14 (34.1)	8 (32.0)	3 (50.0)	32 (21.9)	0.001^*
Overweight, n (%)	11 (23.4)	15 (55.6)	16 (39.0)	9 (36.0)	1 (16.7)	52 (35.6)
Obese I, n (%)	16 (34.1)	4 (14.8)	6 (14.6)	4 (16.0)	1 (16.7)	31 (21.2)
Obese II, n (%)	6 (12.8)	2 (7.41)	1 (2.44)	3 (12.0)	0 (0.00)	12 (8.22)
Obese III, n (%)	12 (25.5)	1 (3.70)	4 (9.76)	1 (4.00)	1 (16.7)	19 (13.1)
BMI, kg/m², mean ± SD	35.0 ± 8.06	28.4 ± 4.34	27.7 ± 5.76	28.4 ± 5.67	30.2 ± 10.5	30.4 ± 7.26	<0.001^*
Weight loss, kg, mean ± SD	27.2 ± 14.7	42.9 ± 13.8	58.4 ± 19.5	59.0 ± 21.9	54.3 ± 9.81	45.3 ± 22.0	<0.001^*
Weight loss %^a, mean ± SD	21.0 ± 8.85	35.1 ± 7.73	42.0 ± 7.67	42.2 ± 9.53	42.4 ± 8.02	34.0 ± 12.5	<0.001^*
Dietitian visit, yes, n (%)	24 (35.8)	19 (28.4)	17 (25.4)	4 (5.97)	3 (4.48)	68 (46.2)	0.002^*
Supplement use, yes, n (%)	37 (43.0)	17 (19.8)	18 (20.9)	12 (14.0)	2 (2.33)	86 (58.9)	0.006^*

Alpha was set at 0.05 to denote significance.

Weight loss was calculated as presurgery weight minus the current weight, while the percentage of weight loss was calculated as weight divided by presurgery weight multiplied by 100.

BMI, body mass index.

Multiple regression analysis was conducted to determine the association of the weight reduction with the time of the procedure. Age, gender, education level, income, and energy intake were adjusted for in the model. Weight reduction of 9.98 kg was positively associated with the time since the procedure was performed; the regression model explained 46% of the change in weight reduction (95% confidence interval 7.70–12.2; p < 0.001).

Dietitian visit and supplement use

Our findings indicated that about half of the sample (46.2%) had visited a dietitian after the surgery; of those, only 27.0% reported additional visits after the surgery. There was a negative association between the number of dietitian visits and the time of performing the surgical procedure (p = 0.017). Thirty-six percent of participants who had surgery within 6 months of the study have visited a dietitian, while only 4.48% of individuals who had surgery >5 years ago visited a dietitian (p = 0.002). Dietitian visit was not linked to weight loss or dietary intake.

Fifty-nine percent of the study sample reported supplement use following the bariatric procedure. There was no link between supplement use and weight reduction after adjusting for the time of the procedure. Fisher's exact test showed that supplement use was declining overtime following bariatric surgery. Forty-three percent of individuals who had the surgery within 6 months were taking supplements, while compliance decreased to 2.33% for individuals who were >5 years from surgery (p = 0.008).

Dietary intakes and the associations with supplement use and time of procedure

Macronutrient and energy-adjusted micronutrient intakes among the participants following bariatric surgery stratified by supplement use are illustrated in Table 3. The participants who were taking supplements had higher energy-adjusted intakes of vitamin B₁₂ and vitamin D from food compared with nonsupplement users. All study participants regardless of supplement compliance had high intake of total sugar (21% and 22% of total energy intake, respectively).

Table 3.

Energy-Adjusted Dietary Intake of Participants Following Bariatric Surgery, Stratified by Supplement Use (n = 146)

	Used supplements (n = 87)	Did not use supplements (n = 59)	Total (n = 146)	p
Energy, kcal	1191 ± 697	1143 ± 621	1172 ± 666	0.694
Carbohydrates, %	53.9 ± 37.6	61.4 ± 69.6	56.9 ± 52.8	0.241
Protein, %	22.2 ± 9.79	21.5 ± 17.6	21.9 ± 13.4	0.268
Fat, %	29.9 ± 13.3	34.8 ± 36.1	31.9 ± 25.1	0.685
Total sugar, g/1000 kcal	51.8 ± 30.0	70.5 ± 94.6	59.4 ± 64.8	0.287
Fiber, g/1000 kcal	11.2 ± 6.33	13.2 ± 10.6	12.0 ± 8.35	0.255
Calcium, mg/1000 kcal	499 ± 353	496 ± 651	498 ± 493	0.448
Vitamin D, ug/1000 kcal	81.9 ± 348	1.07 ± 1.55	49.2 ± 271	<0.001
Iron, mg/1000 kcal	8.46 ± 5.26	8.41 ± 9.71	8.44 ± 7.36	0.344
Folate, ug/1000 kcal	200 ± 138	588 ± 2469	357 ± 1577	0.498
Vitamin B₁₂, ug/1000 kcal	7.27 ± 29.4	1.57 ± 1.82	4.95 ± 22.8	<0.001^*
Zinc, mg/1000 kcal	6.05 ± 3.59	5.56 ± 6.23	5.85 ± 4.82	0.024

All numbers are presented as mean ± SD.

Densities of macronutrients were expressed as proportion of energy.

Densities of micronutrients were expressed as intake per units/1000 kcal.

Alpha was set at .004 to denote significance.

Energy intake was positively associated with the time of procedure (p < 0.001). Furthermore, mean intake of energy-adjusted vitamin B₁₂ significantly differed according to the postoperative period; higher intake of vitamin B₁₂ was observed among participants who underwent the bariatric surgery in <6 months compared with participants in the other groups (p = 0.001), whereas intakes of all other nutrients were not associated with the time of the procedure, see Table 4.

Table 4.

Energy-Adjusted Nutrient Intakes of Participants, Stratified by Postoperative Period Following Bariatric Surgery (n = 146)

	<6 months (n = 47)	6–11 months (n = 27)	1–2 years (n = 41)	3–5 years (n = 25)	>5 years (n = 6)	Total (n = 146)	p
Energy, kcal	730 ± 371	1059 ± 606	1413 ± 574	1592 ± 741	1740 ± 869	1172 ± 666	<0.001^*
Carbohydrates, %	54.4 ± 47.5	73.1 ± 103	52.9 ± 15.3	51.7 ± 15.7	52.3 ± 12.5	56.9 ± 52.8	0.652
Protein, %	25.5 ± 11.3	23.6 ± 24.6	18.7 ± 5.98	18.6 ± 6.21	22.8 ± 12.9	21.9 ± 13.4	0.050
Fat, %	28.5 ± 13.6	39.9 ± 51.7	31.1 ± 13.6	32.4 ± 12.0	25.3 ± 5.58	31.9 ± 25.1	0.447
Total sugar, g/1000 kcal	56.2 ± 37.1	73.0 ± 133	57.6 ± 34.3	55.7 ± 32.8	50.8 ± 26.1	59.4 ± 64.8	0.996
Fiber, g/1000 kcal	12.5 ± 8.75	12.9 ± 11.6	11.2 ± 7.61	11.6 ± 5.09	11.0 ± 4.77	12.0 ± 8.35	0.904
Calcium, mg/1000 kcal	627 ± 697	535 ± 522	380 ± 264	411 ± 234	488 ± 181	498 ± 493	0.194
Vitamin D, ug/1000 kcal	101 ± 447	32.9 ± 164	21.0 ± 90.2	27.6 ± 95.6	1.67 ± 1.97	49.2 ± 271	0.529
Iron, mg/1000 kcal	7.83 ± 5.13	11.1 ± 14.5	7.59 ± 3.67	8.32 ± 4.00	7.67 ± 2.66	8.44 ± 7.36	0.791
Folate, ug/1000 kcal	203 ± 152	490 ± 1466	594 ± 2731	146 ± 77.5	219 ± 76.3	357 ± 1577	0.393
Vitamin B₁₂, ug/1000 kcal	10.3 ± 39.4	2.44 ± 3.69	2.04 ± 2.24	2.96 ± 6.01	2.16 ± 2.13	4.95 ± 22.8	0.001^*
Zinc, mg/1000 kcal	6.82 ± 4.46	5.37 ± 3.27	5.44 ± 6.72	5.27 ± 3.16	5.75 ± 3.58	5.85 ± 4.82	0.059

All numbers are presented as mean ± SD.

Densities of macronutrients were expressed as proportion of energy.

Densities of micronutrients were expressed as intake per units/1000 kcal.

Alpha was set at 0.004 to denote significance.

Discussion

In the presented study, all participants lost weight despite the time since the procedure was performed; however, the mean BMI for all groups indicated that participants were either overweight or obese (BMI >30 kg/m²). Most weight loss occurred in the first 6 months following the bariatric surgery and then stabilized at 2 years.

Weight regain following bariatric surgery has been documented previously in several studies.^9,10 However, no weight regain was observed among the study sample, which could be due to the small number of participants included in the group who underwent the surgery >5 years ago (n = 6). In contrast, increased energy intake of ≈150 kcal/day (4500 kcal/month) was observed among the group who underwent the procedure >5 years ago compared to participants who underwent the procedure since 3–5 years ago. Macronutrient intake should be monitored closely especially when weight stabilizes, as excessive energy intake may result in weight regain or at least slow down the process of weight reduction.^16,17

In the present study, a positive association between energy intake and the postoperative time following the procedure was observed. Energy intake should be of a concern among individuals postprocedure, as the gradual increase in intakes of energy and macronutrients following the bariatric surgery may increase the risk of weight regain.^10,11

Despite the increased energy intake following the procedure, intake of vitamin B₁₂ was found to be significantly lower among the participants who underwent the bariatric surgery after 6 months compared with participants who underwent the procedure <6 months age, whereas the intake of the other micronutrients did not significantly change. The lack of the associations between these nutrients and the time since the procedure was performed could be linked to the poor intake of these nutrients among the Saudi population.^18,19 It is important to ensure adequate intake of all micronutrients among individuals following the bariatric surgery, as they could be at increased risk of micronutrient deficiencies.^8–10 A special consideration should be given to vitamin B₁₂ supplementation, particularly for those reporting low intake of vitamin B₁₂ rich food sources.²⁰

All individuals who underwent an LSG should use daily supplements to prevent micronutrient deficiencies. These deficiencies are caused by gastric capacity restriction, absorptive area reduction, rapid weight loss, and insufficient food intake that may limit the ability to meet the recommendations to prevent and/or treat nutritional deficiencies as suggested by previous studies.^8,10 However, over one-third of the sample were not using any dietary supplements.

The limited use of supplements in Saudi Arabia has been previously linked to low educational status and income.^21,22 Most likely, many individuals who underwent the bariatric surgeries are unable to afford the cost of the supplements. In addition, the data indicated that supplement use was negatively associated with the period following the procedure. Even though supplementations were not counted for in dietary intake, participants who used supplements had higher intakes of vitamin D and vitamin B₁₂ and were more likely to visit a dietitian postprocedure. Supported by the previous literature, this may indicate that supplement users have a better overall quality of diet compared to nonsupplement users.^21,23

Despite the fact that calcium requirement increases for an individual after LSG due to decreased absorption,²⁴ in this study, the mean intake of calcium was below the Recommended Dietary Allowance.²⁵ It is important to clarify that low calcium intake was expected among the study participants as poor calcium intake has been reported previously among the Saudi population.²⁶ Thus, a poor intake of calcium may be independent of bariatric surgery.²⁷

High intake of total sugar (21% of total energy intake) may be linked to the low micronutrient intake, including calcium. It has been suggested that excessive intake of added sugars results in the replacement of many essential nutrients, for example, calcium and zinc.²⁸ Total sugar in this study might be reflective of added sugar intake, as individuals in this study may have poor consumption of natural sugar food sources (milk and fruits) as indicated by the poor calcium and fiber intake. This could be achieved and supported by the role of the registered dietitian in the multidisciplinary team through pre- and postoperative nutrition education.²⁹

The present study has several strengths. First, to our knowledge, this was the first study to assess the dietary intake of postbariatric surgery patients in Saudi Arabia. Second, the sample of this study was representative of the Saudi population, given that the participants were recruited from different income levels and regions in Saudi Arabia. Third, measuring the usual intake for the population was an advantage that allowed for the determination of dietary intake of individuals postprocedure.

However, this study is limited by its design, as cross-sectional data do not reveal causal relationships. In addition, data on nutrient deficiencies were not assessed. Micronutrient intake of the participants was approximate, due to the difficulty of recalling names of dietary supplements, contents, and/or dose. Moreover, data pertaining to physical activity, fat-free mass, and body composition were not available. The anthropometric data collected in the present study were self-reported; however, all the participants were found to have written records of their weight change since the bariatric procedure was performed.

Conclusions

Our findings indicated poor intake of some important nutrients, limited supplement use, and weight stabilization in the long term following bariatric surgeries. Regular follow-ups with registered dietitians following bariatric procedures may assist in long-term weight maintenance and improve nutritional status of the patients. However, strategies utilized by dietitians in counseling individuals postbariatric procedure should be evaluated. In addition, future research must be established to assess the prevalence of malnutrition among patients who underwent bariatric surgeries and to develop evidence-based interventions aiming to improve the nutritional status of the patients.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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