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3.863 0 Td [(Am)-257(J)-263(Med)]TJ /T1_0 1 Tf 4.165 0 Td [(.)-262(2016;129\(9\):952-95)-22(9.)]TJ 24.696 89.599 Td [(82.)-736(Fakhry)-571(TK,)-576(Mhaskar)-571(R,)-571(Schwitalla)-467(T,)-567(Muradova)-577(E,)-571(Gonzalvo)-576(JP,)]TJ 2.109 -1.399 Td [(Murr)-459(MM.)-464(Bariatric)-458(surg)-9(ery)-460(improves)-461(nonalco)-10(holic)-460(fatty)-460(liver)-461(dis-)]TJ 0 -1.399 TD [(ease:)-553(a)-554(contemporary)-555(systematic)-563(review)-553(and)-554(meta-analysis.)]TJ /T1_1 1 Tf 27.923 0 Td (Surg)Tj -27.923 -1.406 Td [(Obes)-267(Relat)-263(Dis)]TJ /T1_0 1 Tf 6.108 0 Td [(.)-262(2019;15\(3\):502-511)-22(.)]TJ -8.217 -1.398 Td [(83.)-736(National)-385(Institute)-377(for)-381(Health)-384(and)-380(Care)-382(Excellence.)]TJ /T1_1 1 Tf 24.658 0 Td [(Quality)-383(St)-8(andard)]TJ -22.549 -1.398 Td [([QS127])-708(Obesity:)-704(Clinical)-711(Assessment)-707(and)-710(Management)]TJ /T1_0 1 Tf 25.285 0 Td [(.)-701(London:)]TJ -25.285 -1.398 Td 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[(Safer)-281(Upper)-286(Limits)-280(for)-281(Vitamins)-288(and)-279(Minerals.)]TJ -10.855 -1.406 Td [(Expert)-337(Group)-343(on)-338(Vitamins)-341(and)-340(Minerals)]TJ /T1_0 1 Tf 16.675 0 Td [(.)-338(1st)-333(ed.)-339(London:)-338(Foods)-343(Stan-)]TJ -16.675 -1.398 Td [(dards)-264(Agency;)-263(2003.)]TJ -2.109 -1.398 Td [(96.)-736(Mahawar)-311(KK,)-307(Reid)-309(A,)-310(Graham)-218(Y,)-309(et)-305(al.)-315(Oral)-306(vitamin)-312(B12)-312(supplemen-)]TJ 2.109 -1.398 Td [(tation)-511(after)-510(Roux-en-Y)-513(gastric)-508(bypas)-10(s:)-502(a)-509(systematic)-517(review.)]TJ /T1_1 1 Tf 27.629 0 Td (Obes)Tj -27.629 -1.398 Td (Surg)Tj /T1_0 1 Tf 1.837 0 Td [(.)-255(2018;28\(7\))-16(:1916-1923.)]TJ -3.946 -1.406 Td [(97.)-736(Harrington)-361(DJ.)-356(Laboratory)-366(assessment)-359(of)-357(vitamin)-358(B12)-365(status.)]TJ /T1_1 1 Tf 29.534 0 Td [(J)-353(Clin)]TJ -27.425 -1.398 Td (Pathol)Tj /T1_0 1 Tf 2.668 0 Td [(.)-262(2017;70\(2\):168-173)-22(.)]TJ -4.777 -1.398 Td 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18.045 -0.77 l 18.045 2.921 l 20.542 2.921 l 21.61 2.921 22.143 2.748 22.427 2.293 c 22.536 2.293 l 22.536 4.271 l 22.427 4.287 l 22.143 3.832 21.61 3.659 20.542 3.659 c 18.045 3.659 l h -6.988 -1.853 m -6.91 -1.853 l -3.046 7.773 l -2.669 8.7 -2.324 9.156 -1.979 9.359 c -1.979 9.454 l -4.303 9.454 l -4.303 9.359 l -3.816 9.093 -3.706 8.37 -4.036 7.539 c -6.407 1.602 l -9.627 9.485 l -9.705 9.485 l -13.097 1.617 l -15.532 7.806 l -15.814 8.543 -15.735 9.093 -15.281 9.359 c -15.281 9.454 l -18.672 9.454 l -18.672 9.359 l -18.311 9.171 -18.044 8.779 -17.714 7.977 c -13.725 -1.853 l -13.647 -1.853 l -10.286 6.109 l -6.988 -1.853 l f Q EMC Q endstreamendobj459 0 obj<>endobj460 0 obj<>stream BT /CS0 cs 0 0 0 scn /GS0 gs /T1_0 1 Tf 7.4999 0 0 7.4999 50.2299 723.855 Tm [(27.)-736(Brouwe)-10(rs)-504(M,)-503(Kho)-505(ME,)-505(Browman)-507(GP,)-501(et)-509(al.)-504(AGREE)-502(II:)-510(advancing)]TJ 2.109 -1.399 Td [(guideline)-381(de)-9(velopment,)-379(reporting)-380(and)-380(evaluation)-380(in)-381(healthcare.)]TJ /T1_1 1 Tf 28.112 0 Td (Can)Tj -28.112 -1.398 Td [(Med)-501(Asso)-10(c)-498(J)]TJ /T1_0 1 Tf 5.616 0 Td [(.)-504(2010;182:E839-E84)-23(2.)-499(https://doi.org/10)-15(.1503/cmaj.)]TJ -5.616 -1.406 Td [(09044)-12(9)-259(Accessed)-268(April)-265(2019)]TJ -2.109 -1.398 Td [(28.)-736(Scottis)-11(h)-635(Intercollegiate)-648(Guidelines)-642(Networ)-10(k)-634(\(SIGN)-10(\).)]TJ /T1_1 1 Tf 26.442 0 Td [(SIGN)-637(50:)-643(A)]TJ -24.333 -1.398 Td [(guideline)-385(developers')-381(handbook)]TJ /T1_0 1 Tf 13.062 0 Td [(.)-376(Edinburgh:)-380(SIGN;)-373(2011)-380(\(SIGN)-380(publi-)]TJ -13.062 -1.398 Td [(cation)-889(no.)-879(50\).)-884(Available)-885(from)-885(https://www.sign)-12(.ac.uk/assets/)]TJ 0 -1.398 TD [(sign50_)-11(2011.pdf)-269(Accessed)-268(December)-264(2018.)]TJ -2.109 -1.406 Td [(29.)-736(Aasheim)-641(ET,)-630(Hofs)-9(\370)-625(D,)-632(Hjelm)-10(es\346th)-633(J,)-636(Birkeland)-637(KI,)-632(B\370hmer)-637(T.)]TJ 2.109 -1.398 Td [(Vitam)-10(in)-411(status)-413(in)-411(morbidly)-415(obese)-420(patients:)-413(a)-418(cross-sectional)-422(study.)]TJ /T1_1 1 Tf T* [(Am)-265(J)-263(Clin)-263(Nutr)]TJ /T1_0 1 Tf 6.093 0 Td [(.)-255(2008;87\(2\))-16(:362-369.)]TJ -8.202 -1.398 Td [(30.)-736(Ernst)-500(B,)-490(Thurnhee)-10(r)-493(M,)-495(Schmid)-495(SM,)-499(Schultes)-499(B.)-494(Evidence)-497(for)-495(the)]TJ 2.109 -1.398 Td [(necess)-11(ity)-643(to)-649(systematically)-655(assess)-647(micronutri)-12(ent)-645(status)-647(prio)-9(r)-644(to)]TJ 0 -1.406 TD [(bariat)-10(ric)-262(surgery.)]TJ /T1_1 1 Tf 7.529 0 Td [(Obes)-267(Surg)]TJ /T1_0 1 Tf 4.226 0 Td [(.)-255(2009;19\(1\))-16(:66-73.)]TJ -13.864 -1.399 Td [(31.)-736(Gehrer)-410(S,)-397(Kern)-405(B,)-399(Peters)-301(T,)-401(Christoffel)-14(-Courtin)-401(C,)-401(Peterli)-411(R.)-401(Fewer)]TJ 2.109 -1.398 Td [(nutrient)-559(deficiencies)-560(afte)-10(r)-545(lapa)-10(roscopic)-556(sleeve)-555(gastrectomy)-566(\(LSG\))]TJ 0 -1.398 TD [(than)-374(after)-374(lapa)-10(roscopic)-374(Roux-Y-gastri)-13(c)-371(bypass)-369(\(LRY)-9(GB\))]TJ /T1_2 1 Tf 24.303 0 Td (\227)Tj /T1_0 1 Tf 0.794 0 Td [(a)-373(prospec-)]TJ -25.096 -1.398 Td [(tive)-267(study.)]TJ /T1_1 1 Tf 4.777 0 Td [(Obes)-267(Surg)]TJ /T1_0 1 Tf 4.218 0 Td [(.)-262(2010;20\(4\))-16(:447-453.)]TJ -11.104 -1.406 Td [(32.)-736(Damms)-11(-Machado)-284(A,)-280(Friedrich)-287(A,)-280(Kram)-10(er)-282(KM,)-278(et)-282(al.)-285(Pre-)-278(and)-282(postop-)]TJ 2.109 -1.398 Td [(erative)-348(nutritional)-339(de)-9(ficiencies)-347(in)-335(obese)-344(patients)-338(undergo)-11(ing)-339(laparo-)]TJ T* [(scop)-9(ic)-261(sleeve)-260(gastrecto)-14(my.)]TJ /T1_1 1 Tf 11.838 0 Td [(Obes)-259(Surg)]TJ /T1_0 1 Tf 4.218 0 Td [(.)-262(2012;22\(6\):881-889)-22(.)]TJ -18.165 -1.398 Td [(33.)-736(De)-285(Luis)-290(DA,)-284(Pacheco)-294(D,)-284(Izaola)-288(O,)-284(Terroba)-290(MC,)-283(Cuellar)-287(L,)-285(Cabezas)-288(G.)]TJ 2.109 -1.398 Td [(Micronutrent)-660(status)-647(in)-653(morbidly)-650(obese)-654(women)-651(before)-649(bariat)-10(ric)]TJ 0 -1.406 TD (surgery.)Tj /T1_1 1 Tf 3.727 0 Td [(Surg)-262(Obes)-267(Relat)-263(Dis)]TJ /T1_0 1 Tf 8.202 0 Td [(.)-262(2013;9\(2\):323-328.)]TJ -14.037 -1.398 Td [(34.)-736(Dogan)-438(K,)-441(Aarts)-439(EO,)-437(Koehestanie)-445(P,)-436(et)-434(al.)-436(Optimization)-440(of)-440(vitamin)]TJ 2.109 -1.398 Td [(suppl)-9(etion)-789(after)-790(Roux-en-Y)-793(gastric)-787(bypass)-792(surgery)-787(can)-789(lower)]TJ 0 -1.398 TD [(postopera)-12(tive)-463(de)-9(ficiencies:)-474(a)-463(randomized)-477(controlled)-471(trial.)]TJ /T1_1 1 Tf 26.019 0 Td (Medicine)Tj -26.019 -1.406 Td (\(Baltimore\))Tj /T1_0 1 Tf 4.505 0 Td [(.)-1162(2014;93\()-16(25\):e1691)]TJ /T1_2 1 Tf 9.827 0 Td (\226)Tj /T1_0 1 Tf 0.575 0 Td [(9.)-1164(https://)-11(doi.org/10.1097/MD.)]TJ -14.907 -1.398 Td [(00000)-12(00000000169)]TJ -2.109 -1.398 Td [(35.)-736(Salgado)-400(W,)-391(Modotti)-10(b)-393(C,)-393(Nonino)-394(CB,)-391(Ceneviv)-13(a)-388(R.)-393(Anemia)-396(and)-395(iron)]TJ 2.109 -1.398 Td [(deficienc)-15(y)-458(before)-467(and)-471(after)-465(bariatric)-468(surgery.)]TJ /T1_1 1 Tf 20.72 0 Td [(Surg)-466(Obes)-471(Relat)-467(Dis)]TJ /T1_0 1 Tf 8.814 0 Td (.)Tj -29.534 -1.398 Td [(2014;10\(1\))-16(:49-54.)]TJ -2.109 -1.406 Td [(36.)-736(Van)-530(Rutte)-528(PWJ,)-531(Aarts)-529(EO,)-528(Smulders)-533(JF,)-527(Nienhuijs)-531(SW.)-527(Nutrien)-10(t)]TJ 2.109 -1.398 Td [(deficienc)-15(ies)-386(before)-384(and)-387(after)-389(sleeve)-388(gastrectomy.)]TJ /T1_1 1 Tf 22.254 0 Td [(Obes)-388(Surg)]TJ /T1_0 1 Tf 4.339 0 Td [(.)-391(2014;)]TJ -26.593 -1.398 Td [(24:1639)-14(-1646.)]TJ -2.109 -1.398 Td [(37.)-736(Gobato)-388(RC,)-373(Cha)-9(ves)-380(DFS,)-376(Cha)-9(im)-378(EA.)-377(Micronutrie)-12(nt)-379(and)-380(physiologic)]TJ 2.109 -1.398 Td [(param)-10(eters)-403(before)-407(and)-410(6)-403(months)-407(after)-404(RYGB.)]TJ /T1_1 1 Tf 20.901 0 Td [(Surg)-405(Obes)-410(Relat)-407(Dis)]TJ /T1_0 1 Tf 8.633 0 Td (.)Tj -29.534 -1.406 Td [(2014;10\(5\))-16(:944-951.)]TJ -2.109 -1.398 Td [(38.)-736(Wolf)-352(E,)-351(Utech)-355(M,)-352(Stehle)-353(P,)-353(B\374sing)-356(M,)-352(Stoffel-Wagner)-356(B,)-354(Ellinger)-355(S.)]TJ 2.109 -1.398 Td [(Preoperati)-14(ve)-300(micronutri)-12(ent)-297(stat)-9(us)-298(in)-305(morbidly)-302(obes)-10(e)-296(patients)-308(before)]TJ T* [(undergo)-11(ing)-332(bariatric)-332(surgery:)-340(results)-334(of)-327(a)-335(cross-sectional)-338(study.)]TJ /T1_1 1 Tf 27.923 0 Td (Surg)Tj -27.923 -1.398 Td [(Obes)-267(Relat)-263(Dis)]TJ /T1_0 1 Tf 6.108 0 Td [(.)-262(2015;11\(5\))-16(:1157-1163.)]TJ -8.217 -1.406 Td [(39.)-736(Lefebvre)-427(P,)-421(Letois)-427(F,)-414(Sultan)-428(A,)-416(Nocca)-428(D,)-420(Mura)-301(T,)-424(Galtier)-427(F.)-418(Nutri-)]TJ 2.109 -1.398 Td [(ent)-456(deficiencies)-461(in)-456(patients)-459(with)-455(obesity)-457(cons)-9(idering)-458(bariatric)-453(sur-)]TJ T* [(gery:)-675(a)-668(cross-section)-13(al)-665(study.)]TJ /T1_1 1 Tf 14.393 0 Td [(Surg)-670(Obes)-675(Relat)-671(Dis)]TJ /T1_0 1 Tf 9.426 0 Td [(.)-670(2014;10\(3\):)]TJ -23.819 -1.398 Td [(540-546)-14(.)]TJ -2.109 -1.406 Td [(40.)-736(Ben-Porat)-412(T,)-408(Elazary)-410(R,)-404(Yuval)-403(JB,)-407(Wiede)-10(r)-402(A,)-409(Khalaileh)-407(A,)-409(Weiss)-402(R.)]TJ 2.109 -1.398 Td [(Nutrit)-10(ional)-718(deficiencies)-733(after)-722(sleeve)-721(gastrectomy:)-732(can)-721(they)-717(be)]TJ T* [(predicted)-606(preoperatively?)]TJ /T1_1 1 Tf 12.027 0 Td [(Surg)-594(Obes)-599(Relat)-603(Dis)]TJ /T1_0 1 Tf 9.207 0 Td [(.)-595(2015;11\(5\):1029-)]TJ -21.234 -1.398 Td (1036.)Tj -2.109 -1.398 Td [(41.)-736(Weng)-607(T-C,)-701(Chang)-701(C-H,)-706(Dong)-700(Y-H,)-697(Chang)-701(Y-C,)-700(Chuang)-708(L-M.)]TJ 2.109 -1.406 Td [(Ana)-9(emia)-465(and)-463(related)-467(nutrient)-461(deficiencies)-476(after)-465(Roux-en-Y)-468(gastric)]TJ T* [(bypass)-407(surgery:)-408(a)-410(systematic)-412(review)-402(and)-410(meta-analysis.)]TJ /T1_1 1 Tf 25.036 0 Td [(BMJ)-403(Open)]TJ /T1_0 1 Tf 4.498 0 Td (.)Tj -29.534 -1.398 Td [(2015;5\()-14(7\):e0069641)]TJ /T1_2 1 Tf 9.011 0 Td (\226)Tj /T1_0 1 Tf 0.575 0 Td [(11.)-1016(https://doi)-11(.org/10.1136/bmj)-18(open-2014-)]TJ -9.585 -1.398 Td [(00696)-12(4)]TJ -2.109 -1.398 Td [(42.)-736(Peterso)-11(n)-340(LA,)-345(Chesk)-11(in)-343(LJ,)-345(Schweitzer)-349(MA,)-351(Magnuson)-237(TH,)-344(Steele)-347(KE.)]TJ 2.109 -1.406 Td [(Treatme)-11(nt)-560(for)-570(vitamin)-569(D)-563(deficiency)-570(prior)-570(to)-566(bariatric)-567(surgery:)-575(a)]TJ T* [(prospectiv)-13(e)-259(cohort)-262(study)-9(.)]TJ /T1_1 1 Tf 11.331 0 Td [(Obes)-267(Surg)]TJ /T1_0 1 Tf 4.226 0 Td [(.)-262(2016;26\(5\):1146-11)-22(49.)]TJ -17.666 -1.398 Td [(43.)-736(Peterso)-11(n)-370(LA,)-375(Cheskin)-376(LJ,)-375(Furtado)-377(M,)-374(et)-373(al.)-368(Maln)-10(utrition)-377(in)-373(bariatric)]TJ 2.109 -1.398 Td [(surgery)-356(candidates:)-354(multiple)-353(micronutri)-12(ent)-350(deficiencies)-355(prior)-350(to)-346(sur-)]TJ T* (gery.)Tj /T1_1 1 Tf 2.389 0 Td [(Obes)-267(Surg)]TJ /T1_0 1 Tf 4.226 0 Td [(.)-255(2016;26\()-16(4\):833-838.)]TJ -8.723 -1.406 Td [(44.)-736(Cha)-9(khtoura)-296(MT,)-305(Nakhoul)-302(NN,)-295(Shawwa)-10(b)-295(K,)-298(Mantzo)-10(rosd)-297(C,)-295(Ghada)-303(A,)]TJ 2.109 -1.398 Td [(El)-635(Hajj)-631(Fuleihan)-636(GE.)-639(Hypovitaminosis)-642(D)-631(in)-630(bariatric)-635(surg)-9(ery:)-634(a)]TJ T* [(systematic)-351(review)-341(of)-342(observa)-10(tional)-342(studies.)]TJ /T1_1 1 Tf 19.298 0 Td (Metabolism)Tj /T1_0 1 Tf 4.845 0 Td [(.)-345(2016;65\(4\):)]TJ -24.144 -1.398 Td [(574-585)-14(.)]TJ 32.724 89.599 Td [(45.)-736(Dix)-523(CF,)-527(Bauer)-532(JD,)-526(Wright)-528(ORL.)-528(A)-528(systematic)-533(review:)-530(vitamin)-524(D)]TJ 2.109 -1.399 Td [(status)-262(and)-259(sleeve)-267(gastrectomy)-14(.)]TJ /T1_1 1 Tf 13.569 0 Td [(Obes)-267(Surg)]TJ /T1_0 1 Tf 4.226 0 Td [(.)-262(2017;27\(1\):215-225)-22(.)]TJ -19.903 -1.398 Td [(46.)-736(Bazuin)-576(I,)-570(Pouwels)-569(S,)-571(Houterman)-578(S,)-571(Nienhuijs)-569(SW,)-576(Smulders)-571(JF,)]TJ 2.109 -1.408 Td [(Boer)-527(AK.)-535(Improved)-532(and)-531(more)-534(effective)-537(algorithms)-537(to)-528(screen)-530(for)]TJ T* [(nutrient)-454(deficiencies)-461(after)-450(bariatric)-461(surgery.)]TJ /T1_1 1 Tf 19.896 0 Td [(Eur)-453(J)-444(Clin)-452(Nutr)]TJ /T1_0 1 Tf 6.629 0 Td [(.)-451(2017;)]TJ -26.525 -1.398 Td (71\(2\):198-202.)Tj -2.109 -1.398 Td [(47.)-736(Ben-Porat)-420(T,)-416(Ela)-10(zary)-415(R,)-419(Goldenshluger)-424(A,)-416(Sherf)-419(Dagan)-420(S,)-420(Mintz)-421(Y,)]TJ 2.109 -1.398 Td [(Weiss)-274(R.)-265(Nutrit)-10(ional)-272(deficiencies)-280(four)-268(years)-278(after)-268(laparoscopi)-13(c)-265(sleeve)]TJ 0 -1.406 TD (gastrectomy)Tj /T1_2 1 Tf 5.367 0 Td (\227)Tj /T1_0 1 Tf 0.794 0 Td [(are)-527(supplements)-528(requ)-10(ired)-520(for)-532(a)-524(lifetime?)]TJ /T1_1 1 Tf 19.117 0 Td [(Surg)-526(Obes)]TJ -25.278 -1.398 Td [(Relat)-263(Dis)]TJ /T1_0 1 Tf 3.719 0 Td [(.)-262(2017;13\(7\):1138-11)-22(44.)]TJ -5.828 -1.398 Td [(48.)-736(Chakhtoura)-902(M,)-888(Rahm)-9(e)-886(M,)-896(El-Hajj)-903(Fuleihan)-893(GE.)-896(Vitamin)-897(D)]TJ 2.109 -1.398 Td [(metabolism)-537(in)-532(bariatric)-536(surgery.)]TJ /T1_1 1 Tf 14.922 0 Td [(Endoc)-12(rinol)-533(Metab)-537(Clin)-536(North)-531(Am)]TJ /T1_0 1 Tf (.)Tj -14.922 -1.398 Td [(2017;46\(4\):947-982)-22(.)]TJ -2.109 -1.406 Td [(49.)-736(Al-Mutawa)-387(A,)-386(Al-Sabah)-389(S,)-382(Anderso)-10(n)-378(AK,)-388(Al-Mutawa)-387(M.)-386(Evaluation)]TJ 2.109 -1.399 Td [(of)-463(nutritional)-468(status)-458(post)-463(laparoscopic)-467(sleeve)-464(gastrecto)-14(my)]TJ /T1_2 1 Tf 26.155 0 Td (\227)Tj /T1_0 1 Tf 0.794 0 Td (5-year)Tj -26.948 -1.398 Td (outcomes.)Tj /T1_1 1 Tf 4.755 0 Td [(Obes)-259(Surg)]TJ /T1_0 1 Tf 4.218 0 Td [(.)-262(2018;28\(6\):)-15(1473-1483.)]TJ -11.082 -1.398 Td [(50.)-736(Krzizek)-458(E-C,)-448(Bri)-9(x)-448(JM,)-450(Herz)-459(CT,)-453(et)-449(al.)-451(Prevalence)-461(of)-448(micronutri)-12(ent)]TJ 2.109 -1.398 Td [(deficiency)-389(in)-373(patients)-383(with)-379(morbid)-383(obesity)-381(before)-384(bariatric)-385(surgery.)]TJ /T1_1 1 Tf T* [(Obes)-267(Surg)]TJ /T1_0 1 Tf 4.218 0 Td [(.)-262(2018;28\(3\))-16(:643-648.)]TJ -6.327 -1.398 Td [(51.)-736(Aills)-417(L,)-421(Blankenshi)-12(p)-416(J,)-417(Buffingto)-12(n)-416(C,)-416(Furta)-10(do)-420(M,)-412(Parrott)-425(J.)-421(ASMBS)]TJ 2.109 -1.398 Td [(allied)-675(health)-683(nutritional)-679(guidelines)-679(for)-684(the)-675(surgical)-678(weight)-680(loss)]TJ 0 -1.398 TD (patient.)Tj /T1_1 1 Tf 3.553 0 Td [(Surg)-262(Obes)-267(Relat)-263(Dis)]TJ /T1_0 1 Tf 8.202 0 Td [(.)-262(2008;4\(5\):S)-16(73-S108.)]TJ -13.864 -1.398 Td [(52.)-736(Heber)-348(D,)-352(Greenway)-353(FI,)-348(Kaplan)-351(LM,)-348(Livingston)-353(E,)-351(Salvador)-348(J,)-349(Still)-351(C.)]TJ 2.109 -1.406 Td [(Endocrine)-338(and)-327(nut)-8(ritional)-331(managem)-11(ent)-328(of)-335(the)-328(pos)-9(t-bariatric)-332(surg)-9(ery)]TJ T* [(patient:)-689(an)-690(endocrine)-693(society)-692(clinical)-693(practice)-691(guideline.)]TJ /T1_1 1 Tf 27.092 0 Td [(J)-686(Clin)]TJ -27.092 -1.398 Td [(Endocrinol)-265(Metab)]TJ /T1_0 1 Tf 7.317 0 Td [(.)-262(2010;95\(11\):4823)-20(-4843.)]TJ -9.426 -1.398 Td [(53.)-736(Bays)-1467(H,)-1471(Kothari)-1473(SN,)-1467(Azagury)-1476(DE,)-1466(et)-1469(al.)-1472(ASMBS)]TJ 2.109 -1.406 Td [(Guidelines/Stat)-14(ements,Part2.)-545(Lipids)-535(and)-539(bariatric)-544(procedures)-544(Part)]TJ T* [(2)-282(of)-274(2:)-282(scient)-10(ific)-276(stat)-9(ement)-281(from)-280(the)-282(America)-12(n)-279(Society)-283(for)-283(Metabolic)]TJ T* [(and)-282(Bariatric)-285(Surgery)-287(\(ASMBS\),)-288(the)-282(National)-279(Lipi)-10(d)-279(Association)-284(\(NLA\),)]TJ T* [(and)-266(Obesity)-273(Medicine)-277(Association)-276(\(OMA\).)]TJ /T1_1 1 Tf 18.482 0 Td [(Surg)-269(Obes)-274(Relat)-271(Dis)]TJ /T1_0 1 Tf 8.224 0 Td [(.)-270(2016;)]TJ -26.706 -1.398 Td (12\(3\):468-495.)Tj -2.109 -1.406 Td [(54.)-736(Welbourn)-289(R,)-283(Hopki)-10(ns)-283(J,)-288(Dixon)-286(JB,)-293(et)-282(al.)-285(Commis)-12(sioning)-290(guidance)-291(for)]TJ 2.109 -1.398 Td [(weight)-529(assessment)-540(and)-531(management)-535(in)-532(adults)-534(and)-531(children)-533(with)]TJ T* [(severe)-263(complex)-268(obesity.)]TJ /T1_1 1 Tf 10.674 0 Td [(Obes)-267(Rev)]TJ /T1_0 1 Tf [(.)-262(2018;19\(1\):14-27.)]TJ -12.783 -1.398 Td [(55.)-736(Edholm)-470(D,)-466(Kullberg)-465(J,)-470(Haenni)-471(A,)-469(et)-464(al.)-466(Preoperative)-473(4-week)-470(low-)]TJ 2.109 -1.398 Td [(calorie)-321(diet)-323(reduces)-318(liver)-325(volume)-322(and)-312(intrahepa)-11(tic)-322(fat,)-319(and)-319(facilitates)]TJ 0 -1.406 TD [(laparoscopic)-558(gastric)-553(bypass)-550(in)-547(morbidl)-11(y)-548(obese.)]TJ /T1_1 1 Tf 21.922 0 Td [(Obes)-546(Surg)]TJ /T1_0 1 Tf 4.505 0 Td [(.)-550(2011;)]TJ -26.427 -1.398 Td (21\(3\):345-350.)Tj -2.109 -1.398 Td [(56.)-736(Baldry)-403(EL,)-401(Leeder)-403(PC,)-398(Idris)-403(IR.)-403(Pre-operative)-403(dietary)-406(restriction)-407(for)]TJ 2.109 -1.398 Td [(patients)-315(undergoing)-313(bariat)-10(ric)-307(surgery)-318(in)-313(the)-305(UK:)-315(observation)-12(al)-310(study)]TJ 0 -1.398 TD [(of)-645(current)-656(practice)-653(and)-652(dietary)-648(effects.)]TJ /T1_1 1 Tf 19.23 0 Td [(Obes)-652(Surg)]TJ /T1_0 1 Tf 4.604 0 Td [(.)-648(2014;24\(3\))-16(:)]TJ -23.834 -1.406 Td (416-421.)Tj -2.109 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[(It)-396(is)-404(recog)12(nized)-397(that)-398(there)-393(is)-397(a)-397(growing)-397(interest)-386(in)-400(OAGB/MGB)-388(and)]TJ T* [(SADIs)-490(and)-490(that,)-492(as)-494(yet,)-496(these)-490(are)-494(not)-495(cover)12(ed)-494(robustly)-492(by)-490(clinical)]TJ 0 -1.63 TD [(practice)-404(guidelines.)-399(Until)-406(such)-403(data)-405(emerge,)-408(it)-406(may)-407(be)-409(hypoth)14(esized)]TJ 0 -1.623 TD [(that)-434(requirem)12(ents)-429(for)-435(nutritional)-428(supplem)16(ents)-436(in)-428(people)-431(undergoin)13(g)]TJ T* [(OAGB/MGB)-275(with)-285(BP)-279(limb)-287(of)-286(150)-282(cm)-286(would)-279(be)-282(at)-291(least)-284(that)-278(of)-286(people)]TJ 0 -1.63 TD [(undergoin)13(g)-369(RYGB,)-365(if)-368(not)-367(more,)-369(and)-363(that)-363(nutritional)-364(requirem)12(ents)-365(for)]TJ 0 -1.623 TD [(people)-431(undergoing)-426(OAGB/MGB)-430(with)-434(BP)-434(limb)-436(greater)-428(than)-434(150)-438(cm)]TJ T* [(and)-278(SADIS)-276(would)-272(be)-282(at)-277(least)-284(that)-271(of)-286(people)-275(undergoi)14(ng)-284(the)-275(traditional)]TJ T* [(BPD/DS)11(.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 78.2362 401.9526 Tm (163)Tj /T1_2 1 Tf 0 Tc 1.71 0 Td (\226)Tj /T1_1 1 Tf 0.0001 Tc 0.576 0 Td (166)Tj 0 Tc 7.9999 0 0 7.9999 106.5826 398.4377 Tm [(We)-540(therefore)-527(recommend)-531(that)-533(healthcare)-533(profes-)]TJ -7.512 -1.63 Td [(sionals)-434(follow)-440(RYGB)-434(nutritional)-435(recommend)14(ations)-438(for)-442(postoperati)11(ve)]TJ T* [(care)-359(after)-357(OAGB/MGB)-353(with)-356(BP)-356(limb)-358(length)-359(of)-356(150)-360(cm)-357(and)-363(BPD/DS)]TJ T* [(recommend)14(ations)-382(for)-385(people)-382(after)-378(OAGB/MGB)-374(with)-384(BP)-378(limb)-386(length)]TJ 0 -1.63 TD [(of)-257(greater)-258(than)-250(150)-261(cm)-258(or)-253(SADIs.)]TJ /T1_0 1 Tf 0.1026 Tc 10.0001 0 0 10.0001 46.4882 320.4283 Tm (10)Tj /T1_1 1 Tf 0 Tc 2.149 0 Td (|)Tj /T1_0 1 Tf 0.0987 Tc 1.151 0 Td [(DI)-7(SCU)-7(SSION)]TJ /T1_1 1 Tf 0 Tc 7.9999 0 0 7.9999 46.4882 294.4062 Tm [(Clinical)-269(guidelines)-266(can)-277(make)-273(a)-276(vitally)-275(important)-267(contrib)13(ution)-271(to)-282(patient)]TJ 0 -1.623 TD [(safety,)-363(and)-363(a)-368(number)-357(of)-363(guidelines)-358(for)-364(the)-367(nutritional)-357(care)-366(of)-363(people)]TJ T* [(undergoin)13(g)-425(bariatric)-423(surgery)-416(have)-423(been)-421(publish)13(ed)-430(over)-421(the)-424(last)-421(few)]TJ 0 -1.63 TD (years.)Tj 5.9998 0 0 5.3325 66.6708 258.9731 Tm (1,3,4,8)Tj /T1_2 1 Tf 2.948 0 Td (\226)Tj /T1_1 1 Tf 0.0001 Tc 0.567 0 Td (11)Tj 0 Tc 7.9999 0 0 7.9999 99.496 255.4015 Tm [(However,)-601(not)-608(all)-605(have)-601(been)-606(specifica)10(lly)-612(related)-596(to)]TJ -6.626 -1.623 Td [(micronutrit)14(ion,)-484(had)-476(dietetic)-474(involvemen)10(t)-482(or)-480(detail)-480(on)-480(recommen)15(da-)]TJ 0 -1.623 TD [(tions)-375(for)-385(the)-374(nutritional)-371(managemen)12(t)-383(of)-378(pregnancy)-376(post-sur)13(gery.)-379(No)]TJ 0 -1.63 TD [(previous)-281(nutritional)-279(guidelin)13(es)-286(for)-286(people)-282(undergoing)-277(bariatric)-282(surgery)]TJ 0 -1.623 TD [(have)-289(included)-283(either)-289(primary)-283(care)-288(or)-289(patient)-292(repres)13(entatives.)-285(Previous)]TJ T* [(guidance)-724(aimed)-726(at)-730(the)-728(manageme)13(nt)-731(of)-732(adolesce)11(nts)-729(undergoing)]TJ 0 -1.63 TD [(bariatric)-1494(surgery)-1493(has)-1494(only)-1492(included)-1495(general)-1489(nutritional)]TJ 0 -1.623 TD [(recommend)14(ations,)]TJ 0.0001 Tc 5.9998 0 0 5.3325 110.2677 167.9811 Tm (12)Tj /T1_2 1 Tf 0 Tc 1.143 0 Td (\226)Tj /T1_1 1 Tf 0.0001 Tc 0.576 0 Td (14)Tj 0 Tc 7.9999 0 0 7.9999 131.3574 164.4094 Tm [(despite)-486(this)-483(vulnerable)-482(group)-482(being)-483(at)-489(high)]TJ -10.609 -1.623 Td [(risk)-259(of)-257(developi)13(ng)-263(nutritiona)16(l)-260(deficiencies.)]TJ 5.9998 0 0 5.3325 190.2047 154.9417 Tm (15)Tj /T1_2 1 Tf 1.143 0 Td (\226)Tj /T1_1 1 Tf 0.0001 Tc 0.576 0 Td (19)Tj 0 Tc 7.9999 0 0 7.9999 61.5118 138.3874 Tm [(H)16(er)24(e,)-346(co)24(mp)25(re)24(he)23(ns)29(iv)19(e)17(,)-363(up)27(-t)24(o-)26(da)21(te)-345(g)14(ui)19(de)30(li)22(ne)23(s)-360(ha)28(ve)-352(be)23(e)17(n)-362(de)23(v)14(el)26(op)23(ed)]TJ -1.878 -1.623 Td [(us)22(in)26(g)-468(ro)23(bu)27(s)16(t)-468(me)21(th)27(od)23(o)16(lo)26(gy)-461(th)27(a)14(t)-468(in)26(cl)24(ud)20(e)-465(g)14(ra)21(de)23(d)-468(re)31(co)24(mm)22(e)17(nd)20(a)14(ti)26(on)23(s)-466(fo)26(r)]TJ T* [(pr)27(eo)19(pe)30(ra)21(ti)26(v)14(e)-252(a)14(nd)-235(po)23(s)16(to)23(pe)23(ra)28(ti)19(v)14(e)-245(nu)27(tr)21(it)26(io)22(na)28(l)-253(m)18(on)23(it)26(or)23(in)26(g)14(,)-250(vi)19(ta)28(mi)23(n)-249(a)14(nd)-235(mi)23(n-)]TJ T* [(er)24(a)14(l)-246(su)22(pp)27(le)26(me)21(nt)27(a)14(ti)19(o)16(n)-249(a)14(nd)-235(c)15(or)23(re)24(c)15(ti)19(o)16(n)-249(of)-236(de)23(f)17(ic)20(ie)22(nc)28(ie)22(s)-246(fo)26(r)-248(pe)23(op)23(l)16(e)-252(un)27(de)30(rg)21(o)16(-)]TJ 0 -1.63 TD [(in)26(g)-411(ba)28(ri)26(at)21(ri)26(c)-411(s)16(ur)20(g)14(e)17(ry)21(.)-409(I)15(mp)25(or)23(ta)28(nt)20(l)16(y)14(,)-413(nu)27(tr)28(it)19(io)29(na)21(l)-409(g)14(ui)26(da)28(nc)21(e)-408(fo)26(r)-411(th)27(e)-408(c)15(a)14(re)-402(o)16(f)]TJ 0 -1.623 TD [(a)14(do)23(le)26(sc)23(en)23(ts)-424(a)14(nd)-420(pr)27(eg)24(na)21(nc)28(y)-432(po)23(s)16(t-)24(su)22(rg)28(er)24(y)-440(ha)28(s)-430(al)24(so)-421(be)23(en)-423(in)26(cl)24(ud)27(ed)23(,)-434(an)21(d)]TJ T* [(th)27(e)-359(g)14(ui)26(da)21(nc)28(e)-359(de)23(v)14(el)26(op)23(me)28(nt)-348(g)14(ro)23(up)-342(w)16(a)14(s)-360(c)15(om)20(po)30(se)26(d)-355(of)-349(a)-354(mu)25(lt)23(id)26(is)21(c)15(ip)26(li)22(na)28(ry)]TJ 0 -1.63 TD [(te)24(a)14(m)-974(f)17(ro)23(m)-967(pr)20(im)31(ar)21(y)-971(a)14(nd)-958(s)16(ec)24(on)23(da)28(ry)-957(ca)22(re)-961(a)14(s)-969(w)16(el)19(l)-969(a)14(s)-969(pa)21(ti)26(en)23(t)]TJ 32.655 84.501 Td [(re)31(pr)20(e)17(se)19(nt)27(a)14(ti)26(on)23(.)-274(T)16(hu)27(s,)-262(en)23(s)16(ur)20(in)26(g)-269(th)20(a)14(t)-270(a)14(ll)-265(pr)27(of)26(es)19(s)16(io)22(ns)-254(in)19(v)14(o)16(lv)23(ed)-260(in)-258(pr)20(e)17(pa)21(ri)26(ng)]TJ 0 -1.623 TD [(pe)30(op)23(l)16(e)-281(fo)26(r)-277(su)22(rg)28(er)24(y)-277(a)14(nd)-264(pr)27(ov)23(id)26(in)26(g)-277(af)24(te)24(rc)21(a)14(re)24(,)-278(a)14(s)-275(we)25(ll)-265(as)-267(pa)28(ti)19(e)17(nt)-263(vi)19(e)17(ws)-266(a)14(nd)]TJ T* [(ne)30(ed)23(s)16(,)-349(w)16(er)24(e)-345(pr)27(op)23(e)17(rl)23(y)-347(c)15(o)16(ns)22(id)26(er)24(ed)23(.)-345(A)14(l)16(th)20(o)16(ug)20(h)-341(th)27(es)26(e)-345(g)14(ui)26(de)23(li)22(ne)23(s)-338(ar)21(e)-345(a)14(im)23(e)17(d)]TJ 0 -1.63 TD [(a)14(t)-241(im)23(pr)27(ov)23(in)26(g)-248(pr)27(a)14(c)15(ti)19(c)15(e)-245(in)-229(th)20(e)-238(U.)23(K.)-235(s)16(et)24(ti)26(ng)-235(a)14(nd)-228(ta)21(ke)-227(ac)22(c)15(ou)23(nt)-228(of)-236(th)27(e)-245(c)15(ur)20(re)31(nt)]TJ 0 -1.623 TD [(m)18(od)23(e)17(l)-302(of)-293(he)30(al)24(th)20(c)15(a)14(re)-288(in)-293(th)27(e)-302(Un)27(it)26(ed)-289(Ki)23(ng)27(do)23(m,)-288(th)27(ey)-288(a)14(re)-295(l)16(ik)23(el)26(y)-305(to)-289(be)-289(a)14(pp)27(li)22(-)]TJ T* [(c)14(a)14(bl)23(e)-302(to)-289(ot)23(he)23(r)-305(he)30(al)24(th)20(c)15(a)14(re)-295(s)16(et)24(ti)26(ng)20(s)16(.)-302(Ho)25(we)25(v)14(er)24(,)-306(w)16(e)-309(ha)28(v)14(e)-302(ad)21(dr)27(es)26(se)26(d)-305(is)21(s)16(ue)23(s)]TJ 0 -1.63 TD [(s)16(pe)23(c)15(if)22(ic)27(al)24(ly)-402(re)24(la)24(te)24(d)-412(to)-402(th)20(e)-408(U.)23(K.)-405(he)30(al)24(th)20(c)15(a)14(re)-402(sy)23(s)16(te)24(m)-414(wh)22(e)17(re)-402(po)23(s)16(si)21(bl)23(e)17(;)-420(f)17(or)]TJ 0 -1.623 TD [(e)17(x)14(am)25(pl)23(e,)-545(bo)30(th)-540(sp)22(e)17(ci)20(a)14(li)22(s)16(t)-553(a)14(nd)-540(no)23(n-)30(sp)22(ec)24(ia)26(li)22(st)-537(ca)22(re)-543(pr)27(o)16(vi)19(de)30(rs)-544(m)18(ay)-546(no)30(t)]TJ T* [(a)14(l)16(wa)23(y)14(s)-352(a)14(bl)23(e)-345(to)-338(a)14(cc)22(es)26(s)-352(a)14(ll)-336(th)27(e)-352(su)22(g)14(g)14(es)26(te)24(d)-348(nu)27(tr)21(it)26(io)22(na)28(l)-352(bl)30(oo)19(d)-348(te)31(st)23(s)-352(s)16(uc)21(h)-348(a)14(s)]TJ 0 -1.63 TD [(v)14(it)26(a)14(mi)23(n)-419(A)-425(a)14(nd)-405(vi)19(ta)28(mi)23(n)-419(K.)-412(C)14(o)16(rr)21(ec)24(ti)26(on)-410(of)-406(so)25(me)-411(nu)27(tr)21(it)26(io)22(na)28(l)-423(de)23(f)17(ic)20(ie)22(nc)28(ie)22(s)16(,)]TJ 0 -1.623 TD [(e)17(sp)22(e)17(ci)20(a)14(ll)26(y)-468(fa)24(t-)24(so)25(lu)23(bl)23(e)-465(v)14(it)26(am)25(in)19(s)16(,)-469(c)15(a)14(n)-468(be)-452(a)-468(ch)21(a)14(ll)26(en)23(g)14(e)-472(a)14(s)-466(th)27(e)-465(us)22(e)-465(of)-456(of)26(f)]TJ T* [(l)16(ic)20(e)17(ns)22(e)-274(m)18(ed)23(ic)20(a)14(ti)26(on)23(s)-267(ma)25(y)-277(be)-260(re)24(qu)27(ir)26(ed)23(.)-274(I)15(n)-270(ad)21(di)26(ti)26(on)23(,)-271(it)-264(is)-255(of)-264(c)15(on)23(c)15(er)24(n)-270(th)27(at)-262(in)]TJ T* [(s)16(om)28(e)-288(pa)28(rt)21(s)-282(of)-271(th)20(e)-281(Un)27(it)19(e)17(d)-284(Ki)23(ng)27(do)23(m,)-274(pe)30(op)23(le)-271(ar)21(e)-281(no)23(t)-284(g)14(iv)19(e)17(n)-284(ac)22(c)15(es)19(s)-282(to)-275(pr)27(e-)]TJ 0 -1.63 TD [(s)16(c)15(ri)19(be)30(d)-355(v)14(it)26(am)25(in)-343(a)14(nd)-335(mi)23(ne)23(ra)28(l)-352(su)22(pp)27(le)26(me)21(nt)27(s)16(,)-356(pa)28(rt)21(ic)27(ul)23(a)14(rl)23(y)-347(fo)19(r)-348(th)27(os)25(e)-352(un)27(de)23(r-)]TJ 0 -1.623 TD [(g)14(o)16(in)26(g)-794(ma)25(la)24(bs)22(o)16(rp)20(ti)26(v)14(e)-798(pr)27(o)16(ce)24(du)20(re)31(s.)-783(Th)22(e)17(se)-782(pe)23(op)23(l)16(e)-798(w)16(il)22(l)-791(ha)28(ve)-784(hi)26(g)14(he)23(r)]TJ T* [(re)31(qu)20(ir)26(em)28(en)23(ts)23(,)-420(bu)27(t)-418(th)27(e)17(re)-409(is)-404(no)-402(ea)24(sy)-409(a)14(c)15(ce)24(ss)-407(to)-402(su)22(pp)27(le)26(me)21(nt)27(s)-416(co)24(nt)27(ai)19(ni)26(ng)]TJ 0 -1.63 TD [(l)16(a)14(rg)21(er)-253(a)14(mo)20(un)27(ts)-254(o)16(f)-273(v)14(it)26(a)14(mi)23(ns)-254(A)14(,)-271(E)-264(an)21(d)-263(K.)-256(T)16(hi)19(s)-267(is)-255(a)-262(po)23(te)24(nt)27(ia)26(ll)19(y)-262(se)26(ri)19(o)16(us)-254(is)21(s)16(ue)]TJ 0 -1.623 TD [(th)27(a)14(t)-418(m)18(us)22(t)-418(be)-402(a)14(dd)27(re)24(s)16(se)19(d.)-402(A)14(c)14(ce)24(ss)25(ib)26(il)22(it)19(y)-411(a)14(nd)-405(a)14(ff)20(o)16(rd)20(a)14(bi)26(li)22(ty)-404(w)16(er)24(e)-415(a)14(mo)28(ng)20(s)16(t)]TJ T* [(th)27(e)-472(fa)24(c)15(to)23(rs)-459(af)17(f)17(ec)24(ti)19(ng)-462(a)14(dh)27(er)24(en)23(c)15(e)-472(to)-466(v)14(it)26(a)14(mi)23(n)-476(a)14(nd)-462(m)18(in)19(e)17(ra)21(l)-473(su)22(pp)27(l)16(em)21(e)17(nt)20(s)]TJ 0 -1.63 TD [(a)14(ft)24(e)17(r)-248(ba)21(ri)26(a)14(tr)21(ic)-235(s)16(ur)20(g)14(er)24(y)-248(in)-237(th)27(e)-245(Un)27(it)19(e)17(d)-249(Ki)23(ng)27(do)23(m)18(.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 461.0267 479.9621 Tm [(16)29(7)]TJ 0 Tc 7.9999 0 0 7.9999 322.696 463.4077 Tm [(The)-273(main)-275(limitations)-273(of)-278(these)-270(guidelines)-273(are)-274(related)-270(to)-282(the)-275(current)]TJ -1.871 -1.623 Td [(evidence)-555(base.)-568(There)-561(have)-565(been)-563(a)-567(very)-565(limited)-563(number)-556(of)-569(RCTs)]TJ T* [(undert)14(aken)-348(in)-350(bariatric)-338(surgery)-345(and)-342(nutrition.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 465.9589 440.9574 Tm (34,68,101,130,135,168)Tj 0 Tc 7.9999 0 0 7.9999 530.3054 437.3857 Tm (There)Tj -27.822 -1.623 Td [(is)-269(also)-277(a)-276(lack)-277(of)-271(evidence)-272(for)-279(optimal)-264(nutritional)-272(supplement)17(ation)-277(after)]TJ 0 -1.623 TD [(bariatric)-353(surgery,)-353(which)-363(is)-362(complicat)13(ed)-367(by)-362(the)-360(fact)-359(that)-363(requirem)12(ents)]TJ T* [(will)-258(vary)-270(accordin)13(g)-269(to)-267(the)-268(surgica)13(l)-274(procedure)12(,)-264(size)-266(of)-271(gastric)-263(pouch)-262(and)]TJ 0 -1.63 TD [(length)-550(of)-562(common)-555(channel.)-555(Becaus)11(e)-564(of)-562(this)-554(lack)-560(of)-562(good)-557(quality)]TJ 0 -1.623 TD [(evidence)-421(and)-427(robust)-423(studies)-423(in)-428(the)-424(area,)-424(the)-431(guideline)-424(groups)-423(were)]TJ T* [(requir)13(ed)-579(to)-572(make)-570(a)-574(number)-563(of)-576(recommen)15(dations)-574(based)-564(on)-573(good)]TJ 0 -1.63 TD [(practic)11(e)-259(and)-257(the)-253(expert)-258(opinion)-250(of)-257(the)-261(group)-255(\(good)-254(practic)11(e)-259(points\).)]TJ /T1_0 1 Tf 0.097 Tc 10.0001 0 0 10.0001 307.729 307.3889 Tm (11)Tj /T1_1 1 Tf 0 Tc 2.143 0 Td (|)Tj /T1_0 1 Tf 0.1013 Tc 1.151 0 Td [(CONC)3(LUSION)]TJ /T1_1 1 Tf 0 Tc 7.9999 0 0 7.9999 307.729 281.4236 Tm [(Preope)11(rative)-284(dietetic)-276(assessment)-275(and)-285(biochem)13(ical)-283(monitoring)-274(are)-288(vital)]TJ 0 -1.623 TD [(to)-643(ensure)-640(that)-646(people)-644(are)-650(able)-641(to)-650(meet)-643(nutritional)-641(needs)-646(after)]TJ 0 -1.63 TD [(bariatric)-473(surgery)-472(and)-483(any)-476(nutritional)-478(deficie)11(ncies)-480(are)-487(identifi)12(ed)-487(and)]TJ 0 -1.623 TD [(correc)12(ted.)]TJ 5.9998 0 0 5.3325 342.6519 245.9904 Tm (3)Tj 7.9999 0 0 7.9999 350.192 242.4188 Tm [(Long-term)-501(biochemi)11(cal)-508(monitoring)-501(is)-510(important)-501(for)-506(the)]TJ -5.308 -1.623 Td [(detec)12(tion)-809(and)-809(treatment)-800(of)-810(emerge)12(nt)-809(postoperati)11(ve)-812(nutritional)]TJ 0 -1.63 TD [(deficie)11(ncies.)]TJ 5.9998 0 0 5.3325 350.1353 219.9684 Tm (1)Tj /T1_2 1 Tf 0.576 0 Td (\226)Tj /T1_1 1 Tf 0.567 0 Td (4,8)Tj /T1_2 1 Tf 1.37 0 Td (\226)Tj /T1_1 1 Tf 0.0001 Tc 0.567 0 Td (11,83)Tj 0 Tc 7.9999 0 0 7.9999 386.3621 216.3968 Tm [(Annual)-326(reviews)-327(enable)-327(nutritional)-322(supplements)]TJ -9.829 -1.623 Td [(to)-416(be)-423(reviewed)-419(and)-420(adjusted)14(.)-423(We)-426(have)-416(systematical)10(ly)-423(review)11(ed)-423(the)]TJ 0 -1.623 TD [(current)-333(evidence)-336(base)-343(for)-343(the)-339(nutritional)-336(care)-337(of)-342(patients)-340(undergoin)13(g)]TJ 0 -1.63 TD [(bariatric)-508(surgery)-515(and)-512(report)-514(our)-516(consensus)-509(guidelines)-507(with)-519(graded)]TJ 0 -1.623 TD [(recomm)13(endations.)-513(These)-516(guidelin)13(es)-520(have)-523(the)-516(potential)-514(to)-515(improve)]TJ T* [(clinical)-255(practice)-255(and)-257(safety)-255(for)-265(people)-254(undergoin)13(g)-262(bariatric)-253(surgery)-260(and)]TJ 0 -1.63 TD [(should)-343(be)-352(considered)-342(for)-357(adopti)13(on)-353(by)-355(healthcare)-342(organizations.)-345(They)]TJ 0 -1.623 TD [(will)-251(be)-260(updated)-249(regularly)-250(as)-260(new)-252(evidence)-258(emerge)12(s.)]TJ /T1_0 1 Tf 0.0952 Tc 0 -3.246 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0 0 7.9999 393.7322 255.4015 Tm [(A)-425(more)-417(frequen)13(t)-425(review)-414(with)-420(the)-416(specialist)]TJ -10.963 -1.623 Td [(bariatric)-402(dietitian)-409(may)-407(be)-416(required.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 429.6755 245.9904 Tm (11,131)Tj 0 Tc 7.9999 0 0 7.9999 451.4456 242.4188 Tm [(It)-418(should)-407(be)-409(noted)-408(that)-412(for)]TJ -18.177 -1.623 Td [(women,)-715(who)-720(have)-714(had)-724(a)-723(gastric)-716(band,)-720(decisions)-712(around)-716(band)]TJ T* [(manage)13(ment)-760(should)-761(be)-763(made)-759(in)-761(clinical)-758(context)-762(as)-763(there)-761(are)]TJ 0 -1.623 TD [(RCTs)-449(to)-452(define)-449(optimum)-447(manage)13(ment)-455(of)-449(the)-452(gastric)-447(band)-456(inflation)]TJ T* [(during)-387(pregnancy.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 369.0141 193.9464 Tm (4,161)Tj /T1_3 1 Tf 0 Tc 10.0001 0 0 10.0001 306.0283 151.4267 Tm (9.9)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_3 1 Tf 1.054 0 Td (Adolescents)Tj /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 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[(growth)-246(and)-257(sexual)-256(developm)12(ent.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 418.5637 50.9669 Tm (12)Tj /T1_1 1 Tf 0 Tc 1.143 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.576 0 Td (19)Tj ET 0.137 0.122 0.125 scn /CS0 CS 0.137 0.122 0.125 SCN 0 w 1 j 1 J /GS1 gs 548.787 748.63 -504 0.453 re B* q 1 0 0 1 526.28 761.102 cm -0.51 0 0.51 -12.019 re B* Q BT 0 0 0 scn /GS0 gs /T1_0 1 Tf 0 Tc 6.9999 0 0 6.9999 44.7874 753.1085 Tm (O'KANE)Tj 4.8997 0 0 4.8997 72.1701 753.1085 Tm [(ET)-384(AL)]TJ 6.9999 0 0 6.9999 85.4929 753.1085 Tm (.)Tj /T1_3 1 Tf 65.036 0 Td (17)Tj ET /Document /MC0 BDC q 455.096 759.571 -66.24 -15.6 re W n q /GS1 gs 66.642 0 0 15.744 388.728 743.928 cm /Im0 Do Q EMC Q /Document /MC1 BDC q 463.578 757.474 54.142 -11.282 re W n 1 1 1 scn /GS1 gs 463.578 746.192 54.142 11.282 re f q 1 0 0 1 482.25 747.988 cm /CS1 cs 1 scn /GS0 gs 0 0 m 0 -0.707 -0.157 -1.162 -0.66 -1.444 c -0.66 -1.539 l 2.451 -1.539 l 2.451 -1.444 l 1.948 -1.162 1.792 -0.707 1.792 0 c 1.792 6.03 l 1.792 6.722 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/T1_0 1 Tf 10.0001 0 0 10.0001 46.4882 528.4345 Tm (9.2.3)Tj /T1_1 1 Tf 2.976 0 Td (|)Tj /T1_0 1 Tf 1.054 0 Td [(Unexplaine)-10(d)-260(anaemia)]TJ /T1_1 1 Tf 7.9999 0 0 7.9999 46.4882 502.4125 Tm [(Unexplain)14(ed)-445(anaemi)11(a)-439(or)-438(fatigue)-437(may)-435(be)-437(a)-439(symptom)-436(of)-434(other)-436(nutri-)]TJ 0 -1.623 TD [(tional)-530(deficienc)10(ies)-536(including)-529(protein,)-525(zinc,)-535(copper)-528(and)-533(seleniu)13(m)-534(so)]TJ 0 -1.63 TD [(levels)-258(of)-257(these)-249(should)-258(all)-258(be)-253(checked.)]TJ 5.9998 0 0 5.3325 174.0472 479.9621 Tm (2)Tj /T1_2 1 Tf 0.567 0 Td (\226)Tj /T1_1 1 Tf 0.0001 Tc 0.576 0 Td (4,114,115,117,144)Tj /T1_0 1 Tf 0 Tc 10.0001 0 0 10.0001 46.4882 437.3857 Tm (9.3)Tj /T1_1 1 Tf 2.177 0 Td (|)Tj /T1_0 1 Tf 1.049 0 Td [(Low)-265(vitamin)-264(D)-260(levels)]TJ /T1_1 1 Tf 7.9999 0 0 7.9999 46.4882 411.4203 Tm [(A)14(lt)23(ho)23(ug)27(h)-405(lo)26(w)-402(se)19(ru)27(m)-400(25)24(OH)20(D)-402(le)26(v)14(el)19(s)-402(a)14(re)-394(no)23(t)-404(a)-404(ba)21(rr)28(ie)22(r)-404(to)-395(ba)28(ri)26(at)21(ri)26(c)-404(su)22(r-)]TJ 0 -1.623 TD [(g)14(er)24(y)14(,)-313(v)14(it)26(am)25(in)-300(D)-310(in)26(s)16(uf)23(fi)22(c)15(ie)22(nc)21(y)-305(or)-296(de)23(fi)22(c)15(ie)22(nc)28(y)-312(sh)22(o)16(ul)23(d)-305(be)-296(tr)21(e)17(at)21(ed)-296(pr)27(eo)19(pe)30(ra)21(-)]TJ 0 -1.63 TD [(ti)26(ve)24(ly)-537(es)19(pe)30(ci)20(a)14(ll)26(y)-553(w)16(he)23(re)-536(th)20(e)-550(s)16(ur)27(gi)19(c)15(a)14(l)-550(pr)20(o)16(c)15(ed)23(ur)20(e)-550(is)-532(li)22(ke)21(l)16(y)-553(to)-537(re)24(s)16(ul)23(t)-553(in)]TJ 0 -1.623 TD [(re)24(du)27(c)15(ti)19(o)16(ns)-375(in)-371(se)19(ru)27(m)-386(25)24(OH)27(D)-388(l)16(ev)24(el)26(s.)]TJ 5.9998 0 0 5.3325 169.6251 375.9873 Tm [(3,)34(44)29(,4)25(8,)34(52)]TJ 7.9999 0 0 7.9999 199.8425 372.4156 Tm [(Fo)26(ll)19(o)16(w)16(in)19(g)-383(su)22(rg)28(er)24(y)14(,)-391(if)-375(pe)30(o-)]TJ -19.169 -1.623 Td [(pl)23(e)-508(pr)27(es)26(en)23(t)-503(w)16(it)19(h)-504(v)14(it)19(a)14(mi)23(n)-504(D)-501(in)19(s)16(uf)23(fi)22(c)15(ie)22(nc)28(y/)22(de)23(f)17(ic)20(ie)22(nc)28(y)14(,)-512(a)14(dh)27(er)24(en)23(c)15(e)-508(w)16(it)19(h)]TJ 0 -1.63 TD [(th)27(e)-649(re)24(c)15(o)16(mm)22(en)23(de)30(d)-646(su)22(pp)27(l)16(em)21(en)23(ts)-629(s)16(ho)23(ul)23(d)-646(be)-629(c)15(he)23(c)15(ke)21(d.)-629(Ho)25(we)25(v)14(er)24(,)-647(fo)19(r)]TJ 0 -1.623 TD [(ma)25(ny)-263(pe)23(op)23(l)16(e,)-268(de)23(s)16(pi)26(te)-267(go)23(od)-268(a)14(dh)27(er)24(en)23(c)15(e,)-268(a)14(dd)27(it)19(io)29(na)21(l)-274(su)22(pp)27(le)26(me)21(nt)27(a)14(ti)19(o)16(n)-277(wi)21(th)]TJ T* [(v)14(it)19(a)14(mi)23(n)-284(D)-289(a)14(nd)-271(hi)19(g)14(he)23(r)-284(ma)25(in)26(te)24(na)21(nc)28(e)-288(do)23(s)16(es)-279(m)18(ay)-277(be)-274(re)24(qu)27(ir)19(e)17(d.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 245.5369 323.9432 Tm [(3,)34(44)29(,4)25(8,)25(62)29(,)20(63)]TJ 0 Tc 7.9999 0 0 7.9999 61.5118 307.3889 Tm [(Vitamin)-440(D)-445(deficiency)-443(requires)-443(correction)-443(with)-448(loading)-439(doses)-446(of)]TJ -1.878 -1.623 Td [(vitamin)-533(D.)]TJ 5.9998 0 0 5.3325 84.1889 297.9779 Tm (3,48)Tj 7.9999 0 0 7.9999 100.1196 294.4062 Tm [(Many)-534(healthcare)-533(professiona)17(ls)-542(have)-537(access)-532(to)-537(local)]TJ -6.704 -1.623 Td [(guidelines/)11(protocols)-522(for)-520(treatment)-524(of)-526(vitamin)-518(D)-530(deficien)10(cy.)-529(In)-524(the)]TJ T* [(absence)-724(of)-739(these,)-726(the)-735(Royal)-731(Osteopo)12(rosis)-734(Society)-725(\(ROS\))-733(gives)]TJ 0 -1.63 TD [(recommend)14(ations)-389(for)-385(replacem)11(ent.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 169.5118 258.9731 Tm (105)Tj 0 Tc 7.9999 0 0 7.9999 182.948 255.4015 Tm [(For)-386(adolesce)11(nts,)-391(refer)-382(to)-388(ROS)]TJ -17.058 -1.623 Td [(paediatri)11(c)-581(guidelines.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 121.6063 245.9904 Tm (145)Tj 0 Tc 7.9999 0 0 7.9999 136.5165 242.4188 Tm [(For)-577(those)-576(people)-573(who)-578(remain)-577(vitamin)-568(D)]TJ -11.254 -1.623 Td [(deficient)-692(or)-700(need)-698(a)-702(more)-693(aggressive)-696(approach,)-689(a)-702(referral)-699(to)-700(a)]TJ T* [(secondar)12(y)-262(care)-252(specialist)-251(is)-262(recommend)14(ed.)]TJ /T1_0 1 Tf 10.0001 0 0 10.0001 46.4882 177.3921 Tm (9.4)Tj /T1_1 1 Tf 2.177 0 Td (|)Tj /T1_0 1 Tf 1.049 0 Td [(Vitami)-7(n)-260(A)-260(deficiency)]TJ /T1_1 1 Tf 7.9999 0 0 7.9999 46.4882 151.4267 Tm [(Vitamin)-922(A)-936(deficie)11(ncy)-929(can)-929(lead)-931(to)-926(visual)-927(problems)-917(such)-928(as)]TJ T* [(xerophthal)11(mia)-253(and)-249(loss)-247(of)-257(night)-252(vision)]TJ 0.0001 Tc 5.9998 0 0 5.3325 176.9952 141.959 Tm (106,108)Tj 0 Tc 7.9999 0 0 7.9999 200.9196 138.3874 Tm [(and)-249(reduced)-252(male)-246(fertility)]TJ -19.304 -1.623 Td [(and)-526(may)-520(also)-525(result)-526(in)-520(foetal)-529(abnormal)14(ities.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 206.5889 128.9763 Tm (95,146)Tj 0 Tc 7.9999 0 0 7.9999 229.3228 125.4047 Tm [(Vitamin)-518(A)-525(levels)]TJ -22.855 -1.623 Td [(should)-272(be)-274(measured)-267(if)-275(there)-272(are)-274(clinical)-276(concerns)12(,)-278(and)-278(if)-275(appropria)11(te,)-276(a)]TJ 0 -1.623 TD [(referral)-295(to)-296(an)-298(ophtha)14(lmologist)-293(should)-294(be)-296(considere)13(d.)-296(For)-301(treatment)-290(of)]TJ 0 -1.63 TD [(vitamin)-398(A)-397(deficiency)-394(in)-400(adults,)-396(oral)-400(supplement)17(ation)-398(with)-398(vitamin)-398(A,)]TJ 0 -1.623 TD [(10)-479(000)]TJ /T1_2 1 Tf 3.338 0 Td (\226)Tj /T1_1 1 Tf 0.567 0 Td [(25)-479(000)-474(IU)-475(d)]TJ /T1_3 1 Tf 5.9998 0 0 5.3325 124.4409 76.989 Tm (\025)Tj /T1_1 1 Tf 0.68 0 Td (1)Tj 7.9999 0 0 7.9999 135.7795 73.4173 Tm [(for)-477(1)]TJ /T1_2 1 Tf 2.303 0 Td (\226)Tj /T1_1 1 Tf 0.574 0 Td [(2)-477(weeks)-469(for)-477(clinical)-474(improveme)12(nt)-476(is)]TJ -14.039 -1.623 Td [(recommend)14(ed.)]TJ 5.9998 0 0 5.3325 97.9653 63.9496 Tm (3,72,84)Tj 7.9999 0 0 7.9999 120.5291 60.4346 Tm [(Higher)-332(doses,)-334(including)-331(intramuscula)11(r)-340(injection)12(s,)]TJ -9.255 -1.63 Td [(may)-464(be)-459(needed)-462(if)-460(the)-466(person)-456(is)-461(experiencin)9(g)-468(night)-458(blindness.)]TJ 5.9998 0 0 5.3325 269.4614 50.9669 Tm (3,4,147)Tj 7.9999 0 0 7.9999 307.729 528.4345 Tm [(The)-676(levels)-676(should)-669(be)-678(rechecked)-670(at)-681(3)-682(months)13(.)]TJ 5.9998 0 0 5.3325 484.6676 531.9495 Tm (72)Tj 7.9999 0 0 7.9999 496.9699 528.4345 Tm [(For)-676(vitamin)-674(A)]TJ -23.655 -1.63 Td [(deficie)11(ncy)-312(that)-313(does)-313(not)-311(respond)-308(to)-310(oral)-315(supplem)16(entation,)-313(an)-313(onward)]TJ T* [(referral)-572(to)-586(a)-581(specialist)-577(is)-581(needed)-575(as)-586(intramuscu)16(lar)-586(injection)12(s)-586(may)]TJ T* [(be)-253(required.)]TJ 1.871 -1.63 Td [(Silva)-451(et)-451(al.)-449(highlight)-444(that)-441(there)-450(are)-451(no)-445(guidelines)-443(for)-449(vitamin)-448(A)]TJ -1.871 -1.623 Td [(replacem)11(ent)-686(in)-690(adolesce)11(nts.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 410.4566 466.9794 Tm (16)Tj 0 Tc 7.9999 0 0 7.9999 422.8723 463.4077 Tm [(We)-681(recommend)-680(seeking)-686(special)11(ist)]TJ -14.393 -1.623 Td (advice.)Tj /T1_0 1 Tf 10.0001 0 0 10.0001 307.729 411.4203 Tm (9.5)Tj /T1_1 1 Tf 2.171 0 Td (|)Tj /T1_0 1 Tf 1.054 0 Td [(Vitamin)-262(E)-261(and)-264(vitamin)-264(K)-264(deficiency)]TJ /T1_1 1 Tf 7.9999 0 0 7.9999 307.729 385.3983 Tm [(Symp)13(toms)-580(of)-576(vitamin)-575(E)-576(deficiency)-578(include)-573(periphera)15(l)-586(neuropat)16(hy,)]TJ T* [(muscle)-422(weakness)-426(and)-434(ataxia.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 410.6833 375.9873 Tm (84)Tj 0 Tc 7.9999 0 0 7.9999 421.0582 372.4156 Tm [(Oral)-433(vitamin)-426(E)-434(100)]TJ /T1_2 1 Tf 8.639 0 Td (\226)Tj /T1_1 1 Tf 0.567 0 Td [(400)-438(IU)-432(d)]TJ /T1_3 1 Tf 5.9998 0 0 5.3325 527.7542 375.9873 Tm (\025)Tj /T1_1 1 Tf 0.68 0 Td (1)Tj 7.9999 0 0 7.9999 538.7526 372.4156 Tm (has)Tj -28.878 -1.623 Td [(been)-386(recommende)10(d)-398(for)-392(maintenance)-385(of)-392(vitamin)-391(E)-399(levels)-385(recognizing)]TJ 0 -1.63 TD [(more)-459(may)-457(be)-466(needed)-462(for)-463(repletion)13(,)]TJ 5.9998 0 0 5.3325 435.7416 349.9652 Tm (3,51)Tj 7.9999 0 0 7.9999 451.1054 346.3936 Tm [(while)-457(Bays)-459(et)-465(al.)-463(suggested)]TJ -17.922 -1.623 Td [(400-)-414(to)-416(800-IU)-422(vitamin)-412(E.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 401.6125 336.9826 Tm (53)Tj 0 Tc 7.9999 0 0 7.9999 411.8172 333.4109 Tm [(Serum)-417(levels)-414(should)-414(be)-423(monito)13(red)-424(and)]TJ -13.011 -1.623 Td [(treatm)13(ent)-339(continued)-333(until)-335(serum)-340(levels)-336(reach)-331(normal)-340(range.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 516.1321 323.9432 Tm (3,53,84)Tj 0 Tc 7.9999 0 0 7.9999 538.6959 320.4283 Tm (For)Tj -28.871 -1.63 Td [(vitamin)-370(E)-378(deficie)11(ncy)-376(that)-377(does)-370(not)-374(respond)-372(to)-374(oral)-371(supplementati)15(on,)]TJ 0 -1.623 TD [(refer)-255(onto)-252(a)-262(special)11(ist)-263(as)-253(intramuscula)11(r)-255(injections)-256(may)-251(be)-260(needed.)]TJ 1.871 -1.623 Td [(Large)-728(vitamin)-731(E)-732(doses)-729(can)-730(result)-732(in)-733(over-repl)11(acement)-728(and)]TJ -1.871 -1.623 Td [(exacerb)12(ate)-961(vitamin)-951(K)-960(deficiency)-961(and)-951(therefore)-960(affect)-955(blood)]TJ 0 -1.63 TD [(coagulatio)11(n,)-413(so)-414(care)-415(should)-407(be)-416(taken.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 441.1841 258.9731 Tm (95)Tj 0 Tc 7.9999 0 0 7.9999 451.3889 255.4015 Tm [(Furthermore)11(,)-420(assessment)-403(of)]TJ -17.958 -1.623 Td [(vitamin)-341(K)-357(should)-343(be)-352(performed)-349(when)-345(there)-350(is)-354(establish)12(ed)-352(fat-soluble)]TJ 0 -1.623 TD [(vitamin)-589(deficiency)-592(with)-597(hepatopathy,)-589(coagulopa)12(thy)-604(or)-593(osteoporo-)]TJ 0 -1.63 TD (sis.)Tj 0.0001 Tc 5.9998 0 0 5.3325 318.2739 219.9684 Tm (2,4,148)Tj 0 Tc 7.9999 0 0 7.9999 345.8267 216.3968 Tm [(For)-960(vitamin)-965(K)-967(deficienc)10(y,)-973(Ketovite)-962(tablets)-958(contain)]TJ -4.762 -1.623 Td [(acetome)12(naphthone)-311(\(vitami)12(n)-320(K\))-317(500)]TJ /T1_4 1 Tf 15.74 0 Td (\003)Tj /T1_1 1 Tf 0.517 0 Td [(g)-319(per)-317(tablet)-315(and)-313(may)-315(be)-317(used)-316(to)]TJ -16.257 -1.623 Td [(treat)-452(vitamin)-462(K)-457(deficiency)-458(although)-452(menadio)13(l)-465(sodium)-456(phosphat)15(e)-465(or)]TJ T* [(phytome)14(nadione)-318(may)-315(be)-317(taken)-320(orally.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 439.54 180.9637 Tm (149)Tj 0 Tc 7.9999 0 0 7.9999 452.4093 177.3921 Tm [(An)-320(oral)-322(dose)-313(of)-321(1)]TJ /T1_2 1 Tf 7.668 0 Td (\226)Tj /T1_1 1 Tf 0.3215 Tc 0.567 0 Td [(2m)322(gd)]TJ /T1_3 1 Tf 0 Tc 5.9998 0 0 5.3325 543.0046 180.9637 Tm (\025)Tj /T1_1 1 Tf 0.671 0 Td (1)Tj 7.9999 0 0 7.9999 307.729 164.4094 Tm [(is)-305(recommend)14(ed.)]TJ 5.9998 0 0 5.3325 367.0298 167.9811 Tm (3)Tj 7.9999 0 0 7.9999 372.9259 164.4094 Tm [(Seek)-307(further)-302(advice)-305(from)-310(a)-305(haematolog)12(ist)-312(if)-311(people)]TJ -8.15 -1.623 Td [(are)-309(taking)-304(anticoagulant)14(s)-317(such)-311(as)-310(warfarin.)-309(Onward)-301(referral)-309(is)-312(needed)]TJ T* [(if)-254(vitamin)-256(K)-258(deficien)10(cy)-262(does)-256(not)-254(respond)-251(to)-253(treatment.)]TJ /T1_0 1 Tf 10.0001 0 0 10.0001 307.729 99.4393 Tm (9.6)Tj /T1_1 1 Tf 2.171 0 Td (|)Tj /T1_0 1 Tf 1.054 0 Td [(Deficiencies)-267(associated)-266(with)-261(neurol)-10(ogical)]TJ -3.226 -1.304 Td [(symptoms/Wernicke's)-272(encepha)-9(lopathy)]TJ /T1_1 1 Tf 7.9999 0 0 7.9999 307.729 60.4346 Tm [(Myelo)13(neuropathy)-261(may)-272(have)-268(a)-269(number)-265(of)-271(causes)-271(includ)12(ing)-272(deficienci)8(es)]TJ T* [(of)-725(vitamin)-717(B12,)-728(thiamine,)-723(copper)-720(or)-721(vitamin)-724(E.)-730(Beri)-722(Beri)-729(and)]TJ ET 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[(Individuals)-265(who)-259(have)-265(malabs)-10(orptive)-265(procedures)-264(have)-265(a)-259(higher)-266(prevalence)-267(of)-267(post-surgery)-266(nutritional)]TJ 0.423 -1.399 Td [(deficiencies)-272(and)-259(care)-270(should)-263(remain)-262(with)-266(the)-260(specialist)-266(centre)]TJ 49.754 1.399 Td (GPP)Tj /T1_2 1 Tf -50.752 -3.266 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(For)-261(OAGB/MGB)-272(with)-259(BP)-266(limb)-262(length)-261(of)-267(150)-264(cm)-262(or)-256(less,)-265(follow)-265(RYGB)-267(nutritional)-263(recommenda)-13(tions)]TJ 50.177 0 Td (GPP)Tj /T1_2 1 Tf -50.752 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(For)-261(OAGB/MGB)-272(with)-259(BP)-266(limb)-262(length)-261(of)-267(greater)-263(than)-260(150)-264(cm)-262(or)-263(SADIs,)-270(follow)-265(BPD/DS)-268(nutritional)]TJ 0.423 -1.399 Td [(recommenda)-13(tions)]TJ 49.754 1.399 Td (GPP)Tj -52.687 -3.704 Td [(Abbreviatio)-12(ns:)-268(BPD/DS,)-284(duodenal)-278(switch;)-275(CKS,)-277(clinical)-277(knowledge)-278(summary)-12(;)-269(EL,)-272(evidence)-284(level)-275(and)-274(depicts)-282(where)-274(the)-275(majority)-281(of)-274(evidence)-276(lies;)-275(GPP,)-278(g)-1(ood)]TJ T* [(practice)-260(point;)-255(OAGB/MGB,)-258(one)-256(anastomosis)-261(gastric)-258(bypass/mini)-257(gastric)-258(bypass;)-253(RYGB,)-261(Roux-en-Y)-256(gastric)-258(bypass;)-253(SADIs,)-255(single)-259(anastomosis)-261(duodena)-1(l)-255(ileal)]TJ T* [(bypass)-263(with)-266(sleeve)-260(gastrecto)-14(my.)]TJ ET 0.137 0.122 0.125 scn 0.137 0.122 0.125 SCN /GS1 gs 550.488 748.63 -504 0.453 re B* q 1 0 0 1 68.995 749.083 cm 0.51 0 -0.51 12.019 re B* Q BT 0 0 0 scn /GS0 gs /T1_0 1 Tf 6.9999 0 0 6.9999 46.4882 753.1085 Tm (16)Tj /T1_1 1 Tf 65.959 0 Td (O'KANE)Tj 4.8997 0 0 4.8997 535.5778 753.1085 Tm [(ET)-372(AL)]TJ 6.9999 0 0 6.9999 548.9006 753.1085 Tm (.)Tj ET /Document /MC0 BDC 1 1 1 scn /GS1 gs 77.499 746.135 54.195 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9.359 l -18.311 9.171 -18.044 8.779 -17.714 7.977 c -13.725 -1.853 l -13.647 -1.853 l -10.286 6.109 l -6.988 -1.853 l f Q EMC /Document /MC1 BDC q 206.441 759.571 -66.24 -15.6 re W n q /GS1 gs 66.642 0 0 15.744 140.088 743.928 cm /Im0 Do Q EMC Q endstreamendobj469 0 obj<>endobj470 0 obj<>stream /CS0 cs 0.82 0.827 0.831 scn /GS0 gs 44.787 699.59 504 18.028 re f 44.787 673.625 504 25.965 re f 0.902 0.906 0.91 scn 44.787 659.622 504 14.003 re f 44.787 624.586 504 35.036 re f q 0.06 782.362 595.215 -782.302 re W n q 44.787 418.11 m 548.787 418.11 l 548.787 544.138 l 44.787 544.138 l W n q BX /Sh0 sh EX Q Q Q q 0.06 782.362 595.215 -782.302 re W n q 44.787 106.583 m 548.787 106.583 l 548.787 330.633 l 44.787 330.633 l W n q BX /Sh1 sh EX Q Q Q 0 0 0 scn /CS0 CS 0 0 0 SCN 0 w 1 j 1 J /GS1 gs 541.814 699.59 -490.053 0.51 re B* BT /T1_0 1 Tf 0.141 Tc 7.9999 0 0 7.9999 44.7874 724.5919 Tm [(TA)-8(BL)-5(E)-258(5)]TJ /T1_1 1 Tf 0 Tc 6.017 0 Td [(\(Continue)12(d\))]TJ /T1_2 1 Tf 7.4999 0 0 7.4999 51.7606 706.11 Tm [(A)-8(bnormal)-261(test)-269(results,)-261(clinical)-267(problems,)-267(pregnancy)-268(and)-266(adolescents)]TJ 0 -3.666 TD [(Recom)-11(mendations)]TJ 51.758 1.398 Td [(Grade,)-263(evidence)-267(level,)-266(range)]TJ 0 -1.398 TD [(of)-261(evidence)]TJ /T1_3 1 Tf -50.752 -1.965 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(When)-263(considering)-263(vitamin)-267(E)-267(nutritional)-263(status,)-263(adjustment)-266(sho)-9(uld)-262(be)-258(made)-265(for)-260(serum)-268(lipids)]TJ 50.177 0 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(For)-261(vitamin)-267(K)-259(deficiency,)-269(treat)-265(with)-266(1-)-258(to)-263(2-mg)-267(oral)-263(vitamin)-259(K)-266(daily)-264(\(Ketovite)-266(tablets,)-266(menadiol)-270(sodium)]TJ 0.423 -1.399 Td [(phosphate)-270(or)-256(phyto)-10(menadione\).)-269(Recheck)-263(levels)-264(afte)-10(r)-258(3)-259(months.)-269(For)-261(those)-261(on)-262(anticoagulants)-273(such)-261(as)-263(warfarin)]TJ 0 -1.406 TD [(or)-263(for)-260(vitamin)-267(K)-259(deficienc)-15(y)-253(that)-269(does)-260(not)-263(respond)-268(to)-256(treatmen)-13(t,)-259(refer)-260(to)-263(specialist)-266(for)-268(assessment)]TJ 49.754 2.805 Td (GPP)Tj -51.758 -4.672 Td [(Neuro)-11(logical)-260(sympto)-11(ms/Wernicke's)-271(encephalopathy)]TJ 1.005 -1.86 Td [(In)-259(patients)-270(who)-259(present)-266(with)-259(ne)-9(urological)-266(symptoms:)]TJ /T1_3 1 Tf 0 -1.867 TD (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Treat)-262(for)-260(thiamine)-264(de)-9(ficiency)-267(\(see)-261(section)-264(prolonged)-271(vomiting/dysphag)-14(ia/poor)-265(oral)-263(intake/risk)-270(of)-259(thiamine)]TJ 0.423 -1.406 Td (deficiency\))Tj 49.754 1.406 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -3.273 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Check)-265(for)-260(vitamin)-267(B12,)-261(copper)-265(and)-266(vitamin)-267(E)-259(deficiencies)-272(and)-259(treat)]TJ 50.178 0 Td (GPP)Tj /T1_3 1 Tf -50.752 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Refer)-261(to)-263(neurologist)-264(and)-266(haematologist)]TJ 50.178 0 Td (GPP)Tj -51.758 -1.86 Td [(Zinc)-264(and)-266(copper)-265(deficiency)]TJ /T1_3 1 Tf 1.005 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(If)-256(both)-263(zin)-9(c)-258(and)-259(copper)-265(low,)-266(consider)-264(prescri)-11(bing)-263(two)-261(Forceval)-267(daily)-264(for)-260(3)-259(months)-263(and)-266(recheck)-269(levels)]TJ 50.177 0 Td (GPP)Tj /T1_3 1 Tf -50.752 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Check)-265(both)-263(zinc)-259(and)-266(copper)-265(levels)-264(when)-263(considering)-271(zinc)-259(or)-263(copper)-265(replacement)]TJ /T1_3 1 Tf -0.575 -1.406 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(With)-258(mild)-262(zin)-9(c)-258(or)-263(copper)-265(deficiency,)-269(consider)-264(giving)-267(two)-261(Forceva)-12(l)-255(daily)-264(and)-266(recheck)-261(level)-10(s)-261(after)-261(3)-259(mon)-9(ths)]TJ 50.178 1.406 Td [(Grade)-266(D)-260(EL)-263(4)]TJ 0 -1.406 TD (GPP)Tj /T1_3 1 Tf -50.752 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(With)-258(severe)-271(zinc)-259(deficiency)-268(and)-266(normal)-267(or)-256(borderline)-268(copper)-265(level)-10(s,)-254(treat)-265(with)-266(high)-263(dose)-260(zinc)-267(supplement)-267(for)]TJ 0.423 -1.398 Td [(3)-259(months)-263(and)-266(recheck)-269(levels.)-261(If)-264(no)-262(improvement)-268(or)-263(copper)-265(levels)-264(fall,)-261(refer)-267(for)-260(specia)-11(list)-263(advice)]TJ 49.754 1.398 Td (GPP)Tj /T1_3 1 Tf -50.752 -3.266 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(With)-258(severe)-271(copper)-265(deficiency,)-269(refer)-260(for)-268(specialist)-266(advice)]TJ 50.177 0 Td (GPP)Tj /T1_3 1 Tf -50.752 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(When)-263(giving)-259(additional)-271(zinc)-267(and)-259(copper,)-266(maintain)-265(a)-259(ratio)-270(of)-259(8-)-266(to)-256(15-mg)-269(zinc)-267(to)-256(1-mg)-267(copper.)-263(Clo)-9(se)-255(mon)-9(itoring)]TJ 0.423 -1.398 Td 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[(18)-262(months)-263(following)-271(surgery)-258(to)-263(allow)-265(weight)]TJ -23.978 -1.406 Td [(stabilization)-270(and)-259(a)-267(varied)-261(nutritious)-267(diet)]TJ 49.754 1.406 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -3.266 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Women)-265(with)-259(a)-267(BMI)-259(<)-259(29.9)-270(kg)-260(m)]TJ 5.6248 0 0 4.9992 167.9243 285.6755 Tm (2)Tj 7.4999 0 0 7.4999 171.1559 282.3873 Tm [(,)-258(planni)-10(ng)-261(for)-260(pregnancy,)-271(should)-263(take)-261(an)-259(additional)-271(400)-264(micrograms/d)-14(ay)-256(folic)]TJ -13.916 -1.406 Td [(acid)-263(prior)-267(to)-256(concepti)-12(on)-262(until)-259(the)-267(12th)-263(week)-264(of)-259(pregnancy)]TJ 49.754 1.406 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -3.273 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Women)-265(with)-259(type)-264(2)-259(diabetes)-270(mellitus)-266(or)-263(a)-259(BMI)-259(>)-267(30)-262(kg)-260(m)]TJ 5.6248 0 0 4.9992 250.1291 261.1841 Tm (2)Tj 7.4999 0 0 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[(Pregnant)-264(women,)-266(following)-264(bariat)-10(ric)-262(surgery,)-266(should)-263(undergo)-261(nut)-8(ritional)-263(screening)-265(during)-265(each)-269(trimester.)-267(This)]TJ 0.423 -1.398 Td [(should)-263(include)-267(ferritin,)-266(folate,)-263(vitamin)-267(B12,)-268(calcium,)-267(vitamin)-267(D,)-262(vitamin)-267(A)]TJ 49.754 1.398 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -3.266 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Pregnant)-264(women,)-266(following)-264(bariat)-10(ric)-262(surgery,)-266(especially)-269(those)-261(who)-259(have)-265(had)-266(long-limbed)-269(bypass)-263(or)-263(BPD/DS)]TJ 0.423 -1.398 Td [(procedures,)-273(may)-260(be)-258(at)-268(risk)-256(of)-267(low)-257(vitamins)-271(E)-259(and)-259(K)-266(levels.)-261(These)-263(sho)-9(uld)-262(be)-258(monitored)-270(during)-265(pregnancy)-263(if)]TJ T* [(clinically)-271(indicated)]TJ 49.754 2.797 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -4.664 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(A)-256(more)-269(frequent)-267(review)-266(with)-259(the)-260(specia)-11(list)-263(bariatric)-264(dietitian)-264(may)-268(be)-258(required)]TJ 50.177 0 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Reference)-265(ranges)-270(change)-265(in)-260(pregnancy.)-268(Please)-261(refer)-267(to)-263(perinatal)-266(reference)-271(ranges)-262(when)-263(checking)-265(blood)-264(results)]TJ 0.423 -1.406 Td [(http://perin)-12(atology.com/Reference)-18(/Reference)-271(Ranges/Reference)-270(for)-268(Serum.htm)]TJ 49.754 1.406 Td (GPP)Tj -51.758 -3.273 Td [(Adol)-9(escents)]TJ /T1_3 1 Tf 1.005 -1.859 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Adolescents)-264(who)-267(have)-265(undergone)-262(bariat)-10(ric)-262(surgery)-265(should)-263(be)-258(monito)-11(red)-260(for)-260(dietary)-270(adherence)-265(and)-259(nut)-8(ritional)]TJ 0.423 -1.406 Td 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obj<>endobj472 0 obj<>endobj473 0 obj<>stream /CS0 cs 0.82 0.827 0.831 scn /GS0 gs 46.488 699.59 504 18.028 re f 46.488 673.625 504 25.965 re f q 0.06 782.362 595.215 -782.302 re W n q 46.488 337.606 504 297.524 re W n q BX /Sh0 sh EX Q Q Q q 0.06 782.362 595.215 -782.302 re W n q 46.488 176.598 504 122.513 re W n q BX /Sh1 sh EX Q Q Q 0.902 0.906 0.91 scn 46.488 85.606 504 14.003 re f 46.488 71.603 504 14.003 re f 46.488 47.112 504 24.491 re f 0 0 0 scn /CS0 CS 0 0 0 SCN 0 w 1 j 1 J /GS1 gs 543.515 699.59 -490.053 0.51 re B* BT /T1_0 1 Tf 0.141 Tc 7.9999 0 0 7.9999 46.4882 724.5919 Tm [(TA)-8(BL)-5(E)-258(5)]TJ /T1_1 1 Tf 0 Tc 6.017 0 Td [(Abnormal)-249(test)-251(results,)-257(clinical)-255(problems,)-246(pregnancy)-255(and)-249(adolescents)]TJ /T1_2 1 Tf 7.4999 0 0 7.4999 53.4614 706.11 Tm [(A)-8(bnormal)-261(test)-269(results,)-261(clinical)-267(problems,)-267(pregnancy)-268(and)-266(adolescents)]TJ 0 -3.666 TD [(Recom)-11(mendations)]TJ 51.758 1.398 Td [(Grade,)-263(evidence)-267(level,)-266(range)]TJ 0 -1.398 TD [(of)-261(evidence)]TJ /T1_1 1 Tf -51.758 -1.965 Td [(Protein)-273(malnutrition/protein)-271(energy)-269(malnutrition/oedema)]TJ /T1_3 1 Tf 1.005 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(If)-256(people)-270(present)-266(with)-259(signs/sympt)-12(oms)-263(of)-259(protein)-269(malnutrition/protein)-271(energy)-269(malnutrition/oedema)-17(,)-258(investigate)]TJ 0.423 -1.399 Td [(potential)-269(causes)-262(and)-266(refer)-260(back)-266(to)-263(bariatric)-264(centre)]TJ 49.754 1.399 Td (GPP)Tj -51.758 -3.266 Td [(Ana)-9(emia)]TJ 1.005 -1.867 Td [(Iron)-265(deficiency)-268(anaemia)]TJ /T1_3 1 Tf 0 -1.867 TD (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Sources)-265(of)-259(blood)-264(loss)-260(sho)-9(uld)-262(be)-258(considered,)-267(investigated)-275(and)-259(excluded)-268(in)-260(individual)-12(s)-261(who)-259(present)-266(with)-259(iro)-9(n)]TJ 0.423 -1.398 Td [(deficiency)-268(anaem)-10(ia)]TJ 49.754 1.398 Td [(Grade)-266(D)-260(EL4)]TJ /T1_3 1 Tf -50.752 -3.266 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(For)-261(people)-262(over)-269(12)-262(years)-262(old)-259(and)-266(pregnant)-267(women)-265(diagnosed)-261(with)-266(iron)-266(deficiency)-268(anaemia,)-266(treat)-265(iron)-266(deficiency)]TJ 0.423 -1.406 Td [(following)-264(NICE)-272(CKS)-261(Anaemia)]TJ /T1_3 1 Tf 12.707 0 Td (\227)Tj /T1_1 1 Tf 0.794 0 Td [(iron)-266(deficiency)]TJ 36.254 1.406 Td [(Grade)-266(D)-260(EL)-263(4)]TJ -50.752 -3.273 Td [(Vitamin)-262(B12)-267(deficiency)]TJ /T1_3 1 Tf 0 -1.86 TD (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Treat)-262(vitamin)-267(B12)-259(deficien)-14(cy)-262(immediately)-265(using)-267(NICE)-264(CKS:)-260(Anaemia)]TJ /T1_3 1 Tf 29.534 0 Td (\227)Tj /T1_1 1 Tf 0.786 0 Td [(B12)-267(and)-259(fola)-10(te)-260(deficiency.)-266(Do)-265(not)-263(give)]TJ -29.896 -1.406 Td 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[(For)-261(people)-262(with)-266(no)-262(neurological)-267(involvem)-12(ent,)-261(NICE)-264(recommend)-268(administe)-11(ring)-257(hydroxocobal)-15(amin)-259(1)-267(mg)]TJ 0.423 -1.398 Td [(intramuscularly)-269(three)-270(times)-263(a)-259(week)-264(for)-260(2)-259(weeks)]TJ 49.754 1.398 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -3.266 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(After)-265(treatment)-264(of)-259(vitamin)-267(B12)-267(deficiency,)-269(provide)-264(main)-9(tenance)-264(treatment)-264(with)-266(1)-259(mg)-265(intramuscularly)-269(every)]TJ 0.423 -1.406 Td (2)Tj /T1_3 1 Tf 0.575 0 Td (\226)Tj /T1_1 1 Tf 0.575 0 Td [(3)-259(months)-263(lifelong)]TJ 48.605 1.406 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -3.273 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Seek)-262(urgent)-265(specialist)-266(advice)-268(from)-265(neurologist)-264(and)-266(haematologist,)-267(if)-265(there)-262(is)-264(possible)-264(neurologica)-12(l)-255(involvem)-12(ent,)]TJ 0.423 -1.398 Td [(such)-261(as)-263(unexplained)-272(sensory)-261(and/or)-264(motor)-266(and)-259(gai)-9(t)-258(symptoms)]TJ 49.754 1.398 Td (GPP)Tj -50.752 -3.266 Td [(Folic)-261(acid)-263(defici)-12(ency)]TJ /T1_3 1 Tf 0 -1.867 TD (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Check)-265(and)-259(treat)-265(for)-260(vitamin)-267(B12)-267(deficiency,)-269(before)-263(initiating)-269(folic)-268(acid)-263(treatment)-264(to)-263(avoid)-263(precipitation)-271(of)]TJ 0.423 -1.398 Td [(subacute)-266(combined)-271(degeneration)-270(of)-259(the)-260(spinal)-263(cord)]TJ 49.754 1.398 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -3.266 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Treat)-262(folic)-260(acid)-270(deficiency)-268(using)-260(NICE)-264(CKS:)-268(Anaemia)]TJ /T1_3 1 Tf 22.587 0 Td (\227)Tj /T1_1 1 Tf 0.794 0 Td [(B12)-259(and)-266(folate)-262(deficien)-14(cy.)-259(Folic)-261(acid)-270(5)-259(mg)-258(orally)-265(daily)-264(for)]TJ -22.957 -1.398 Td 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[(Vitamin)-270(D)-260(and)-259(Bone)-268(Health:)-263(A)-264(Practical)-263(Clinical)-268(Guideline)-267(for)-260(Patient)-270(Management)]TJ 49.754 1.398 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -3.266 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(In)-259(absence)-267(of)-259(local)-268(children)-268(and)-259(young)-262(people)-270(guidelines)-263(for)-260(vita)-10(min)-256(D)-260(repla)-10(cement,)-260(refer)-267(to)-263(National)]TJ 0.423 -1.398 Td [(Osteoporosis)-270(Society)-268(guidance:)-267(A)-256(Practi)-13(cal)-258(Clinical)-268(Guideline)-267(for)-260(Patient)-270(Management)-269(in)-260(Children)-267(and)-259(Young)]TJ 0 -1.406 TD [(People)-267(or)-263(a)-259(paediatrician)]TJ 49.754 2.804 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -4.664 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(If)-256(the)-267(person)-261(remains)-266(vitamin)-267(D)-260(deficient)-272(despite)-260(treatmen)-13(t,)-259(refer)-260(to)-263(a)-259(seco)-11(ndary)-257(care)-270(specialist)]TJ 50.177 0 Td (GPP)Tj /T1_3 1 Tf -50.752 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(In)-259(people)-262(with)-266(severe)-263(vitamin)-267(D)-260(deficiency,)-269(high)-263(dose)-267(vitamin)-267(D)-260(injections)-262(might)-269(be)-258(required,)-266(which)-265(should)-263(be)]TJ 0.423 -1.406 Td [(given)-262(follo)-10(wing)-261(specialist)-266(consultation)-12(,)-258(in)-260(people)-270(with)-259(known)-266(history/high)-265(risk)-264(of)-267(hypercalcaemia,)-272(e.g.,)-259(people)]TJ 0 -1.398 TD [(with)-266(kidney)-264(stones,)-266(sarcoidosis,)-267(renal)-260(impa)-9(irment)-261(and)-266(atrial)-265(fibrillation)]TJ 49.754 2.805 Td (GPP)Tj -51.758 -4.672 Td [(Vitam)-10(in)-260(A)-264(deficiency/disturbances)-276(in)-260(night)-265(vision/xeropht)-13(halmia)]TJ /T1_3 1 Tf 1.005 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(In)-259(adults,)-263(treat)-265(vitamin)-267(A)-264(deficiency,)-269(with)-259(10)-262(000-)-271(to)-256(25)-270(000-IU)-262(oral)-263(vitamin)-267(A)-264(daily)-264(for)-260(1)]TJ /T1_3 1 Tf 38.325 0 Td (\226)Tj /T1_1 1 Tf 0.575 0 Td [(2)-259(weeks)-268(for)-260(clinical)]TJ -38.476 -1.398 Td [(improvement.)-273(Recheck)-263(vitamin)-267(A)-264(levels)-264(at)-261(3)-259(months)]TJ 49.754 1.398 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -3.266 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(For)-261(vitamin)-267(A)-256(defici)-12(ency)-263(that)-262(does)-260(not)-263(respond)-268(to)-263(treatment,)-265(refer)-267(to)-256(specia)-11(list)-255(for)-268(assessment)-268(and)]TJ 0.423 -1.398 Td [(consideration)-268(of)-267(intramuscular)-267(vitamin)-267(A)-264(injections)]TJ 49.754 1.398 Td (GPP)Tj /T1_3 1 Tf -50.752 -3.266 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(In)-259(adolescents,)-268(with)-266(vitamin)-267(A)-256(deficienc)-15(y,)-255(refer)-267(for)-260(specia)-11(list)-263(support)]TJ 50.177 0 Td (GPP)Tj -51.757 -1.867 Td [(Vitam)-10(in)-260(E)-259(and)-266(vitamin)-267(K)-259(deficiency)]TJ /T1_3 1 Tf 1.005 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Treat)-262(vitamin)-267(E)-259(deficiency)-268(with)-266(oral)-263(vitamin)-267(E)-259(100)]TJ /T1_3 1 Tf (\226)Tj /T1_1 1 Tf 22.209 0 Td [(400)-264(IU)-263(d)]TJ /T1_4 1 Tf 5.6248 0 0 4.9992 260.3338 79.2 Tm (\025)Tj /T1_1 1 Tf 0.675 0 Td (1)Tj 7.4999 0 0 7.4999 267.3637 75.8551 Tm [(.)-262(Recheck)-263(levels)-264(after)-268(3)-259(months)]TJ 23.237 0 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -50.752 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(For)-261(vitamin)-267(E)-259(deficiency)-268(that)-262(does)-267(not)-263(respond)-260(to)-263(treatment,)-265(refer)-267(to)-263(specialist)-266(for)-260(assessment)-268(and)]TJ 0.423 -1.398 Td 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18.045 2.921 l 20.542 2.921 l 21.61 2.921 22.143 2.748 22.427 2.293 c 22.536 2.293 l 22.536 4.271 l 22.427 4.287 l 22.143 3.832 21.61 3.659 20.542 3.659 c 18.045 3.659 l h -6.988 -1.853 m -6.91 -1.853 l -3.046 7.773 l -2.669 8.7 -2.324 9.156 -1.979 9.359 c -1.979 9.454 l -4.303 9.454 l -4.303 9.359 l -3.816 9.093 -3.706 8.37 -4.036 7.539 c -6.407 1.602 l -9.627 9.485 l -9.705 9.485 l -13.097 1.617 l -15.532 7.806 l -15.814 8.543 -15.735 9.093 -15.281 9.359 c -15.281 9.454 l -18.672 9.454 l -18.672 9.359 l -18.311 9.171 -18.044 8.779 -17.714 7.977 c -13.725 -1.853 l -13.647 -1.853 l -10.286 6.109 l -6.988 -1.853 l f Q EMC /Document /MC1 BDC q 206.441 759.571 -66.24 -15.6 re W n q /GS2 gs 66.642 0 0 15.744 140.088 743.928 cm /Im0 Do Q EMC Q endstreamendobj474 0 obj<>endobj475 0 obj<>endobj476 0 obj<>stream BT /CS0 cs 0 0 0 scn /GS0 gs /T1_0 1 Tf 7.9999 0 0 7.9999 44.7874 723.4014 Tm [(bariatric)-296(surgery.)-293(Additional)-293(seleniu)13(m)-301(may)-301(be)-296(needed)-299(by)-299(some)-294(people)]TJ 0 -1.623 TD [(following)-514(RYGB)-512(and)-519(especia)12(lly)-520(following)-514(BPD/DS)11(.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 228.3023 713.9904 Tm (69,73,89,107)Tj 0 Tc 7.9999 0 0 7.9999 267.307 710.4187 Tm (Over-)Tj -27.815 -1.623 Td [(the-coun)12(ter)-785(preparati)12(ons)-783(or)-778(Brazil)-779(nuts)-780(may)-776(also)-780(be)-778(used)-777(to)]TJ 0 -1.63 TD [(supplement)-245(selenium.)]TJ /T1_1 1 Tf 10.0001 0 0 10.0001 44.7874 645.392 Tm (8.9)Tj /T1_0 1 Tf 2.177 0 Td (|)Tj /T1_1 1 Tf 1.049 0 Td (Thiamine)Tj /T1_0 1 Tf 7.9999 0 0 7.9999 44.7874 619.4266 Tm [(People)-638(are)-635(at)-638(high)-634(risk)-641(of)-640(developi)13(ng)-639(thiamine)-637(deficien)10(cy)-638(post-)]TJ T* [(bariatric)-438(surgery)-437(\(see)-441(Section)-442(7.6\).)-441(Garg)-441(et)-444(al.)-449(reporte)13(d)-447(that)-441(people)]TJ 0 -1.623 TD [(who)-351(saw)-351(a)-354(dietitian)-345(had)-349(more)-346(favourable)-346(thiamine)-346(levels)-350(at)-355(3-month)]TJ T* [(post-surg)13(ery.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 90.3685 583.9935 Tm (126)Tj 0 Tc 7.9999 0 0 7.9999 59.811 567.4392 Tm [(The)-513(complete)-504(multivitam)12(in)-520(and)-512(mineral)-511(supplement)-500(containing)]TJ -1.878 -1.63 Td [(thiamine)-438(may)-443(not)-438(be)-444(sufficient)-442(to)-445(prevent)-436(deficien)10(cy.)-444(Parrott)-441(et)-444(al.)]TJ T* [(recommend)-390(that)-398(all)-407(peopl)13(e)-408(take)-398(12)-401(mg)-400(d)]TJ /T1_2 1 Tf 5.9998 0 0 5.3325 192.4157 544.9888 Tm (\025)Tj /T1_0 1 Tf 0.671 0 Td (1)Tj 7.9999 0 0 7.9999 203.1306 541.4172 Tm [(thiamin)13(e)-408(and)-398(preferab)13(ly)]TJ -19.793 -1.623 Td [(50-mg)-246(dose)-249(of)-250(thiamine)-247(once)-251(or)-253(twice)-246(a)-255(day)-249(from)-246(a)-255(vitamin)-242(B-complex)]TJ 0 -1.63 TD (supplement.)Tj 5.9998 0 0 5.3325 87.0803 518.9668 Tm (3)Tj 7.9999 0 0 7.9999 93.4299 515.3951 Tm [(We)-355(were)-362(unable)-359(to)-360(find)-362(sufficien)12(t)-362(evidence)-357(to)-360(support)]TJ -6.08 -1.623 Td [(this;)-414(however,)-412(we)-421(recognize)-413(that)-412(further)-415(research)-412(and)-420(evidence)-406(are)]TJ 0 -1.623 TD [(needed)-377(in)-385(this)-384(important)-374(area.)-378(For)-386(people)-374(in)-385(which)-377(there)-386(is)-383(concern)]TJ 0 -1.63 TD [(that)-299(a)-298(complete)-292(multivitam)12(in)-300(and)-292(mineral)-299(supplemen)18(t)-305(contain)13(ing)-301(thia-)]TJ 0 -1.623 TD [(mine)-449(is)-447(not)-452(sufficien)12(t,)-456(considerat)17(ion)-454(should)-443(be)-452(given)-447(to)-445(prescribing)]TJ T* [(additional)-399(thiamine)-403(or)-402(a)-411(vitamin)-405(B-comple)13(x)-411(supplement)-394(for)-406(the)-409(first)]TJ 0 -1.63 TD [(three)-258(to)-253(four)-258(postoper)14(ative)-255(months.)]TJ 1.878 -1.623 Td [(If)-301(peopl)13(e)-302(present)-293(with)-299(prolonged)-291(vomiting,)-291(dysphag)13(ia,)-301(poor)-294(nutri-)]TJ -1.878 -1.623 Td [(tional)-459(intake,)-459(inability)-452(to)-466(tolerate)-459(vitamin)-455(and)-462(mineral)-455(supplements)12(,)]TJ 0 -1.623 TD [(high)-259(alcohol)-254(intake)-259(or)-260(fast)-265(weight)-254(loss,)-263(additional)-250(thiamine)-254(supplemen-)]TJ 0 -1.63 TD [(tation)-433(should)-428(be)-437(administere)12(d)-440(immediatel)11(y)-440(to)-438(prevent)-429(the)-438(develop-)]TJ 0 -1.623 TD [(ment)-377(of)-385(Wernicke's)-372(encephalopat)14(hy.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 174.3873 375.9873 Tm (122,124)Tj /T1_3 1 Tf 0 Tc 3.657 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.567 0 Td (128)Tj 0 Tc 7.9999 0 0 7.9999 213.1086 372.4156 Tm [(Consideratio)10(n)-383(should)]TJ -21.04 -1.623 Td [(be)-267(given)-270(to)-267(admission)-265(and)-264(immediate)-261(parenteral)-264(replacem)11(ent)-275(with)-264(thi-)]TJ 0 -1.63 TD [(amine)-499(in)-499(people)-495(where)-490(thiamine)-495(deficien)10(cy)-503(is)-496(suspected;)-492(see)-503(Sec-)]TJ 0 -1.623 TD [(tions)-254(7.6)-257(and)-257(9.6.)]TJ 1.878 -1.623 Td [(Given)-320(the)-331(severe)-324(consequen)14(ces)-328(that)-327(arise)-331(from)-324(untreated)-317(or)-331(late)]TJ -1.878 -1.63 Td [(treatment)-248(of)-257(thiamine)-247(deficiency,)-254(we)-251(recommend)-248(that)-256(people)-247(are)-260(edu-)]TJ 0 -1.623 TD [(cated)-402(about)-396(potential)-401(risks)-399(of)-406(thiamine)-403(deficie)11(ncy)-405(and)-405(to)-402(seek)-400(early)]TJ T* [(advice.)-317(Clinicians)-308(in)-322(both)-319(primary)-311(and)-320(second)13(ary)-319(care)-316(need)-322(education)]TJ T* [(on)-445(the)-452(factors)-440(that)-448(may)-443(predispose)-440(to)-452(thiamin)13(e)-451(deficiency)-443(and)-448(the)]TJ 0 -1.63 TD [(importance)-250(of)-257(initiating)-251(immediate)-254(treatmen)15(t.)]TJ /T1_1 1 Tf 10.0001 0 0 10.0001 44.7874 216.3968 Tm (9)Tj /T1_0 1 Tf 1.474 0 Td (|)Tj /T1_1 1 Tf 0.1013 Tc 1.151 0 Td [(ABNORMAL)-262(TEST)-258(RESULTS)-259(AND)]TJ 0.1009 Tc -2.625 -1.298 Td [(CLINICAL)-262(PROBLEMS)]TJ /T1_0 1 Tf 0 Tc 7.9999 0 0 7.9999 44.7874 177.3921 Tm [(Detailed)-249(recommendat)14(ions)-261(are)-253(listed)-259(in)-144(Table)-249(5.)]TJ /T1_1 1 Tf 10.0001 0 0 10.0001 44.7874 138.3874 Tm (9.1)Tj /T1_0 1 Tf 2.177 0 Td (|)Tj /T1_1 1 Tf 1.049 0 Td [(Protein)-269(malnutrition/pro)-15(tein)]TJ /T1_4 1 Tf 12.625 0 Td (\226)Tj /T1_1 1 Tf 0.573 0 Td [(ener)-8(gy)]TJ -16.424 -1.298 Td [(malnutrit)-10(ion/oedema)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 44.7874 99.4393 Tm [(This)-545(can)-546(presen)12(t)-553(several)-537(years)-549(following)-536(bariatric)-544(surgery.)-541(Causes)]TJ T* [(include)-382(poor)-379(dietary)-384(protein)-382(intake)-386(as)-381(well)-388(as)-381(malabsorption)15(.)-387(People)]TJ 0 -1.623 TD [(who)-281(have)-282(difficulty)-274(progressing)-273(their)-284(diet)-277(because)-278(of)-286(a)-283(stricture,)-277(over-)]TJ T* [(tight)-393(band)-385(or)-395(food)-390(intoleranc)10(es)-392(are)-394(at)-390(risk)-393(in)-392(addition)-387(to)-395(those)-384(with)]TJ 0 -1.63 TD [(protein)-254(malabsorp)16(tion.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 122.9669 50.9669 Tm (69,71,89,94,142)Tj 0 Tc 7.9999 0 0 7.9999 320.9952 723.4014 Tm [(Oedema)-341(is)-340(an)-348(important)-331(indicator)-344(of)-342(protein)-339(energy)-336(malnutrition)]TJ -1.871 -1.623 Td [(and)-320(may)-329(mask)-323(muscle)-323(wasting)-326(and)-327(weight)-325(loss.)-323(Whilst)-322(it)-335(is)-326(necessary)]TJ 0 -1.623 TD [(to)-360(exclude)-355(the)-353(many)-358(other)-358(causes)-356(of)-356(oedema,)-359(people)-353(should)-350(also)-362(be)]TJ 0 -1.63 TD [(referred)-246(back)-259(to)-260(the)-253(bariatric)-253(centre)-251(for)-257(further)-252(investigation)12(.)]TJ /T1_1 1 Tf 10.0001 0 0 10.0001 306.0283 645.392 Tm (9.2)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_1 1 Tf 1.054 0 Td (Anaemia)Tj -3.226 -2.596 Td (9.2.1)Tj /T1_0 1 Tf 2.976 0 Td (|)Tj /T1_1 1 Tf 1.049 0 Td [(Iron)-263(de)-7(ficiency)-260(anaemia)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 593.4045 Tm [(Iron)-402(deficien)10(cy)-404(anaemia)-400(may)-407(be)-402(dietary)-405(in)-407(origin,)-402(with)-398(oral)-407(diet)-404(and)]TJ 0 -1.623 TD [(iron)-348(supplement)17(s)-360(being)-348(insufficie)10(nt)-355(to)-352(meet)-345(the)-353(needs)-349(of)-356(people)-346(fol-)]TJ T* [(lowing)-316(bariatric)-324(surgery)-316(\(see)-328(Section)-314(7.2\).)-328(Sources)-318(of)-328(blood)-321(loss,)-327(both)]TJ 0 -1.63 TD [(related)-341(and)-349(unrelate)13(d)-355(to)-345(bariatric)-345(surgery,)-339(should)-343(also)-348(be)-352(considere)13(d,)]TJ 0 -1.623 TD [(investig)13(ated)-261(and)-249(excluded.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 397.7007 544.9888 Tm (143)Tj 0 Tc 7.9999 0 0 7.9999 320.9952 528.4345 Tm [(If)-379(there)-372(is)-376(a)-376(low)-370(haemoglo)12(bin)-379(and)-370(low)-370(mean)-377(cell)-368(volume)-372(\(MCV\),)]TJ -1.871 -1.63 Td [(serum)-304(ferritin)-305(levels)-300(should)-308(be)-303(measured.)-300(Levels)-310(of)-307(serum)-304(ferritin)-305(less)]TJ T* [(than)-285(15)]TJ /T1_5 1 Tf 3.664 0 Td (\003)Tj /T1_0 1 Tf 0.2908 Tc 0.524 0 Td (gL)Tj /T1_2 1 Tf 0 Tc 5.9998 0 0 5.3325 350.022 505.9841 Tm (\025)Tj /T1_0 1 Tf 0.671 0 Td (1)Tj 7.9999 0 0 7.9999 359.8298 502.4125 Tm [(confirm)-284(iron)-291(deficiency)-287(anaemi)11(a.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 472.8188 505.9841 Tm (143)Tj 0 Tc 7.9999 0 0 7.9999 485.4613 502.4125 Tm [(Acute)-282(and)-292(chronic)]TJ -22.429 -1.623 Td [(inflamma)11(tory)-580(conditions,)-576(liver)-586(disease)-582(and)-583(malignant)-572(disease)-582(may)]TJ 0 -1.63 TD [(result)-264(in)-265(increased)-266(ferritin)-262(levels)-265(independ)14(ent)-268(of)-271(iron)-270(status;)-262(therefore)11(,)]TJ 0 -1.623 TD [(peopl)13(e)-593(with)-583(chronic)-582(inflamma)11(tion)-582(and)-590(a)-588(ferritin)-581(concentra)10(tion)-582(of)]TJ T* (50)Tj /T1_5 1 Tf 1.602 0 Td (\003)Tj /T1_0 1 Tf 0.4609 Tc 0.517 0 Td (gL)Tj /T1_2 1 Tf 0 Tc 5.9998 0 0 5.3325 334.8282 453.94 Tm (\025)Tj /T1_0 1 Tf 0.68 0 Td (1)Tj 7.9999 0 0 7.9999 345.9967 450.4251 Tm [(or)-466(higher)-455(could)-457(still)-457(be)-459(iron)-461(deficien)10(t.)-459(If)-464(inflamma)11(tion)-461(is)]TJ -4.996 -1.63 Td [(though)14(t)-312(to)-310(be)-303(affecting)-306(the)-303(ferritin)-305(levels,)-302(other)-308(markers)-300(of)-307(inflamma-)]TJ 0 -1.623 TD [(tion)-249(such)-247(as)-246(C-reactive)-250(protein)-240(or)-253(measures)-243(of)-250(iron)-249(status)-246(such)-247(as)-253(total)]TJ T* [(iron)-256(binding)-262(capacity)-258(should)-258(be)-267(considere)13(d.)-268(If)-266(there)-258(is)-269(doubt)-256(about)-262(the)]TJ T* [(tests)-476(to)-480(be)-487(request)12(ed)-487(or)-480(interpretati)12(on)-488(of)-484(results)14(,)-491(special)11(ist)-482(advice)]TJ 0 -1.63 TD [(should)-251(be)-253(sought.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 367.0865 388.97 Tm (143)Tj /T1_1 1 Tf 0 Tc 10.0001 0 0 10.0001 306.0283 346.3936 Tm (9.2.2)Tj /T1_0 1 Tf 2.976 0 Td (|)Tj /T1_1 1 Tf 1.049 0 Td [(Vitam)-8(in)-259(B12)-264(and)-264(folate)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 320.4283 Tm [(The)-400(most)-403(common)-399(causes)-405(of)-406(megalobl)12(astic,)-406(macrocyt)13(ic)-413(anaemi)11(a)-411(are)]TJ T* [(vitamin)-270(B12)-280(and)-278(folate)-274(deficien)10(cy,)]TJ 0.0001 Tc 5.9998 0 0 5.3325 424.403 310.9606 Tm (132)Tj 0 Tc 7.9999 0 0 7.9999 436.9322 307.3889 Tm [(and)-278(folate)-274(supplementati)15(on)-282(may)]TJ -16.363 -1.623 Td [(mask)-429(severe)-430(vitamin)-433(B12)-436(depletion)-427(\(see)-441(Section)-428(7.2\).)-434(It)-439(is)-439(essential)]TJ 0 -1.623 TD [(that)-434(vitamin)-440(B12)-443(deficien)10(cy)-446(is)-439(treated)-436(immediately)-436(before)-437(initiating)]TJ T* [(additional)-243(folic)-264(acid)-250(\(see)-257(Section)-258(7.2\).)]TJ 1.871 -1.63 Td [(In)-291(vitamin)-285(B12)-287(deficien)10(cy)-290(with)-285(possible)-283(neurologi)12(cal)-288(involvemen)10(t,)]TJ -1.871 -1.623 Td [(such)-375(as)-388(unexplained)-374(sensory)-383(and/or)-375(motor)-382(and)-384(gait)-385(symptoms)13(,)-384(vita-)]TJ 0 -1.623 TD [(min)-275(B12)-273(deficiency)-273(should)-272(be)-274(treated)-273(immediatel)11(y)-284(and)-271(urgent)-276(special)11(-)]TJ 0 -1.63 TD [(ist)-993(advice)-999(sought)-997(from)-997(a)-999(neurologi)12(st)-1005(and)-994(haematolo)12(gist.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 538.4691 219.9684 Tm (132)Tj 0 Tc 7.9999 0 0 7.9999 306.0283 203.4141 Tm [(Hydroxo)12(cobalamin)-427(1)-434(mg)-435(intramuscu)16(larly)-435(should)-428(be)-437(admini)13(stered)-434(on)]TJ 0 -1.623 TD [(alternate)-504(days)-516(until)-512(there)-513(is)-510(no)-516(further)-514(improve)13(ment,)-513(then)-509(hydro-)]TJ 0 -1.63 TD [(xocobal)13(amin)-438(1)-441(mg)-435(intramuscula)11(rly)-438(administere)12(d)-440(every)-435(2)-441(months.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 538.4691 180.9637 Tm (132)Tj 0 Tc 7.9999 0 0 7.9999 306.0283 164.4094 Tm [(For)-350(people)-353(with)-349(vitamin)-348(B12)-358(deficien)10(cy)-354(and)-356(no)-353(neurologic)13(al)-359(involve-)]TJ 0 -1.623 TD [(ment,)-265(hydroxoco)12(balamin)-266(1)-278(mg)-272(intramu)14(scularly)-271(should)-265(be)-274(administere)12(d)]TJ 0 -1.63 TD [(three)-336(times)-341(a)-340(week)-344(for)-343(2)-342(weeks,)-343(followed)-332(by)-341(maintenance)-335(treatment)]TJ 0 -1.623 TD [(with)-250(1)-264(mg)-251(intramuscula)11(rly)-253(every)-258(2)]TJ /T1_3 1 Tf 14.684 0 Td (\226)Tj /T1_0 1 Tf 0.567 0 Td [(3)-264(months)-249(for)-257(life.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 487.3889 128.9763 Tm (132)Tj 0 Tc 7.9999 0 0 7.9999 320.9952 112.422 Tm [(Folic)-392(acid)-392(deficien)10(cy)-397(may)-386(indicate)-393(non-adh)16(erence)-390(with)-391(the)-395(daily)]TJ -1.871 -1.623 Td [(multivita)15(min)-282(and)-278(mineral)-277(supplemen)18(t)-284(or)-282(malabsorpt)15(ion.)-282(Some)-279(medica-)]TJ 0 -1.63 TD [(tions,)-454(such)-453(as)-466(anticon)13(vulsants,)-451(sulfasalazine)-457(and)-455(methotrexa)10(te,)-460(may)]TJ 0 -1.623 TD [(affect)-325(folic)-327(acid)-335(levels.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 384.0377 76.989 Tm (102)Tj 0 Tc 7.9999 0 0 7.9999 396.9637 73.4173 Tm [(For)-329(treatment)-326(of)-328(folic)-335(acid)-328(deficien)10(cy)-333(\(after)]TJ -11.367 -1.623 Td [(excludin)15(g)-305(vitamin)-299(B12)-302(deficie)11(ncy\),)-302(oral)-301(folic)-299(acid)-300(5)-307(mg)-294(daily)-305(should)-294(be)]TJ 0 -1.63 TD [(given)-249(for)-258(a)-262(minimum)-248(of)-257(4)-264(months)13(.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 422.759 50.9669 Tm (132)Tj ET 0.137 0.122 0.125 scn /CS0 CS 0.137 0.122 0.125 SCN 0 w 1 j 1 J /GS1 gs 548.787 748.63 -504 0.453 re B* q 1 0 0 1 526.28 761.102 cm -0.51 0 0.51 -12.019 re B* Q BT 0 0 0 scn /GS0 gs /T1_0 1 Tf 0 Tc 6.9999 0 0 6.9999 44.7874 753.1085 Tm (O'KANE)Tj 4.8997 0 0 4.8997 72.1701 753.1085 Tm [(ET)-384(AL)]TJ 6.9999 0 0 6.9999 85.4929 753.1085 Tm (.)Tj /T1_1 1 Tf 65.036 0 Td (13)Tj ET /Document /MC0 BDC q 455.096 759.571 -66.24 -15.6 re W n q /GS1 gs 66.642 0 0 15.744 388.728 743.928 cm /Im0 Do Q EMC Q /Document /MC1 BDC q 463.578 757.474 54.142 -11.282 re W n 1 1 1 scn /GS1 gs 463.578 746.192 54.142 11.282 re f q 1 0 0 1 482.25 747.988 cm /CS1 cs 1 scn /GS0 gs 0 0 m 0 -0.707 -0.157 -1.162 -0.66 -1.444 c -0.66 -1.539 l 2.451 -1.539 l 2.451 -1.444 l 1.948 -1.162 1.792 -0.707 1.792 0 c 1.792 6.03 l 1.792 6.722 1.948 7.177 2.451 7.475 c 2.451 7.554 l -0.66 7.554 l -0.66 7.475 l -0.157 7.177 0 6.722 0 6.03 c 0 0 l h 13.836 -1.539 m 14.275 0.377 l 14.182 0.408 l 13.647 -0.424 12.83 -0.77 11.621 -0.77 c 8.073 -0.77 l 8.073 5.951 l 8.073 6.722 8.261 7.161 8.794 7.475 c 8.794 7.554 l 5.67 7.554 l 5.654 7.475 l 6.141 7.177 6.282 6.737 6.282 6.109 c 6.282 -0.079 l 6.282 -0.724 6.141 -1.146 5.654 -1.444 c 5.67 -1.539 l 13.836 -1.539 l h 28.991 -1.444 m 29.005 -1.539 l 32.148 -1.539 l 32.148 -1.444 l 31.628 -1.146 31.472 -0.675 31.472 0.079 c 31.472 2.215 l 34.237 6.155 l 34.739 6.879 35.163 7.318 35.524 7.475 c 35.524 7.554 l 33.074 7.554 l 33.074 7.475 l 33.514 7.224 33.575 6.611 33.106 5.937 c 31.08 3.015 l 28.849 6.298 l 28.504 6.8 28.566 7.256 28.975 7.475 c 28.975 7.554 l 25.534 7.554 l 25.534 7.475 l 25.944 7.303 26.196 7.067 26.635 6.439 c 29.682 2.088 l 29.682 0.079 l 29.682 -0.675 29.509 -1.146 28.991 -1.444 c 18.045 3.659 m 18.045 6.783 l 21.311 6.783 l 22.803 6.783 23.368 6.549 23.903 5.795 c 23.997 5.826 l 23.808 7.554 l 15.642 7.554 l 15.626 7.475 l 16.114 7.177 16.255 6.737 16.255 6.109 c 16.255 -0.079 l 16.255 -0.724 16.114 -1.146 15.626 -1.444 c 15.642 -1.539 l 24.232 -1.539 l 24.546 0.313 l 24.468 0.345 l 23.918 -0.393 23.259 -0.77 21.783 -0.77 c 18.045 -0.77 l 18.045 2.921 l 20.542 2.921 l 21.61 2.921 22.143 2.748 22.427 2.293 c 22.536 2.293 l 22.536 4.271 l 22.427 4.287 l 22.143 3.832 21.61 3.659 20.542 3.659 c 18.045 3.659 l h -6.988 -1.853 m -6.91 -1.853 l -3.046 7.773 l -2.669 8.7 -2.324 9.156 -1.979 9.359 c -1.979 9.454 l -4.303 9.454 l -4.303 9.359 l -3.816 9.093 -3.706 8.37 -4.036 7.539 c -6.407 1.602 l -9.627 9.485 l -9.705 9.485 l -13.097 1.617 l -15.532 7.806 l -15.814 8.543 -15.735 9.093 -15.281 9.359 c -15.281 9.454 l -18.672 9.454 l -18.672 9.359 l -18.311 9.171 -18.044 8.779 -17.714 7.977 c -13.725 -1.853 l -13.647 -1.853 l -10.286 6.109 l -6.988 -1.853 l f Q EMC Q endstreamendobj477 0 obj<>endobj478 0 obj<>stream BT /CS0 cs 0 0 0 scn /GS0 gs /T1_0 1 Tf 7.9999 0 0 7.9999 46.4882 723.4014 Tm [(Adherence)-1235(to)-1245(oral)-1243(supplementat)17(ion)-1248(is)-1247(more)-1239(difficult)-1238(to)]TJ 0 -1.623 TD [(determin)12(e.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 83.622 713.9904 Tm (34,96,133)Tj /T1_1 1 Tf 0 Tc (\226)Tj /T1_0 1 Tf 0.0001 Tc 5.017 0 Td (135)Tj 0 Tc 7.9999 0 0 7.9999 128.5795 710.4187 Tm [(Given)-561(the)-572(serious)-562(conseq)13(uences)-568(of)-569(vitamin)]TJ -10.262 -1.623 Td [(B12)-415(deficien)10(cy,)-420(we)-407(recommend)-404(routine)-410(supplementati)15(on)-417(with)-413(three)]TJ 0 -1.63 TD [(monthly)-603(intramu)14(scular)-606(vitamin)-603(B12)-606(injection)12(s)-608(for)-612(SG,)-603(RYGB)-604(and)]TJ 0 -1.623 TD [(malabsorpt)15(ive)-262(procedure)12(s)-260(such)-255(as)-253(BPD/DS.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 197.1779 674.9856 Tm (134)Tj /T1_2 1 Tf 0 Tc 10.0001 0 0 10.0001 46.4882 632.4093 Tm (8.5)Tj /T1_0 1 Tf 2.177 0 Td (|)Tj /T1_2 1 Tf 1.049 0 Td [(Calcium)-268(and)-258(vitamin)-270(D)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 46.4882 606.3872 Tm [(Vitamin)-299(D3)-312(supplemen)18(tation)-306(requirement)14(s)-310(to)-310(maintain)-299(optimal)-299(serum)]TJ T* [(25OHD)-471(levels)-478(greater)-478(than)-477(75)-479(nmol)-474(L)]TJ /T1_3 1 Tf 5.9998 0 0 5.3325 187.3133 596.9762 Tm (\025)Tj /T1_0 1 Tf 0.68 0 Td (1)Tj 7.9999 0 0 7.9999 198.6519 593.4045 Tm [(post-bariatri)14(c)-482(surgery)-472(are)]TJ -19.021 -1.623 Td [(higher)-448(than)-448(for)-449(a)-453(non-bariat)14(ric)-456(surgery)-444(population.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 228.5858 583.9935 Tm (3,4,10,44,48,52,62,137)Tj 0 Tc 7.9999 0 0 7.9999 46.4882 567.4392 Tm [(Starting)-618(regimens)-616(of)-626(2000)]TJ /T1_1 1 Tf 12.373 0 Td (\226)Tj /T1_0 1 Tf 0.567 0 Td [(4000)-625(IU)-624(of)-619(vitamin)-618(D3)-624(per)-622(day)-625(are)]TJ -12.94 -1.63 Td [(recommend)14(ed)-473(to)-466(maintain)-462(serum)-467(25OHD)-464(levels)-471(after)-463(surgery)-465(with)]TJ T* [(adjustme)12(nts)-1140(being)-1135(made)-1135(depende)12(nt)-1142(on)-1140(results.)]TJ 5.9998 0 0 5.3325 242.9858 544.9888 Tm (3,48,62)Tj 7.9999 0 0 7.9999 271.8991 541.4172 Tm (With)Tj -28.177 -1.623 Td [(malabsorpt)15(ive)-410(procedure)12(s)-409(such)-403(as)-402(BPD/DS,)-401(higher)-405(doses)-403(of)-406(vitamin)]TJ 0 -1.63 TD [(D3)-369(supplementa)17(tion)-369(are)-373(likely)-367(to)-367(be)-367(needed.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 204.9448 518.9668 Tm (52,69,70,74)Tj 0 Tc 7.9999 0 0 7.9999 239.3574 515.3951 Tm [(Dietary)-367(intake)]TJ -24.109 -1.623 Td [(of)-257(vitamin)-256(D)-253(and)-257(weight)-254(bearing)-249(activity)-260(should)-251(also)-256(be)-253(encouraged)12(.)]TJ 5.9998 0 0 5.3325 280.7999 505.9841 Tm (51)Tj 7.9999 0 0 7.9999 61.5118 489.4298 Tm [(Calcium)-1229(absorption)-1232(is)-1240(adversely)-1239(affecte)11(d)-1241(by)-1241(bariatric)]TJ -1.878 -1.63 Td (surgery.)Tj 0.0001 Tc 5.9998 0 0 5.3325 74.0409 479.9621 Tm (70,138)Tj 0 Tc 7.9999 0 0 7.9999 99.7228 476.3904 Tm [(Several)-883(guidelines)-883(recommend)-879(additional)-888(calcium)]TJ -6.654 -1.623 Td [(supplementa)17(tion.)]TJ 5.9998 0 0 5.3325 106.2992 466.9794 Tm (2)Tj /T1_1 1 Tf 0.576 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.567 0 Td (4,9,51)Tj 0 Tc 7.9999 0 0 7.9999 134.8157 463.4077 Tm [(However,)-644(the)-657(optimal)-646(calcium)-655(intake)-648(for)]TJ -11.041 -1.623 Td [(people)-325(who)-323(have)-331(had)-320(bariatric)-324(surgery)-323(is)-333(not)-325(known.)-325(Dietary)-317(sources)]TJ T* [(of)-576(calcium)-563(should)-570(be)-572(encourage)13(d)-575(as)-572(it)-576(is)-574(more)-565(bioavailable)-563(than)]TJ 0 -1.623 TD [(supplementa)17(l)-281(calcium)-279(and)-278(may)-280(have)-275(a)-283(protective)-273(role)-277(in)-279(the)-282(formation)]TJ T* [(of)-519(kidney)-514(stones.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 109.474 414.992 Tm (139)Tj 0 Tc 7.9999 0 0 7.9999 123.9307 411.4203 Tm [(Parrott)-519(et)-515(al.)-520(recommend)-510(1200-)-516(to)-523(1500-mg)]TJ -9.68 -1.623 Td [(calcium)-378(per)-388(day)-377(from)-388(food)-383(and)-377(supplements)-378(following)-373(AGB,)-385(SG)-381(and)]TJ 0 -1.63 TD [(RYGB)-250(and)-257(1800)]TJ /T1_1 1 Tf 7.002 0 Td (\226)Tj /T1_0 1 Tf 0.567 0 Td [(2400)-256(mg)-258(d)]TJ /T1_3 1 Tf 5.9998 0 0 5.3325 144.4535 388.97 Tm (\025)Tj /T1_0 1 Tf 0.671 0 Td (1)Tj 7.9999 0 0 7.9999 154.0346 385.3983 Tm [(following)-245(BPD/DS.)]TJ 5.9998 0 0 5.3325 219.7984 388.97 Tm (3)Tj 7.9999 0 0 7.9999 61.5118 372.4156 Tm [(Discussio)12(n)-525(continu)12(es)-527(as)-523(to)-523(whether)-520(calcium)-513(citrate)-524(should)-513(be)]TJ -1.878 -1.623 Td [(favoured)-604(over)-605(calcium)-605(carbonate.)-604(However,)-601(there)-605(have)-608(been)-606(no)]TJ T* [(large)-881(RCTs)-881(comparing)-876(the)-884(two)-883(supplements)-874(for)-888(all)-881(bariatric)]TJ 0 -1.623 TD [(procedure)12(s.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 87.137 336.9826 Tm (51,103,140)Tj 0 Tc 7.9999 0 0 7.9999 125.7448 333.4109 Tm [(Although)-1055(calcium)-1059(citrate)-1063(may)-1059(be)-1068(more)]TJ -9.907 -1.623 Td [(bioavailab)13(le)-505(and)-505(the)-502(preferred)-502(option)-496(for)-506(people)-495(at)-511(risk)-500(of)-505(kidney)]TJ 0 -1.63 TD (stones,)Tj 0.0001 Tc 5.9998 0 0 5.3325 70.9228 310.9606 Tm (141)Tj 0 Tc 7.9999 0 0 7.9999 84.3023 307.3889 Tm [(calcium)-371(carbonate)-373(may)-386(be)-381(better)-372(tolerated.)]TJ 5.9998 0 0 5.3325 237.6566 310.9606 Tm (3)Tj 7.9999 0 0 7.9999 244.1763 307.3889 Tm [(Parrott)-377(et)-380(al.)]TJ -24.711 -1.623 Td [(advise)-324(taking)-318(calcium)-322(in)-322(divided)-323(doses,)-320(taking)-318(calcium)-322(carbonate)-316(with)]TJ 0 -1.623 TD [(meals)-492(and)-490(calcium)-485(citrate)-489(with)-491(or)-494(without)-489(meals.)]TJ 5.9998 0 0 5.3325 226.2614 284.9952 Tm (3)Tj 7.9999 0 0 7.9999 233.6314 281.4236 Tm [(Care)-494(should)-485(be)]TJ -23.393 -1.623 Td [(taken)-257(to)-260(ensure)-250(that)-256(there)-258(is)-255(not)-261(excess)-253(calcium)-258(intake,)-253(and)-257(healthcare)]TJ 0 -1.63 TD [(professional)12(s)-438(should)-435(be)-437(mindful)-427(of)-441(the)-438(risk)-436(of)-434(kidney)-436(stones.)-430(Good)]TJ 0 -1.623 TD [(hydratio)12(n)-263(should)-251(be)-260(encourage)13(d.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 159.8173 245.9904 Tm (48)Tj /T1_2 1 Tf 0 Tc 10.0001 0 0 10.0001 46.4882 203.4141 Tm (8.6)Tj /T1_0 1 Tf 2.177 0 Td (|)Tj /T1_2 1 Tf 1.049 0 Td [(Vitami)-7(ns)-260(A,)-263(E)-261(and)-258(K)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 46.4882 177.3921 Tm [(Following)-1018(AGB)-1022(and)-1029(SG,)-1021(people)-1026(should)-1017(be)-1026(able)-1030(to)-1026(meet)]TJ T* [(requirem)12(ents)-436(for)-435(vitamin)13(s)-438(A,)-434(E)-434(and)-434(K)-428(through)-426(their)-433(oral)-435(diet)-433(and)-427(a)]TJ T* [(complete)-589(multivitam)12(in)-598(and)-590(mineral)-589(supplement.)-583(Given)-596(that)-590(lower)]TJ 0 -1.63 TD [(levels)-931(of)-937(vitamin)-929(A)-928(or)-941(deficie)11(ncy)-936(has)-934(been)-932(reporte)13(d)-936(after)]TJ 0 -1.623 TD (RYGB,)Tj 0.0001 Tc 5.9998 0 0 5.3325 69.1086 128.9763 Tm (93,107,108)Tj 0 Tc 7.9999 0 0 7.9999 105.5055 125.4047 Tm [(some)-783(people)-785(may)-783(require)-785(additional)-775(vitamin)-781(A)]TJ -7.377 -1.623 Td [(supplementa)17(tion.)-679(Whilst)-676(we)-676(did)-677(not)-679(find)-674(sufficient)-676(evidence)-676(to)]TJ 0 -1.623 TD [(recommend)-609(routine)-609(additional)-612(supplementati)15(on)-622(beyond)-607(the)-622(com-)]TJ 0 -1.63 TD [(plete)-525(multivita)15(min)-523(and)-526(mineral)-518(supplement,)-516(this)-519(may)-520(be)-530(identifi)12(ed)]TJ 0 -1.623 TD [(through)-391(monitoring)-388(\(see)-399(Section)-392(7.4\).)]TJ 1.878 -1.623 Td [(The)-577(optimum)-574(level)-579(of)-583(supplementat)17(ion)-582(to)-586(prevent)-571(vitamin)-582(A)]TJ -1.878 -1.63 Td [(deficienc)10(y)-560(following)-550(BPD/DS)-548(is)-553(not)-552(known.)-552(There)-547(are)-557(reports)-548(of)]TJ 32.655 84.501 Td [(vitamin)-887(A)-893(deficien)10(cies)-897(developin)12(g)-893(despite)-890(supplementati)15(on)-891(of)]TJ T* (5000)Tj /T1_1 1 Tf 2.282 0 Td (\226)Tj /T1_0 1 Tf 0.567 0 Td [(25)-599(000)-594(IU)-595(d)]TJ /T1_3 1 Tf 5.9998 0 0 5.3325 380.0692 713.9904 Tm (\025)Tj /T1_0 1 Tf 0.68 0 Td (1)Tj 7.9999 0 0 7.9999 387.6093 710.4187 Tm (.)Tj 0.0001 Tc 5.9998 0 0 5.3325 389.4235 713.9904 Tm (71,89,94)Tj 0 Tc 7.9999 0 0 7.9999 417.4298 710.4187 Tm [(For)-591(BPD/DS)-591(with)-590(100-cm)-594(commo)13(n)]TJ -13.713 -1.623 Td [(channel,)-303(Homan)-312(et)-317(al.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 383.7542 700.951 Tm (74)Tj 0 Tc 7.9999 0 0 7.9999 393.1653 697.436 Tm [(recommen)15(ded)-318(starting)-307(vitamin)-306(A)-319(supplemen-)]TJ -10.68 -1.63 Td [(tation)-356(with)-356(50)-365(000)-360(IU)-362(week)]TJ /T1_3 1 Tf 5.9998 0 0 5.3325 407.3385 687.9683 Tm (\025)Tj /T1_0 1 Tf 0.671 0 Td (1)Tj 7.9999 0 0 7.9999 414.8219 684.3967 Tm [(,)-363(checking)-358(blood)-356(levels)-357(after)-357(3)-363(months)]TJ -13.387 -1.623 Td [(and)-342(adjusting)-345(the)-346(dosage)-342(if)-353(necessary.)-337(Homan)-347(et)-345(al.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 490.3369 674.9856 Tm (74)Tj 0 Tc 7.9999 0 0 7.9999 499.9747 671.414 Tm [(also)-348(estimated)]TJ -24.031 -1.623 Td [(that)-427(an)-433(oral)-428(dose)-426(of)-434(7500)]TJ /T1_1 1 Tf 11.821 0 Td (\226)Tj /T1_0 1 Tf 0.574 0 Td [(15)-429(000)-431(IU)-432(d)]TJ /T1_3 1 Tf 5.9998 0 0 5.3325 452.5227 661.9463 Tm (\025)Tj /T1_0 1 Tf 0.671 0 Td (1)Tj 7.9999 0 0 7.9999 463.4644 658.4313 Tm [(\(solubilized)-422(vitamin)-426(A\))-435(is)]TJ -19.467 -1.63 Td [(needed)-377(to)-388(prevent)-387(vitamin)-384(A)-390(deficien)10(cy)-390(after)-385(BPD/DS,)-387(while)-266(Topart)]TJ T* [(et)-402(al.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 325.5306 635.981 Tm (89)Tj 0 Tc 7.9999 0 0 7.9999 335.6786 632.4093 Tm [(suggested)-397(that)-405(vitamin)-405(A)-411(50)-408(000)-403(IU)-411(d)]TJ /T1_3 1 Tf 5.9998 0 0 5.3325 473.5558 635.981 Tm (\025)Tj /T1_0 1 Tf 0.671 0 Td (1)Tj 7.9999 0 0 7.9999 484.3274 632.4093 Tm [(in)-407(tablet)-400(form)-409(was)]TJ -22.075 -1.623 Td [(needed)-809(to)-827(prevent)-812(deficienc)10(y.)-827(Homan)-815(et)-820(al.)-825(noted)-812(that)-823(this)]TJ 0 -1.63 TD 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[(BPD/DS)11(,)-469(Slater)-468(et)-465(al.)-470(supplemente)13(d)-468(with)-462(60)-472(IU)-468(vitamin)-462(E)-470(per)-473(day)]TJ T* [(although)-296(a)-312(small)-301(number)-301(of)-314(participan)15(ts)-310(still)-308(presen)12(ted)-310(with)-306(vitamin)-299(E)]TJ 0 -1.63 TD [(deficie)11(ncy)-270(at)-262(4)-271(years.)]TJ 5.9998 0 0 5.3325 380.8629 518.9668 Tm (70)Tj 7.9999 0 0 7.9999 389.877 515.3951 Tm [(We)-263(suggest)-265(starting)-257(with)-264(100)-268(IU)-269(vitamin)-256(E)-271(per)]TJ -10.269 -1.623 Td [(day)-256(follow)13(ing)-258(BPD/DS)-258(and)-249(adjusting)-253(as)-260(required)15(.)]TJ 1.871 -1.623 Td [(The)-365(optimal)-363(level)-359(of)-371(vitamin)-362(K)-364(supplement)17(ation)-369(to)-360(prevent)-366(defi-)]TJ -1.871 -1.63 Td [(ciencies)-323(after)-335(malab)13(sorptive)-330(procedure)12(s)-331(is)-333(not)-332(known.)-325(Although,)-326(Aills)]TJ 0 -1.623 TD [(et)-253(al.)-258(suggest)-250(300-)]TJ /T1_4 1 Tf 7.965 0 Td (\003)Tj /T1_0 1 Tf 0.517 0 Td [(g)-255(vitamin)-256(K)-258(daily.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 434.5511 466.9794 Tm (51)Tj 0 Tc 7.9999 0 0 7.9999 322.696 450.4251 Tm [(Water-m)12(iscible)-820(forms)-811(of)-817(fat-soluble)-814(vitamins)-807(may)-818(improve)]TJ -1.871 -1.63 Td [(absorpti)14(on)-261(especia)12(lly)-258(after)-257(malabsorpti)13(ve)-260(procedure)12(s.)]TJ 5.9998 0 0 5.3325 492.1511 440.9574 Tm (2)Tj /T1_1 1 Tf 0.567 0 Td (\226)Tj /T1_0 1 Tf 0.576 0 Td (4,51)Tj /T1_2 1 Tf 10.0001 0 0 10.0001 307.729 398.4377 Tm (8.7)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_2 1 Tf 1.054 0 Td [(Zinc)-259(and)-264(copper)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 307.729 372.4156 Tm [(T)16(he)-430(c)15(om)28(pl)23(et)24(e)-444(m)18(ul)23(ti)26(vi)19(ta)28(mi)23(n)-440(a)14(nd)-427(mi)23(ne)23(ra)28(l)-444(su)22(pp)27(l)16(em)21(e)17(nt)-433(m)18(ay)-432(no)30(t)-447(c)15(on)23(ta)28(in)]TJ 0 -1.623 TD 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5.3325 452.1259 245.9904 Tm (\025)Tj /T1_0 1 Tf 0.671 0 Td (1)Tj 7.9999 0 0 7.9999 462.1605 242.4188 Tm (copper.)Tj 0.0001 Tc 5.9998 0 0 5.3325 488.0125 245.9904 Tm (67,117)Tj 0 Tc 7.9999 0 0 7.9999 509.0455 242.4188 Tm [(People)-312(who)]TJ -25.165 -1.623 Td [(have)-331(had)-335(long)-337(limbed)-327(gastric)-334(bypass)-331(or)-338(BPD/DS)-329(may)-336(have)-338(additional)]TJ 0 -1.63 TD [(requir)13(ements.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 355.4645 219.9684 Tm (74,89,112)Tj 0 Tc 7.9999 0 0 7.9999 322.696 203.4141 Tm [(If)-422(additional)-413(zinc)-413(supplements)-406(are)-423(given,)-413(monitor)-413(both)-418(zinc)-420(and)]TJ -1.871 -1.623 Td [(copper)-386(levels)-393(as)-388(normally)-387(a)-397(ratio)-390(of)-399(8)]TJ /T1_1 1 Tf 16.795 0 Td (\226)Tj /T1_0 1 Tf 0.574 0 Td [(15)-394(mg)-393(of)-392(zinc)-392(for)-392(each)-395(1-mg)]TJ -17.369 -1.63 Td [(copper)-968(should)-974(be)-983(maintain)13(ed)-983(to)-976(avoid)-979(zinc-ind)11(uced)-976(copper)]TJ 0 -1.623 TD [(deficie)11(ncy.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 344.7495 167.9811 Tm (3,4)Tj 0 Tc 7.9999 0 0 7.9999 355.2377 164.4094 Tm [(The)-280(current)-283(complete)-277(multivita)15(min)-289(and)-278(mineral)-277(available)]TJ -5.939 -1.623 Td [(on)-615(prescripti)13(on)-615(\(Forceval\))-612(in)-619(the)-615(United)-619(Kingdom)-610(contain)13(s)-622(2-mg)]TJ 0 -1.63 TD [(copper)-542(and)-554(15-mg)-550(zinc,)-556(and)-554(doublin)14(g)-560(up)-547(on)-558(the)-551(dosage)-547(may)-556(be)]TJ 0 -1.623 TD [(sufficien)12(t)-262(in)-258(some)-251(cases)-256(to)-260(meet)-253(the)-253(additional)-250(requirements.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 518.0597 128.9763 Tm (112)Tj /T1_2 1 Tf 0 Tc 10.0001 0 0 10.0001 307.729 86.3999 Tm (8.8)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_2 1 Tf 1.054 0 Td (Selenium)Tj /T1_0 1 Tf 7.9999 0 0 7.9999 307.729 60.4346 Tm [(Although)-275(the)-289(evidence)-286(is)-291(limited,)-281(a)-290(complete)-285(multivitam)12(in)-293(and)-285(mineral)]TJ 0 -1.63 TD 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[(prevent)-1173(iron)-1170(deficiency,)-1175(and)-1171(additional)-1171(elementa)13(l)-1181(iron)-1177(is)]TJ 0 -1.623 TD (required.)Tj 5.9998 0 0 5.3325 75.685 245.9904 Tm (2)Tj /T1_1 1 Tf 0.576 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.567 0 Td (4,19,34,35,74,92,130)Tj 0 Tc 7.9999 0 0 7.9999 145.5874 242.4188 Tm [(We)-873(suggest)-874(adding)-876(200-mg)-871(ferrous)]TJ -12.6 -1.623 Td [(sulphate,)-260(210-mg)-269(ferrous)-261(fumarate)-268(or)-267(300-mg)-269(ferrous)-261(gluconate)-264(daily.)]TJ 0 -1.63 TD [(However,)-388(this)-391(may)-393(not)-389(be)-395(sufficient)-385(to)-395(prevent)-387(anaemia.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 247.9747 219.9684 Tm (35,47,74,88,89)Tj 0 Tc 7.9999 0 0 7.9999 44.7874 203.4141 Tm [(Women,)-727(of)-739(reproduct)16(ive)-736(age)-735(and)-731(who)-734(are)-735(menstru)14(ating,)-735(have)]TJ 0 -1.623 TD [(additional)-704(requirem)12(ents)-712(of)-711(50-)-710(to)-714(100-mg)-708(element)13(al)-713(iron)-710(daily)]TJ 0 -1.63 TD [(\(i.e.,)-282(two)-280(200-mg)-276(ferrous)-275(sulphate)-279(or)-282(210-mg)-276(ferrous)-275(fumarate)-275(tablets)]TJ 0 -1.623 TD (daily\).)Tj 0.0001 Tc 5.9998 0 0 5.3325 64.8 167.9811 Tm (53,130)Tj 0 Tc 7.9999 0 0 7.9999 86.4566 164.4094 Tm [(Taking)-394(iron)-391(supplements)-385(alongside)-385(citrus)-391(fruits/drinks)-386(or)]TJ -5.209 -1.623 Td [(vitamin)-398(C)-397(may)-400(aid)-399(absorption.)-393(Iron)-402(and)-398(calcium)-393(supplements)-392(should)]TJ 0 -1.63 TD [(be)-260(taken)-250(1)]TJ /T1_1 1 Tf 4.571 0 Td (\226)Tj /T1_0 1 Tf 0.567 0 Td [(2)-264(h)-256(apart)-256(to)-253(avoid)-256(affecting)-257(absorpti)14(on)-261(of)-257(each.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 248.2582 141.959 Tm (3,53)Tj /T1_2 1 Tf 0 Tc 10.0001 0 0 10.0001 44.7874 99.4393 Tm (8.3)Tj /T1_0 1 Tf 2.177 0 Td (|)Tj /T1_2 1 Tf 1.049 0 Td [(Folic)-262(aci)-7(d)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 44.7874 73.4173 Tm [(Folic)-555(acid)-555(requirem)12(ents)-556(for)-555(people)-552(who)-557(have)-551(undergone)-549(bariatric)]TJ 0 -1.623 TD [(surgery)-373(are)-373(unknown.)-369(Complete)-370(multivitam)12(in)-378(and)-377(minerals)-375(that)-370(con-)]TJ 0 -1.63 TD [(tain)-705(less)-700(than)-703(400)]TJ /T1_3 1 Tf 9.716 0 Td (\003)Tj /T1_0 1 Tf 0.517 0 Td [(g)-709(daily)-702(may)-705(not)-700(be)-707(sufficient)-697(to)-707(prevent)]TJ 22.422 26.001 Td [(deficie)11(ncies.)]TJ 5.9998 0 0 5.3325 348.4345 258.9731 Tm (3)Tj 7.9999 0 0 7.9999 356.4849 255.4015 Tm [(There)-575(are)-572(increased)-570(requirem)12(ents)-571(for)-576(preconcep)13(tual)]TJ -6.307 -1.623 Td [(care,)-254(pregnancy)-248(and)-257(lactation)-254(\(see)-250(Section)-258(9.8\).)]TJ 0.0001 Tc 5.9998 0 0 5.3325 467.8298 245.9904 Tm (11,131)Tj /T1_2 1 Tf 0 Tc 10.0001 0 0 10.0001 306.0283 203.4141 Tm (8.4)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_2 1 Tf 1.054 0 Td [(Vitamin)-262(B12)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 177.3921 Tm [(Given)-476(the)-480(risk)-485(of)-484(developi)13(ng)-483(vitamin)-476(B12)-486(deficienc)10(y)-489(following)-472(SG,)]TJ 0 -1.623 TD [(RYGB)-789(and)-795(BPD/DS)-789(\(see)-796(Section)-796(7.2\),)-792(additional)-789(vitamin)-795(B12)]TJ T* [(supplem)16(entation)-453(is)-461(required)-453(for)-456(prevention.)-449(Untreated)-452(vitamin)-455(B12)]TJ 0 -1.63 TD [(deficie)11(ncy)-256(may)-258(result)-250(in)-258(irrevers)11(ible)-253(neuropathy)-247(or)-253(subacute)-253(combine)13(d)]TJ 0 -1.623 TD [(degene)13(ration)-561(of)-569(spinal)-559(cord,)-567(which)-562(may)-563(occur)-558(in)-570(the)-565(absence)-554(of)]TJ T* [(megalobl)12(astic)-255(anaemia.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 385.5117 115.9937 Tm (95,132)Tj 0 Tc 7.9999 0 0 7.9999 320.9952 99.4393 Tm [(Discussio)12(n)-582(continues)-579(as)-579(to)-579(the)-579(optimal)-583(dosage)-575(and)-575(route)-578(of)]TJ -1.871 -1.63 Td [(supplem)16(entation.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 365.7826 89.9716 Tm (133)Tj /T1_1 1 Tf 0 Tc 1.72 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.576 0 Td (135)Tj 0 Tc 7.9999 0 0 7.9999 393.2219 86.3999 Tm [(Some)-407(studies)-416(suggest)-406(that)-412(supplementat)17(ion)]TJ -10.899 -1.623 Td [(with)-547(high)-556(doses)-552(of)-555(oral)-549(vitamin)-554(B12)-557(may)-549(prevent)-550(or)-558(reduce)-549(the)]TJ T* [(developm)12(ent)-360(of)-356(deficiency)10(.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 401.4424 63.9496 Tm (34,135)Tj 0 Tc 7.9999 0 0 7.9999 422.8156 60.4346 Tm [(Further)-352(research)-355(is)-362(needed,)-350(as)-360(defi-)]TJ -14.599 -1.63 Td [(ciency)-531(may)-528(still)-535(occur)-537(in)-534(the)-537(presen)12(ce)-536(of)-541(high)-528(oral)-534(doses.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 522.1416 50.9669 Tm (34,92,136)Tj ET 0.82 0.827 0.831 scn /GS1 gs 44.787 691.597 504 26.022 re f 0.902 0.906 0.91 scn 44.787 677.594 504 14.003 re f 44.787 653.102 504 24.491 re f 44.787 625.096 504 28.006 re f 44.787 600.605 504 24.491 re f 44.787 464.088 504 14.003 re f 44.787 450.085 504 14.003 re f 44.787 425.594 504 24.491 re f 0.82 0.827 0.831 scn /CS0 CS 0.82 0.827 0.831 SCN 0 w 1 j 1 J 548.787 298.602 -504 1.02 re B* BT 0 0 0 scn /GS0 gs /T1_4 1 Tf 0.141 Tc 7.9999 0 0 7.9999 44.7874 724.5919 Tm [(TA)-8(BL)-5(E)-258(4)]TJ /T1_0 1 Tf 0 Tc 6.017 0 Td [(\(Continue)12(d\))]TJ /T1_2 1 Tf 7.4999 0 0 7.4999 51.7606 696.5856 Tm [(Pos)-10(toperative)-265(vitamin)-266(and)-266(mineral)-266(supplementation)]TJ 50.306 1.406 Td [(Grade,)-263(evidence)-267(level)-261(\(EL\),)-265(\(range)]TJ 0 -1.406 TD [(of)-261(evidence\))]TJ /T1_0 1 Tf -49.301 -1.965 Td [(Vitamin)-262(K)]TJ /T1_1 1 Tf 0 -1.867 TD (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Following)-264(malabsorptive)-268(procedures)-272(such)-261(BPD/DS,)-269(recommend)-268(daily)-264(oral)-263(supplementa)-12(tion)-258(with)-266(additional)]TJ 0.423 -1.398 Td [(vitamin)-267(K)]TJ 48.303 1.398 Td [(Grade)-259(C)-264(EL)-263(2)-259(\(1+)-267(to)-263(4\))]TJ /T1_1 1 Tf -49.301 -3.266 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Following)-264(malabsorptive)-268(procedures)-272(such)-261(BPD/DS,)-269(we)-264(suggest)-260(star)-9(ting)-257(with)-266(300-)]TJ /T1_3 1 Tf 35.422 0 Td (\003)Tj /T1_0 1 Tf 0.522 0 Td [(g)-261(oral)-263(vitamin)-259(K)-266(daily)-3718(GPP)]TJ -36.518 -1.867 Td [(Water-miscible)-273(forms)-261(of)-259(fat-s)-11(oluble)-259(vitamins)]TJ /T1_1 1 Tf T* (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Water-miscible)-273(forms)-261(of)-259(fat-solubl)-11(e)-259(vitamins)-271(may)-260(improve)-268(absorption)-263(especially)-269(after)-268(malabsorptive)]TJ 0.423 -1.398 Td (procedures)Tj 48.303 1.398 Td [(Grade)-259(D)-260(EL)-263(4)]TJ -50.306 -3.266 Td [(Zinc)-264(and)-266(copper)]TJ /T1_1 1 Tf 1.005 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Recommend)-269(a)-259(multivitamin)-266(and)-266(mineral)-267(containing)-268(at)-261(least)-264(the)-260(government)-272(recommended)-269(daily)-264(allowance)]TJ 0.423 -1.398 Td [(for)-260(zinc)]TJ 48.303 1.398 Td [(Grade)-259(B)-262(EL)-263(2)]TJ /T1_1 1 Tf -49.301 -3.266 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Following)-264(RYGB)-267(and)-259(SG,)-266(the)-260(optimal)-263(level)-267(of)-259(zin)-9(c)-258(supplementa)-12(tion)-258(is)-264(not)-263(known;)-263(however,)-269(we)-264(recommend)]TJ 0.423 -1.398 Td [(15-mg)-269(zinc)-259(oral)-263(daily,)-265(which)-265(may)-260(be)-266(contained)-270(within)-261(the)-260(multiv)-10(itamin)-263(and)-259(mineral)-267(supplement)]TJ 48.303 1.398 Td (GPP)Tj /T1_1 1 Tf -49.301 -3.266 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Following)-264(malabsorptive)-268(procedures)-272(such)-261(BPD/DS,)-269(the)-260(opti)-9(mal)-261(level)-260(of)-267(zinc)-259(suppl)-9(ementation)-262(is)-264(not)-263(known)]TJ 0.423 -1.398 Td [(but)-265(will)-261(be)-258(higher)-266(than)-260(that)-269(for)-260(RYGB)-259(or)-263(SG.)-262(We)-263(recommend)-268(starting)-266(with)-266(at)-261(least)-264(30-mg)-262(oral)-263(zinc)-267(daily,)]TJ 0 -1.406 TD [(which)-265(may)-260(be)-266(contained)-263(wit)-9(hin)-259(the)-260(oral)-263(multivitamin)-273(and)-259(mineral)-267(supplement)]TJ 48.303 2.804 Td [(Grade)-259(C)-264(EL)-263(2)]TJ /T1_1 1 Tf -49.301 -4.664 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Following)-264(RYGB,)-268(SG)-257(and)-266(BPD/DS,)-269(recommend)-268(complete)-269(multivitamin)-266(and)-266(mineral)-259(oral)-263(suppl)-9(ement)]TJ 0.423 -1.406 Td [(containing)-268(2-mg)-267(copper)]TJ 48.303 1.406 Td [(Grade)-259(D)-260(EL)-263(4)]TJ -50.306 -3.273 Td [(Sel)-10(enium)]TJ /T1_1 1 Tf 1.005 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Recommend)-269(a)-259(complete)-269(multivitamin)-266(and)-266(mineral)-259(suppl)-9(ement)-266(containing)-268(selenium)]TJ 48.726 0 Td [(Grade)-259(D)-260(EL)-263(2)-267(\(2)]TJ /T1_5 1 Tf (\025)Tj /T1_0 1 Tf 7.62 0 Td (\))Tj /T1_1 1 Tf -56.92 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Following)-264(malabsorptive)-268(procedures)-272(such)-261(as)-263(BPD/DS,)-269(additional)-263(routin)-10(e)-259(oral)-263(supplementatio)-14(n)-257(with)-266(selenium)]TJ 0.423 -1.398 Td [(may)-260(be)-266(needed)-269(to)-256(prevent)-266(deficiency)]TJ 48.303 1.398 Td [(Grade)-259(B)-262(EL)-263(2)-259(\(1+)-267(to)-263(2)]TJ /T1_5 1 Tf 9.411 0 Td (\025)Tj /T1_0 1 Tf 0.673 0 Td (\))Tj -60.39 -3.266 Td [(Thi)-9(amine)]TJ /T1_1 1 Tf 1.005 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Recommend)-269(a)-259(complete)-269(multivitamin)-266(and)-266(mineral)-259(suppl)-9(ement)-266(containing)-268(at)-261(least)-264(government)-265(dietary)]TJ 0.423 -1.398 Td [(recommenda)-13(tions)-262(for)-260(thiamine)]TJ 48.303 1.398 Td [(Grade)-259(B)-262(EL)-263(2)]TJ /T1_1 1 Tf -49.301 -3.266 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Consider)-263(recommendi)-14(ng)-261(oral)-263(thiamine)-264(or)-263(vitamin)-267(B)-262(co)-255(strong)-265(tabl)-9(ets)-256(for)-268(first)-263(3-)-258(to)-263(4-month)-268(post-surgery)-3494(GPP)]TJ /T1_1 1 Tf -0.575 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Prescribe)-267(oral)-263(thiamine)-264(200)]TJ /T1_1 1 Tf 11.936 0 Td (\226)Tj /T1_0 1 Tf 0.575 0 Td [(300)-264(mg)-258(daily,)-265(vitamin)-267(B)-262(co)-263(strong)-265(1)-259(or)-263(2)-259(tablets,)-266(three)-262(times)-263(a)-259(day)-263(to)-263(people)]TJ -12.087 -1.398 Td [(with)-266(symptoms)-261(such)-269(as)-256(dyspha)-10(gia,)-260(vomiting,)-267(poor)-268(dietary)-263(intake)-264(or)-263(fast)-262(weight)-264(loss)]TJ 48.303 1.398 Td [(Grade)-259(D)-260(EL)-263(4)]TJ /T1_1 1 Tf -49.301 -3.266 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Clinicians)-262(sho)-9(uld)-262(be)-258(educated)-264(about)-265(the)-267(factors,)-262(which)-265(may)-260(pred)-10(ispose)-259(to)-263(thiamine)-264(de)-9(ficiency)-267(and)-259(the)]TJ 0.423 -1.398 Td [(importance)-268(of)-267(initiating)-262(immediat)-12(e)-259(treatment)]TJ 48.303 1.398 Td (GPP)Tj /T1_1 1 Tf -49.301 -3.266 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(People)-267(should)-263(be)-258(educated)-264(about)-265(the)-267(risks)-260(of)-259(potenti)-12(al)-257(thiamine)-264(de)-9(ficiency)-267(and)-259(asked)-263(to)-263(seek)-263(early)-264(advice)-268(if)]TJ 0.423 -1.398 Td [(they)-264(experience)-270(prolonged)-263(vo)-9(miting)-265(or)-256(poor)-268(dietary)-263(intake)]TJ 48.303 1.398 Td (GPP)Tj -51.236 -3.704 Td 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[(This)-311(creates)-312(a)-312(dilemma)-308(as)-310(many)]TJ -16.448 -1.623 Td [(centres)-688(are)-699(unable)-685(to)-700(request)-690(measurem)14(ent)-693(of)-697(vitamin)-696(K,)-692(and)]TJ T* [(coagulatio)11(n)-256(screens)-247(are)-253(not)-254(a)-255(reliable)-248(indication)-247(of)-257(vitamin)-249(K)-251(status.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 277.285 570.9542 Tm (111)Tj 0 Tc 7.9999 0 0 7.9999 44.7874 554.3998 Tm [(Conseque)14(ntly,)-617(we)-612(recommend)-609(that)-611(postoperat)13(ive)-616(care)-621(of)-611(people)]TJ T* [(following)-564(malabsorp)16(tive)-567(procedures)-560(\(BPD/DS\))-560(should)-563(remain)-563(with)]TJ T* [(specialist)-322(centres)-320(lifelong)-324(with)-320(routine)-318(monitoring)-317(of)-328(serum)-326(vitamin)-320(E)]TJ 0 -1.63 TD [(and)-257(K)-258(levels.)]TJ 1.878 -1.623 Td [(Follow)12(ing)-265(AGB,)-265(SG)-261(or)-267(RYGB,)-259(routine)-254(monitoring)-260(of)-264(serum)-255(vitamin)]TJ -1.878 -1.623 Td [(E)-378(and)-370(K)-372(levels)-371(is)-369(not)-374(recommend)14(ed)-374(but)-370(may)-372(be)-374(measured)-366(in)-371(people)]TJ T* [(presenting)-870(with)-880(unexplain)14(ed)-884(anaemi)11(a,)-880(neuropathy,)-872(bruising)-869(or)]TJ 0 -1.623 TD [(uncontroll)13(ed)-260(bleeding.)]TJ 5.9998 0 0 5.3325 121.7763 466.9794 Tm (2)Tj /T1_2 1 Tf 0.576 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.576 0 Td (4,51)Tj /T1_3 1 Tf 0 Tc 10.0001 0 0 10.0001 44.7874 424.403 Tm (7.5)Tj /T1_0 1 Tf 2.177 0 Td (|)Tj /T1_3 1 Tf 1.049 0 Td [(Trace)-266(minerals:)-263(zinc,)-267(copper,)-267(selenium)-262(and)]TJ -3.226 -1.298 Td (magnesium)Tj /T1_0 1 Tf 7.9999 0 0 7.9999 44.7874 385.3983 Tm [(Zinc)-380(deficien)10(cy)-383(occasion)11(ally)-385(occurs)-372(following)-373(SG)-381(or)-381(RYGB)-378(and)-377(more)]TJ 0 -1.623 TD [(common)12(ly)-1089(following)-1088(BPD/DS)11(.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 161.9149 375.9873 Tm (31,36,37,53,58,67,69,72)Tj /T1_2 1 Tf 0 Tc 10.687 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.576 0 Td (74,89,94,101,112,113)Tj 0 Tc 7.9999 0 0 7.9999 44.7874 359.433 Tm [(Factors)-880(may)-889(includ)12(e)-890(length)-883(of)-888(time)-888(after)-881(surgery)-883(and)-880(limb)]TJ 0 -1.63 TD (length.)Tj 0.0001 Tc 5.9998 0 0 5.3325 68.3149 349.9652 Tm (112,113)Tj 0 Tc 7.9999 0 0 7.9999 94.337 346.3936 Tm [(Zinc)-508(deficiency)-507(may)-506(present)-505(as)-515(poor)-507(wound)-502(healing,)]TJ -6.194 -1.623 Td [(taste)-591(changes,)-594(glossitis)-590(and)-590(hair)-598(loss.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 183.6283 336.9826 Tm (53)Tj 0 Tc 7.9999 0 0 7.9999 195.2503 333.4109 Tm [(Serum/plas)12(ma)-598(zinc)-590(levels)]TJ -18.808 -1.623 Td [(should)-506(be)-515(monito)13(red)-516(if)-509(there)-513(are)-515(unexplai)15(ned)-516(sympto)14(ms)-511(including)]TJ T* [(anaemia)-293(or)-296(changes)-288(in)-300(taste)-294(acuity)-293(and)-292(at)-298(least)-291(annually)-296(follow)13(ing)-301(SG,)]TJ 0 -1.623 TD [(RYGB)-250(and)-257(BPD/DS.)]TJ 5.9998 0 0 5.3325 114.2362 297.9779 Tm (2)Tj /T1_2 1 Tf 0.576 0 Td (\226)Tj /T1_0 1 Tf 0.567 0 Td (4)Tj 7.9999 0 0 7.9999 59.811 281.4236 Tm [(Copper)-415(deficien)10(cy)-425(may)-421(present)-420(following)-415(RYGB)]TJ 0.0001 Tc 5.9998 0 0 5.3325 231.0802 284.9952 Tm (37,67,114)Tj /T1_2 1 Tf 0 Tc (\226)Tj /T1_0 1 Tf 0.0001 Tc 5.008 0 Td (117)Tj 0 Tc 7.9999 0 0 7.9999 274.8472 281.4236 Tm (and)Tj -28.758 -1.623 Td [(more)-927(commo)13(nly)-927(following)-925(BPD/DS)11(.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 184.7055 271.9558 Tm (72,89,112)Tj 0 Tc 7.9999 0 0 7.9999 218.8346 268.4409 Tm [(Symptom)11(s)-927(include)]TJ -21.756 -1.63 Td [(anaemia,)-1273(leucopoe)11(nia,)-1280(thrombocy)13(topenia)-1275(and)-1277(neuromuscu)15(lar)]TJ 0 -1.623 TD [(abnormali)12(ties.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 93.033 245.9904 Tm (114,115,118)Tj /T1_2 1 Tf 0 Tc 5.594 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.567 0 Td (120)Tj 0 Tc 7.9999 0 0 7.9999 144.3968 242.4188 Tm [(Elhag)-497(et)-508(al.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 185.7826 245.9904 Tm (19)Tj 0 Tc 7.9999 0 0 7.9999 196.7244 242.4188 Tm [(reported)-498(a)-510(fall)-503(in)-506(copper)]TJ -18.992 -1.623 Td [(levels)-719(in)-725(adolesce)11(nts)-722(who)-720(had)-724(SG.)-719(In)-723(addition,)-722(high-do)14(se)-725(zinc)]TJ 0 -1.63 TD [(supplementa)17(tion)-568(over)-563(time)-569(can)-567(cause)-563(copper)-564(deficie)11(ncy)-568(and)-568(vice)]TJ 0 -1.623 TD (versa.)Tj 0.0001 Tc 5.9998 0 0 5.3325 64.9701 206.9858 Tm (118)Tj /T1_2 1 Tf 0 Tc 1.72 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.567 0 Td (120)Tj 0 Tc 7.9999 0 0 7.9999 91.559 203.4141 Tm [(Serum)-304(copper)-309(should)-308(be)-317(monitor)12(ed)-317(following)-302(SG,)-312(RYGB)]TJ -5.846 -1.623 Td [(and)-342(BPD/DS)11(,)-349(in)-343(people)-339(who)-337(are)-345(on)-339(high)-337(doses)-340(of)-342(zinc)-342(and)-342(in)-343(people)]TJ 0 -1.63 TD [(who)-252(present)-257(with)-250(unexplained)-253(anaemi)11(a)-262(and)-257(myelone)13(uropathy.)]TJ 5.9998 0 0 5.3325 259.8802 180.9637 Tm (2)Tj /T1_2 1 Tf 0.567 0 Td (\226)Tj /T1_0 1 Tf 0.576 0 Td (4)Tj 7.9999 0 0 7.9999 59.811 164.4094 Tm [(Serum)-516(selenium)-514(levels)-520(are)-522(not)-523(commonly)-517(measured,)-517(but)-519(defi-)]TJ -1.878 -1.623 Td [(ciency)-389(has)-389(been)-393(reporte)13(d)-398(after)-385(SG,)-397(RYGB)-385(and)-391(BPD/DS)11(.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 244.5165 154.9417 Tm (67,69,73,89,107)Tj 0 Tc 7.9999 0 0 7.9999 44.7874 138.3874 Tm [(Given)-384(that)-377(there)-386(are)-387(reports)-378(of)-385(selenium)-380(deficien)10(cy,)-384(we)-386(recommend)]TJ 0 -1.623 TD [(routine)-538(monitoring)-536(of)-548(serum)-538(selenium)-543(levels)-541(after)-541(SG,)-546(RYGB)-541(and)]TJ T* [(BPD/DS)-534(or)-537(if)-538(there)-535(is)-539(chronic)-540(diarrho)12(ea,)-538(metabolic)-537(bone)-535(disease)13(,)]TJ T* [(unexplained)-246(anaemia)-251(or)-260(unexplained)-246(cardiomyop)12(athy.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 230.57 102.9543 Tm (2,4)Tj 0 Tc 7.9999 0 0 7.9999 59.811 86.3999 Tm [(There)-1057(was)-1060(insufficie)10(nt)-1064(evidence)-1058(to)-1061(recommend)-1049(routine)]TJ -1.878 -1.623 Td [(monitoring)-714(of)-718(magnesiu)12(m;)-721(however,)-717(people)-715(with)-717(hypocalca)10(emia)]TJ T* [(should)-513(be)-522(investigated)-517(for)-520(hypomagne)13(saemia)-518(and)-519(treated)-514(prior)-519(to)]TJ 0 -1.63 TD [(calcium)-251(supplementati)15(on.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 132.6614 50.9669 Tm (121)Tj /T1_3 1 Tf 0 Tc 10.0001 0 0 10.0001 306.0283 723.4014 Tm (7.6)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_3 1 Tf 1.054 0 Td (Thiamine)Tj /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 697.436 Tm [(People)-255(are)-260(at)-262(risk)-259(of)-257(developing)-257(thiamin)13(e)-267(deficien)10(cy)-262(if)-261(they)-261(experienc)12(e)]TJ T* [(prolonge)14(d)-497(vomiting,)-497(rapid)-493(weight)-495(loss,)-497(poor)-493(dietary)-497(intake,)-494(alcohol)]TJ 0 -1.623 TD [(abuse,)-417(oedema)-428(or)-423(symptoms)-420(of)-427(neuropathy)15(.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 464.5983 674.9856 Tm (34,122)Tj /T1_2 1 Tf 0 Tc 3.08 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.567 0 Td (128)Tj 0 Tc 7.9999 0 0 7.9999 500.2582 671.414 Tm [(All)-421(healthcare)]TJ -24.279 -1.623 Td [(profession)17(als)-471(involved)-465(in)-470(the)-473(aftercare)-467(of)-470(bariatric)-466(surgery)-465(patients)]TJ 0 -1.63 TD [(should)-372(be)-381(aware)-379(of)-385(the)-381(potential)-380(risk)-379(for)-385(severe)-373(thiamine)-382(deficien)10(cy)]TJ 0 -1.623 TD [(\(see)-250(Sections)-256(8.9)-257(and)-257(9.6\).)]TJ 1.871 -1.623 Td [(Symptom)11(s)-452(of)-449(thiamine)-445(deficien)10(cy)-453(includ)12(e)-451(ataxia,)-450(confusio)13(n)-454(and)]TJ -1.871 -1.63 Td [(coma)-256(\(Cerebral)-251(Beri)-262(Beri)-262(and)-257(Wernicke's)-252(encephalopat)14(hy\),)-260(neuropathy)]TJ T* [(and)-618(neuritis)-618(especially)-615(in)-626(lower)-622(limbs)-618(\(Dry)-618(Beri)-623(Beri\))-625(or)-622(cardiac)]TJ T* [(insufficie)10(ncy)-539(with)-540(tachycard)12(ia)-548(and)-533(respiratory)-536(symptom)-535(\(Wet)-535(Beri)]TJ T* (Beri\).)Tj 0.0001 Tc 5.9998 0 0 5.3325 323.9432 570.9542 Tm (95,124,125)Tj 0 Tc 7.9999 0 0 7.9999 357.392 567.4392 Tm [(If)-422(thiamine)-417(deficienc)10(y)-425(is)-418(suspected,)-413(either)-416(because)-412(of)]TJ -6.42 -1.63 Td [(risk)-273(factors)-277(or)-282(clinical)-283(sympto)14(ms,)-279(oral)-286(or)-275(intravenous)-275(treatment)-276(should)]TJ T* [(be)-253(initiated)-253(immediatel)11(y)-262(and)-249(not)-261(delayed)-249(pending)-251(tests)-257(results.)]TJ /T1_3 1 Tf 10.0001 0 0 10.0001 306.0283 502.4125 Tm (7.7)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_3 1 Tf 1.054 0 Td (Dyslipidaemia)Tj /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 476.3904 Tm [(Treatment)-777(needs)-781(for)-782(dyslipidaem)12(ia)-789(should)-783(be)-785(reassessed)-780(after)]TJ 0 -1.623 TD [(achievem)14(ent)-261(of)-257(weight)-254(loss.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 402.1794 466.9794 Tm (10)Tj /T1_3 1 Tf 0 Tc 10.0001 0 0 10.0001 306.0283 424.403 Tm (8)Tj /T1_0 1 Tf 1.468 0 Td (|)Tj /T1_3 1 Tf 0.1009 Tc 1.151 0 Td [(VITAMIN)-262(AND)-262(MINERAL)]TJ -2.619 -1.298 Td (SUPPLEMENTATION)Tj /T1_0 1 Tf 0 Tc 7.9999 0 0 7.9999 306.0283 385.3983 Tm [(Becaus)11(e)-451(peoples')-438(requirement)14(s)-452(and)-441(adherence)-441(may)-443(vary)-447(over)-442(time,)]TJ 0 -1.623 TD [(we)-421(recommend)-418(that)-427(supplement)17(s)-430(should)-421(be)-423(reviewed)-426(regularl)13(y)-432(and)]TJ T* [(adjusted)-241(accordin)13(gly.)-251(Details)-242(of)-250(the)-253(recomm)13(ended)-245(vitamin)-249(and)-249(mineral)]TJ 0 -1.63 TD [(supplem)16(ents)-259(are)-253(shown)-258(in)-144(Table)-249(4.)]TJ /T1_3 1 Tf 10.0001 0 0 10.0001 306.0283 307.3889 Tm (8.1)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_3 1 Tf 1.054 0 Td [(Complete)-265(multivi)-10(tamin)-263(and)-258(m)-6(ineral)]TJ -3.226 -1.298 Td (supplements)Tj /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 268.4409 Tm [(Follow)12(ing)-733(all)-732(bariatric)-721(procedures,)-725(a)-730(complete)-724(multivitami)10(n)-738(and)]TJ T* [(mineral)-696(supplement)-691(\(containing)-694(thiamine,)-695(iron,)-704(zinc,)-705(copper)-698(and)]TJ 0 -1.623 TD [(seleniu)13(m\))-487(is)-489(recommende)10(d.)]TJ 5.9998 0 0 5.3325 403.4834 245.9904 Tm (2)Tj /T1_2 1 Tf 0.567 0 Td (\226)Tj /T1_0 1 Tf 0.576 0 Td (4)Tj 7.9999 0 0 7.9999 417.7133 242.4188 Tm [(A)-482(minimum)-482(of)-491(2)-484(mg)-492(of)-484(copper)-486(and)]TJ -13.961 -1.623 Td [(15-mg)-331(zinc)-342(per)-339(day)-341(is)-340(advised)-332(following)-330(SG,)-340(RYGB)-335(and)-342(BPD/DS)-329(\(see)]TJ 0 -1.63 TD [(Section)-293(8.7\).)-299(Care)-302(should)-294(be)-303(taken)-299(to)-303(check)-298(that)-299(the)-303(multivitam)12(in)-307(and)]TJ 0 -1.623 TD [(mineral)-646(supplement)-642(contains)-651(sufficien)12(t)-659(amounts)-646(of)-654(vitamins)-651(and)]TJ T* [(mineral)13(s)-508(to)-515(counter)-500(the)-509(malabsorp)16(tive)-510(effects)-505(of)-512(bariatric)-501(surgery;)]TJ 0 -1.63 TD [(howe)13(ver,)-262(additional)-250(supplement)17(s)-260(will)-258(be)-253(needed.)]TJ /T1_3 1 Tf 10.0001 0 0 10.0001 306.0283 138.3874 Tm (8.2)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_3 1 Tf 1.054 0 Td (Iron)Tj /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 112.422 Tm [(F)16(ol)26(lo)26(wi)21(ng)-369(in)26(s)16(er)24(ti)19(o)16(n)-383(o)16(f)-387(A)14(GB)28(,)-384(pe)23(o)16(pl)23(e)-380(sh)22(o)16(ul)23(d)-383(be)-367(a)14(bl)23(e)-380(to)-367(me)21(et)-366(th)20(e)17(ir)-371(ir)19(o)16(n)]TJ 0 -1.623 TD [(re)31(qu)20(ir)26(em)28(en)23(ts)-254(by)-256(o)16(ra)21(l)-267(di)26(et)-260(a)14(nd)-257(a)-262(co)24(mp)25(le)26(te)-260(m)18(ul)23(ti)26(vi)19(ta)28(mi)23(n)-270(a)14(nd)-257(m)18(in)26(er)24(al)-260(s)16(up)27(-)]TJ 0 -1.63 TD [(pl)30(em)21(e)17(nt)-228(co)24(nt)20(a)14(in)26(in)26(g)-241(th)20(e)-238(re)24(co)24(mm)22(e)17(nd)27(ed)-232(da)28(il)22(y)-241(al)24(lo)26(wa)23(nc)28(e)-245(o)16(f)-245(ir)19(o)16(n.)-232(A)-241(di)26(et)24(et)24(ic)]TJ 0 -1.623 TD [(re)31(vi)19(e)17(w)-239(ma)25(y)-234(be)-225(ne)23(ed)23(ed)-225(to)-225(c)15(he)23(c)15(k)-237(nu)20(tr)28(it)26(io)22(na)28(l)-239(ad)21(e)17(qu)27(ac)22(y)-241(o)16(f)-238(th)27(ei)22(r)-241(di)26(et)24(.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 527.5274 76.989 Tm [(12)29(9)]TJ 0 Tc 7.9999 0 0 7.9999 320.9952 60.4346 Tm [(Following)-671(SG,)-673(RYGB)-668(and)-675(malabsorpti)13(ve)-678(procedure)12(s)-678(such)-673(as)]TJ -1.871 -1.63 Td [(BPD/DS)11(,)-427(a)-425(complete)-419(multivitam)12(in)-428(and)-427(mineral)-419(supplement)-415(may)-421(not)]TJ ET 0.137 0.122 0.125 scn /CS0 CS 0.137 0.122 0.125 SCN 0 w 1 j 1 J /GS1 gs 548.787 748.63 -504 0.453 re B* q 1 0 0 1 526.28 761.102 cm -0.51 0 0.51 -12.019 re B* Q BT 0 0 0 scn /GS0 gs /T1_0 1 Tf 6.9999 0 0 6.9999 44.7874 753.1085 Tm (O'KANE)Tj 4.8997 0 0 4.8997 72.1701 753.1085 Tm [(ET)-384(AL)]TJ 6.9999 0 0 6.9999 85.4929 753.1085 Tm (.)Tj /T1_3 1 Tf 65.611 0 Td (9)Tj ET /Document /MC0 BDC q 455.096 759.571 -66.24 -15.6 re W n q /GS1 gs 66.642 0 0 15.744 388.728 743.928 cm /Im0 Do Q EMC Q /Document /MC1 BDC q 463.578 757.474 54.142 -11.282 re W n 1 1 1 scn /GS1 gs 463.578 746.192 54.142 11.282 re f q 1 0 0 1 482.25 747.988 cm /CS1 cs 1 scn /GS0 gs 0 0 m 0 -0.707 -0.157 -1.162 -0.66 -1.444 c -0.66 -1.539 l 2.451 -1.539 l 2.451 -1.444 l 1.948 -1.162 1.792 -0.707 1.792 0 c 1.792 6.03 l 1.792 6.722 1.948 7.177 2.451 7.475 c 2.451 7.554 l -0.66 7.554 l -0.66 7.475 l -0.157 7.177 0 6.722 0 6.03 c 0 0 l h 13.836 -1.539 m 14.275 0.377 l 14.182 0.408 l 13.647 -0.424 12.83 -0.77 11.621 -0.77 c 8.073 -0.77 l 8.073 5.951 l 8.073 6.722 8.261 7.161 8.794 7.475 c 8.794 7.554 l 5.67 7.554 l 5.654 7.475 l 6.141 7.177 6.282 6.737 6.282 6.109 c 6.282 -0.079 l 6.282 -0.724 6.141 -1.146 5.654 -1.444 c 5.67 -1.539 l 13.836 -1.539 l h 28.991 -1.444 m 29.005 -1.539 l 32.148 -1.539 l 32.148 -1.444 l 31.628 -1.146 31.472 -0.675 31.472 0.079 c 31.472 2.215 l 34.237 6.155 l 34.739 6.879 35.163 7.318 35.524 7.475 c 35.524 7.554 l 33.074 7.554 l 33.074 7.475 l 33.514 7.224 33.575 6.611 33.106 5.937 c 31.08 3.015 l 28.849 6.298 l 28.504 6.8 28.566 7.256 28.975 7.475 c 28.975 7.554 l 25.534 7.554 l 25.534 7.475 l 25.944 7.303 26.196 7.067 26.635 6.439 c 29.682 2.088 l 29.682 0.079 l 29.682 -0.675 29.509 -1.146 28.991 -1.444 c 18.045 3.659 m 18.045 6.783 l 21.311 6.783 l 22.803 6.783 23.368 6.549 23.903 5.795 c 23.997 5.826 l 23.808 7.554 l 15.642 7.554 l 15.626 7.475 l 16.114 7.177 16.255 6.737 16.255 6.109 c 16.255 -0.079 l 16.255 -0.724 16.114 -1.146 15.626 -1.444 c 15.642 -1.539 l 24.232 -1.539 l 24.546 0.313 l 24.468 0.345 l 23.918 -0.393 23.259 -0.77 21.783 -0.77 c 18.045 -0.77 l 18.045 2.921 l 20.542 2.921 l 21.61 2.921 22.143 2.748 22.427 2.293 c 22.536 2.293 l 22.536 4.271 l 22.427 4.287 l 22.143 3.832 21.61 3.659 20.542 3.659 c 18.045 3.659 l h -6.988 -1.853 m -6.91 -1.853 l -3.046 7.773 l -2.669 8.7 -2.324 9.156 -1.979 9.359 c -1.979 9.454 l -4.303 9.454 l -4.303 9.359 l -3.816 9.093 -3.706 8.37 -4.036 7.539 c -6.407 1.602 l -9.627 9.485 l -9.705 9.485 l -13.097 1.617 l -15.532 7.806 l -15.814 8.543 -15.735 9.093 -15.281 9.359 c -15.281 9.454 l -18.672 9.454 l -18.672 9.359 l -18.311 9.171 -18.044 8.779 -17.714 7.977 c -13.725 -1.853 l -13.647 -1.853 l -10.286 6.109 l -6.988 -1.853 l f Q EMC Q endstreamendobj486 0 obj<>endobj487 0 obj<>stream BT /CS0 cs 0 0 0 scn /GS0 gs /T1_0 1 Tf 7.9999 0 0 7.9999 46.4882 281.4236 Tm [(supplementa)17(tion,)-329(high)-323(folate)-331(levels)-322(or)-324(iron)-327(deficiency.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 234.1984 284.9952 Tm (95)Tj 0 Tc 7.9999 0 0 7.9999 243.6661 281.4236 Tm [(It)-333(is)-326(essential)]TJ -24.647 -1.623 Td [(to)-438(assess)-437(all)-442(haemati)11(nics)-440(before)-437(recommend)14(ing)-442(additional)-427(folic)-441(acid)]TJ 0 -1.63 TD [(supplements)12(.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 92.1826 258.9731 Tm (97,102)Tj /T1_1 1 Tf 0 Tc 10.0001 0 0 10.0001 46.4882 216.3968 Tm (7.3)Tj /T1_0 1 Tf 2.177 0 Td (|)Tj /T1_1 1 Tf 1.049 0 Td [(Vitami)-7(n)-260(D,)-258(calciu)-8(m)-261(and)-258(PTH)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 46.4882 190.4314 Tm [(Vitamin)-433(D)-438(plays)-436(an)-440(important)-430(part)-441(in)-442(musculosk)15(eletal)-437(health)-436(and)-441(is)]TJ T* [(essential)-254(for)-265(calcium)-258(absorption)-254(and)-264(bone)-259(mineraliza)12(tion.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 242.8157 180.9637 Tm (44,48,64,103,104)Tj 0 Tc 7.9999 0 0 7.9999 46.4882 164.4094 Tm [(Following)-309(bariatric)-310(surgery,)-311(the)-317(desirable)-313(serum)-311(25-hydroxy)13(vitamin)-313(D)]TJ 0 -1.623 TD [(\(25OHD\))-440(levels)-449(to)-452(optimize)-442(bone)-443(health,)-445(prevent)-444(secondar)12(y)-454(hyper-)]TJ 0 -1.63 TD [(parathyro)14(idism,)-461(improve)-462(bone)-457(mineral)-455(density)-460(and)-462(calcium)-456(balance,)]TJ 0 -1.623 TD [(and)-370(decrease)-367(fracture)-372(risk,)-374(are)-366(not)-374(known.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 197.1779 128.9763 Tm (44,48)Tj 0 Tc 7.9999 0 0 7.9999 215.2062 125.4047 Tm [(Many)-371(guidelines)-366(rec-)]TJ -21.09 -1.623 Td [(ommend)-392(25OHD)-393(levels)-393(of)-399(>75)-396(nmol)-389(L)]TJ /T1_2 1 Tf 5.9998 0 0 5.3325 185.2724 115.9937 Tm (\025)Tj /T1_0 1 Tf 0.68 0 Td (1)Tj 7.9999 0 0 7.9999 192.7558 112.422 Tm (.)Tj 5.9998 0 0 5.3325 194.6267 115.9937 Tm (2)Tj /T1_3 1 Tf 0.567 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.576 0 Td (4,52)Tj 0 Tc 7.9999 0 0 7.9999 216.2834 112.422 Tm [(However,)-388(Chaktoura)]TJ -21.225 -1.623 Td [(suggested)-256(that)-264(these)-263(were)-263(based)-259(on)-268(expert)-258(opinion)-257(rather)-261(than)-264(robust)]TJ 0 -1.63 TD [(evidence)-378(and)-377(proposed)-376(serum)-375(25OHD)-379(levels)-378(of)-385(50)-380(nmol)-382(L)]TJ /T1_2 1 Tf 5.9998 0 0 5.3325 256.3653 89.9716 Tm (\025)Tj /T1_0 1 Tf 0.671 0 Td (1)Tj 7.9999 0 0 7.9999 266.9102 86.3999 Tm [(with)-377(a)]TJ -27.553 -1.623 Td [(call)-257(for)-258(further)-252(research.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 129.4866 76.989 Tm (48)Tj 0 Tc 7.9999 0 0 7.9999 61.5118 60.4346 Tm [(Normal)-274(25OHD)-280(levels)-279(accompani)11(ed)-289(by)-284(persiste)13(ntly)-283(elevated)-282(PTH)]TJ -1.878 -1.63 Td [(and)-618(high)-613(serum)-616(calcium)-619(levels)-612(may)-620(be)-615(an)-624(indication)-608(of)-619(primary)]TJ 32.655 29.254 Td [(hyperp)14(arathyroidis)12(m)-825(hence)-825(the)-820(need)-818(to)-827(check)-823(PTH)-821(levels)-818(at)]TJ 0 -1.623 TD [(baseline)13(.)]TJ 5.9998 0 0 5.3325 337.6629 271.9558 Tm (10)Tj 7.9999 0 0 7.9999 347.7542 268.4409 Tm [(All)-393(people)-396(are)-394(at)-397(risk)-393(of)-399(developi)13(ng)-398(vitamin)-391(D)-395(deficiency)]TJ -5.003 -1.63 Td [(follow)13(ing)-301(bariatric)-289(surgery,)]TJ 0.0001 Tc 5.9998 0 0 5.3325 400.1952 258.9731 Tm (44)Tj 0 Tc 7.9999 0 0 7.9999 409.4361 255.4015 Tm [(but)-292(those)-292(who)-295(have)-296(more)-296(malab)13(sorptive)]TJ -12.714 -1.623 Td [(procedur)16(es)-279(are)-281(at)-284(greate)12(r)-284(risk.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 411.8172 245.9904 Tm (68)Tj /T1_3 1 Tf 0 Tc 1.143 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.576 0 Td (73,89,94)Tj 0 Tc 7.9999 0 0 7.9999 447.5904 242.4188 Tm [(Therefore,)-272(serum)-276(calcium)-272(and)]TJ -17.483 -1.623 Td [(25OHD)-542(levels)-556(should)-549(be)-551(monitored)-546(following)-550(bariatric)-544(surgery.)-548(If)]TJ 0 -1.63 TD [(vitamin)-448(D)-452(supplementat)17(ion)-454(is)-454(adjusted,)-448(serum)-453(calcium)-449(and)-448(25OHD)]TJ 0 -1.623 TD [(levels)-251(should)-251(be)-260(rechecke)11(d.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 402.2361 206.9858 Tm (105)Tj /T1_1 1 Tf 0 Tc 10.0001 0 0 10.0001 307.729 164.4094 Tm (7.4)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_1 1 Tf 1.054 0 Td [(Fat-soluble)-267(vitamin)-9(s)-260(A,)-258(E)-261(and)-264(K)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 307.729 138.3874 Tm [(Vitamin)-823(A)-836(deficiency)-833(has)-828(been)-832(reported)-831(after)-831(RYGB)-831(and)-831(in)]TJ T* [(adolesce)11(nts.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 350.2487 128.9763 Tm (15,93,106)Tj /T1_3 1 Tf 0 Tc (\226)Tj /T1_0 1 Tf 0.0001 Tc 5.017 0 Td (108)Tj 0 Tc 7.9999 0 0 7.9999 397.0771 125.4047 Tm [(Although)-799(clinical)-800(problems)-804(rarely)-797(occur,)]TJ -11.169 -1.623 Td [(considerat)17(ion)-305(should)-301(be)-303(given)-305(to)-303(monitoring)-296(serum)-297(vitamin)-306(A)-305(levels)-300(if)]TJ 0 -1.623 TD [(there)-372(are)-387(conce)12(rns)-382(such)-382(as)-381(deterio)11(ration)-384(in)-378(night)-380(vision,)-378(dry)-377(eyes)-383(or)]TJ 0 -1.63 TD (protein)Tj /T1_3 1 Tf 3.125 0 Td (\226)Tj /T1_0 1 Tf 0.567 0 Td [(energy)-797(malnutrition.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 411.4203 89.9716 Tm (3,4,53)Tj 0 Tc 7.9999 0 0 7.9999 434.2109 86.3999 Tm [(Vitamin)-795(A)-801(deficiency)-798(is)-801(more)]TJ -15.81 -1.623 Td [(commo)13(n)-433(following)-415(BPD/DS.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 408.3589 76.989 Tm (68)Tj /T1_3 1 Tf 0 Tc 1.143 0 Td (\226)Tj /T1_0 1 Tf 0.576 0 Td (74)Tj 7.9999 0 0 7.9999 428.9952 73.4173 Tm [(Conse)13(quently,)-425(after)-427(malabsorp)16(tive)]TJ -15.158 -1.623 Td [(procedur)16(es)-555(such)-545(as)-551(BPD/DS)-548(procedure)12(s,)-553(there)-549(should)-549(be)-551(routine)]TJ T* [(monito)13(ring)-414(of)-420(serum)-411(vitamin)-412(A)-411(levels.)-419(Many)-406(primary)-410(and)-420(second)13(ary)]TJ ET 0.82 0.827 0.831 scn /GS1 gs 46.488 691.597 504 26.022 re f q 0.06 782.362 595.215 -782.302 re W n q 46.488 415.105 504 223.994 re W n q BX /Sh0 sh EX Q Q Q 0.902 0.906 0.91 scn 46.488 362.608 504 14.003 re f 46.488 348.605 504 14.003 re f 46.488 334.602 504 14.003 re f 0.82 0.827 0.831 scn /CS0 CS 0.82 0.827 0.831 SCN 0 w 1 j 1 J 550.488 333.638 -504 0.964 re B* BT 0 0 0 scn /GS0 gs /T1_4 1 Tf 0.141 Tc 7.9999 0 0 7.9999 46.4882 724.5919 Tm [(TA)-8(BL)-5(E)-258(3)]TJ /T1_0 1 Tf 0 Tc 6.017 0 Td [(\(Continue)12(d\))]TJ /T1_1 1 Tf 7.4999 0 0 7.4999 53.4614 696.5856 Tm [(Pos)-10(toperative)-265(care)-265(and)-258(biochem)-13(ical)-255(monitor)-13(ing)]TJ 52.12 1.406 Td [(Grade,)-263(evidence)-267(level,)-266(range)]TJ 0 -1.406 TD [(of)-261(evidence)]TJ /T1_0 1 Tf -51.115 -1.965 Td [(Vitamin)-262(K)]TJ /T1_3 1 Tf 0 -1.867 TD (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Check)-265(vitamin)-259(K1)-269(and)-259(PIVKA-II)-266(level)-10(s)-261(at)-261(regular)-265(intervals)-264(following)-264(malabs)-10(orptive)-265(procedures)-264(such)-261(as)-263(BPD/DS)-2777(Grade)-266(B)-262(EL)-256(2)-267(\(1+)-259(to)-263(3\))]TJ /T1_3 1 Tf -0.575 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Consider)-263(monitoring)-268(of)-267(serum)-260(vitamin)-267(K1)-261(and)-259(PIVKA)-271(levels)-264(at)-261(least)-264(annually)-268(following)-264(malabsorptive)-268(procedures)]TJ 0.423 -1.398 Td [(such)-261(as)-263(BPD/DS)]TJ 50.117 1.398 Td (GPP)Tj -52.12 -3.266 Td [(Trac)-11(e)-259(minerals:)-263(zin)-9(c,)-259(copper,)-266(selenium)-269(and)-259(magnesiu)-11(m)]TJ 1.005 -1.867 Td (Zinc)Tj /T1_3 1 Tf T* (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Check)-265(serum/plasma)-270(zinc)-259(level)-10(s)-253(at)-268(regular)-265(intervals)-264(following)-264(SG,)-266(RYGB)-267(or)-256(BPD/DS)]TJ 50.54 0 Td [(Grade)-266(B)-262(EL)-256(2)-267(\(1+)-259(to)-263(3\))]TJ /T1_3 1 Tf -51.115 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Consider)-263(monitoring)-268(serum/plasma)-270(zinc)-267(levels)-264(at)-261(least)-264(annually)-268(following)-264(SG,)-266(RYGB)-259(or)-263(BPD/DS)]TJ 50.54 0 Td (GPP)Tj /T1_3 1 Tf -51.115 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Check)-265(serum/plasma)-270(zinc)-259(level)-10(s)-253(if)-265(unexplained)-272(anaemia,)-266(hair)-263(loss)-260(or)-263(changes)-269(in)-260(taste)-260(acuity)]TJ 50.54 0 Td (GPP)Tj -51.115 -1.86 Td (Copper)Tj /T1_3 1 Tf T* (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Check)-265(serum)-260(copper)-265(levels)-264(at)-261(regular)-265(interv)-11(als)-261(following)-264(SG,)-266(RYGB)-259(or)-263(BPD/DS)]TJ 50.54 0 Td [(Grade)-266(C)-256(EL)-263(3)-259(\(2)]TJ /T1_2 1 Tf 6.849 0 Td (\025)Tj /T1_0 1 Tf 0.937 0 Td [(to)-263(3\))]TJ /T1_3 1 Tf -58.901 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Consider)-263(monitoring)-268(serum)-268(copper)-265(levels)-264(at)-261(least)-264(annually)-268(following)-264(SG,)-266(RYGB)-259(or)-263(BPD/DS)]TJ 50.54 0 Td (GPP)Tj /T1_3 1 Tf -51.114 -1.867 Td (\201)Tj /T1_0 1 Tf 0.832 0 Td [(serum)-268(copper)-265(levels)-264(if)-257(une)-9(xplained)-263(anaemia)-265(or)-263(poor)-260(wound)-266(healing)]TJ 50.283 0 Td (GPP)Tj /T1_3 1 Tf -51.115 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Serum)-260(copper)-265(shou)-8(ld)-255(be)-266(monitored)-270(in)-260(patients)-262(taking)-266(zinc)-267(supplements)-263(and)-266(vice)-259(versa)]TJ 50.54 0 Td (GPP)Tj -51.115 -1.867 Td (Selenium)Tj /T1_3 1 Tf T* (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Check)-265(serum)-260(selenium)-269(levels)-264(if)-265(there)-262(is)-264(chronic)-259(diarrhoea,)-274(metabolic)-265(bone)-263(disease,)-267(unexplained)-272(anaemia)-265(or)]TJ 0.423 -1.398 Td [(unexplained)-272(cardiomyopathy)]TJ 50.117 1.398 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -51.115 -3.266 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Check)-265(serum)-260(selenium)-269(levels)-264(at)-261(regular)-265(interval)-11(s)-253(follo)-10(wing)-261(RYGB)]TJ /T1_3 1 Tf -0.575 -1.406 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Check)-265(serum)-260(selenium)-269(levels)-264(at)-261(regular)-265(interval)-11(s)-253(follo)-10(wing)-261(malabsorptive)-268(procedures)-272(such)-261(as)-263(BPD/DS)]TJ /T1_3 1 Tf -0.575 -1.398 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Consider)-263(monitoring)-268(serum)-268(selenium)-261(level)-10(s)-253(at)-268(least)-264(annually)-261(followi)-11(ng)-261(RYGB)-259(or)-263(malabsorptive)-268(procedures)-272(such)]TJ -0.575 -1.398 Td [(as)-263(BPD/DS)]TJ 51.115 4.203 Td [(Grade)-266(D)-260(EL)-263(2)-259(\(2)]TJ /T1_2 1 Tf 6.939 0 Td (\025)Tj /T1_0 1 Tf 0.68 0 Td (\))Tj -7.62 -1.406 Td [(Grade)-266(C)-256(EL)-263(2)-259(\(2+\))]TJ 0 -1.398 TD (GPP)Tj -52.12 -3.266 Td [(Thi)-9(amine)]TJ /T1_3 1 Tf 1.005 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(If)-256(the)-267(patient)-266(presents)-262(with)-266(rapid)-263(weight)-264(loss,)-261(poor)-268(dietary)-263(intake,)-265(vomiting,)-267(alcohol)-265(abuse,)-266(oedema)-264(or)-263(symptoms)]TJ 0.423 -1.398 Td [(of)-259(ne)-9(uropathy,)-264(initiate)-264(treatment)-272(for)-260(thiamine)-264(deficiency)-268(immediat)-12(ely.)-258(Do)-265(not)-263(delay)-262(pending)-265(blood)-264(results)]TJ 50.117 1.398 Td (GPP)Tj -52.12 -3.266 Td (HbA)Tj 5.6248 0 0 4.9992 68.3716 365.6125 Tm (1c)Tj 7.4999 0 0 7.4999 74.211 366.8597 Tm [(,)-258(lipids)]TJ /T1_3 1 Tf -1.761 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Monitor)-260(HbA1c)-270(in)-260(patients)-262(wit)-9(h)-257(preoperative)-272(diabetes)]TJ 50.54 0 Td (GPP)Tj /T1_3 1 Tf -51.115 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Monitor)-260(lipids)-264(in)-267(patients)-262(with)-266(preoperative)-264(dyslipi)-11(daemia)]TJ 50.54 0 Td (GPP)Tj -53.05 -2.298 Td [(Abbreviatio)-12(ns:)-373(AGB,)-380(adjustable)-374(gastric)-379(band)-9(;)-367(BP)-9(D/DS,)-373(duodenal)-384(switch;)-381(EL,)-371(evidence)-382(level)-381(and)-372(de)-9(picts)-371(where)-380(the)-381(majority)-379(of)-372(evidence)-382(lies;)-381(GPP,)-377(good)]TJ T* [(practice)-267(point;)-263(PIVKA-II,)-268(protein)-269(induced)-269(by)-261(vitamin)-267(K)-259(absence)-267(or)-263(antagonism;)-265(RYGB,)-268(Roux-en-Y)-264(gastric)-266(bypass,)-264(SG,)-266(sleeve)-267(gastrectomy.)]TJ ET 0.137 0.122 0.125 scn 0.137 0.122 0.125 SCN /GS1 gs 550.488 748.63 -504 0.453 re B* q 1 0 0 1 68.995 749.083 cm 0.51 0 -0.51 12.019 re B* Q BT 0 0 0 scn /GS0 gs /T1_1 1 Tf 6.9999 0 0 6.9999 46.4882 753.1085 Tm (8)Tj /T1_0 1 Tf 65.959 0 Td (O'KANE)Tj 4.8997 0 0 4.8997 535.5778 753.1085 Tm [(ET)-372(AL)]TJ 6.9999 0 0 6.9999 548.9006 753.1085 Tm (.)Tj ET /Document /MC0 BDC 1 1 1 scn /GS1 gs 77.499 746.135 54.195 11.338 re f q 1 0 0 1 96.171 747.988 cm /CS1 cs 1 scn /GS0 gs 0 0 m 0 -0.707 -0.157 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l 29.682 -0.675 29.509 -1.146 28.991 -1.444 c 18.045 3.659 m 18.045 6.783 l 21.311 6.783 l 22.803 6.783 23.368 6.549 23.903 5.795 c 23.997 5.826 l 23.808 7.554 l 15.642 7.554 l 15.626 7.475 l 16.114 7.177 16.255 6.737 16.255 6.109 c 16.255 -0.079 l 16.255 -0.724 16.114 -1.146 15.626 -1.444 c 15.642 -1.539 l 24.232 -1.539 l 24.546 0.313 l 24.468 0.345 l 23.918 -0.393 23.259 -0.77 21.783 -0.77 c 18.045 -0.77 l 18.045 2.921 l 20.542 2.921 l 21.61 2.921 22.143 2.748 22.427 2.293 c 22.536 2.293 l 22.536 4.271 l 22.427 4.287 l 22.143 3.832 21.61 3.659 20.542 3.659 c 18.045 3.659 l h -6.988 -1.853 m -6.91 -1.853 l -3.046 7.773 l -2.669 8.7 -2.324 9.156 -1.979 9.359 c -1.979 9.454 l -4.303 9.454 l -4.303 9.359 l -3.816 9.093 -3.706 8.37 -4.036 7.539 c -6.407 1.602 l -9.627 9.485 l -9.705 9.485 l -13.097 1.617 l -15.532 7.806 l -15.814 8.543 -15.735 9.093 -15.281 9.359 c -15.281 9.454 l -18.672 9.454 l -18.672 9.359 l -18.311 9.171 -18.044 8.779 -17.714 7.977 c -13.725 -1.853 l -13.647 -1.853 l -10.286 6.109 l -6.988 -1.853 l f Q EMC /Document /MC1 BDC q 206.441 759.571 -66.24 -15.6 re W n q /GS1 gs 66.642 0 0 15.744 140.088 743.928 cm /Im0 Do Q EMC Q endstreamendobj488 0 obj<>endobj489 0 obj<>stream /CS0 cs 0.82 0.827 0.831 scn /GS0 gs 44.787 691.597 504 26.022 re f 0.902 0.906 0.91 scn 44.787 579.628 504 14.003 re f 44.787 565.625 504 14.003 re f 44.787 485.121 504 14.003 re f 44.787 471.118 504 14.003 re f 44.787 446.627 504 24.491 re f q 0.06 782.362 595.215 -782.302 re W n q 44.787 208.63 m 548.787 208.63 l 548.787 394.129 l 44.787 394.129 l W n q BX /Sh0 sh EX Q Q Q BT 0 0 0 scn /GS1 gs /T1_0 1 Tf 0.141 Tc 7.9999 0 0 7.9999 44.7874 724.5919 Tm [(TA)-8(BL)-5(E)-258(3)]TJ /T1_1 1 Tf 0 Tc 6.017 0 Td [(Postope)13(rative)-255(care)-260(and)-257(biochem)13(ical)-262(monito)13(ring)]TJ /T1_2 1 Tf 7.4999 0 0 7.4999 51.7606 696.5856 Tm [(Pos)-10(toperative)-265(care)-265(and)-258(biochem)-13(ical)-255(monitor)-13(ing)]TJ 52.12 1.406 Td [(Grade,)-263(evidence)-267(level,)-266(range)]TJ 0 -1.406 TD [(of)-261(evidence)]TJ /T1_1 1 Tf -52.12 -1.965 Td [(Recomm)-11(endations)]TJ /T1_3 1 Tf 1.005 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Specialist)-266(postoperative)-271(dietetic)-269(support)-260(should)-263(be)-266(provided)-264(including)-264(indiv)-9(idualized)-263(nutritional)-271(supplementation,)]TJ 0.423 -1.398 Td [(support)-268(and)-259(guidance)-268(to)-263(achieve)-262(long-term)-271(weight)-264(loss)-260(and)-266(weight)-264(maintenance)]TJ 50.117 1.398 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -51.115 -3.266 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(People)-267(who)-259(have)-265(bariatric)-264(surgery)-265(should)-263(have)-265(a)-259(postopera)-12(tive)-259(follow-up)-271(care)-263(package)-267(within)-261(the)-267(bariatric)]TJ 0.423 -1.398 Td [(surgery)-265(service)-265(for)-260(a)-267(minimum)-268(of)-259(2)-259(years.)-268(This)-263(should)-263(include)-267(monitoring)-268(nutritional)-263(intake,)-265(dietary)-270(and)]TJ 0 -1.398 TD [(nutritional)-271(assessment,)-262(advice)-268(and)-266(support)]TJ 50.117 2.797 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -51.115 -4.664 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(People)-267(discharged)-265(from)-265(bariatric)-264(surgery)-265(service)-265(follow-up)-271(should)-263(undergo)-261(mo)-9(nitoring)-259(of)-267(nutritional)-263(stat)-9(us)-261(at)]TJ 0.423 -1.398 Td [(least)-264(once)-264(a)-259(year)-266(as)-263(part)-262(of)-259(a)-259(shared)-266(care)-263(mo)-9(del)-256(of)-267(management)]TJ 50.117 1.398 Td [(Grade)-266(D)-260(EL)-263(4)]TJ -52.12 -3.266 Td [(Urea)-266(and)-266(electrolytes,)-268(renal)-260(and)-266(liver)-264(function)-263(tests)]TJ /T1_3 1 Tf 1.005 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Monitor)-260(renal)-267(and)-259(liver)-264(function)-271(3,)-261(6)-259(and)-266(12)-262(months)-263(in)-260(the)-260(first)-263(year)-266(and)-259(then)-267(at)-261(least)-264(annually)]TJ 50.54 0 Td (GPP)Tj -52.12 -1.867 Td [(Haem)-12(atinics)]TJ 1.005 -1.867 Td [(Full)-257(blood)-264(count)-263(and)-266(ferritin)]TJ /T1_3 1 Tf 0 -1.867 TD (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Check)-265(full)-257(blood)-264(count)-263(and)-266(serum)-260(ferritin)-265(at)-268(regular)-265(intervals)-264(post-surgery)]TJ 50.54 0 Td [(Grade)-266(B)-262(EL)-256(2)-267(\(2+)-259(to)-263(2)]TJ /T1_4 1 Tf 9.411 0 Td (\025)Tj /T1_1 1 Tf 0.68 0 Td (\))Tj /T1_3 1 Tf -61.206 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Consider)-263(the)-260(follo)-10(wing)-261(frequency)-270(of)-259(monitoring)-268(of)-259(full)-265(blood)-264(count)-263(and)-266(ferritin)-265(levels:)-263(3,)-261(6)-259(and)-266(12)-262(months)-263(in)-260(the)]TJ 0.423 -1.398 Td [(first)-263(year)-266(and)-259(at)-261(least)-264(annual)-9(ly)-259(thereafter)-266(so)-266(that)-262(changes)-261(in)-267(status)-262(may)-260(be)-266(detected)]TJ 50.117 1.398 Td (GPP)Tj -52.12 -3.266 Td [(Fola)-10(te)]TJ /T1_3 1 Tf 1.005 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Check)-265(serum)-260(folate)-270(levels)-264(at)-261(regular)-265(intervals)-264(post-surg)-10(ery)]TJ 50.54 0 Td [(Grade)-266(B)-262(EL)-256(2)-267(\(1+)-259(to)-263(2)]TJ /T1_4 1 Tf 9.411 0 Td (\025)Tj /T1_1 1 Tf 0.68 0 Td (\))Tj /T1_3 1 Tf -61.206 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Consider)-263(the)-260(follo)-10(wing)-261(frequency)-270(of)-259(monitoring)-268(of)-259(serum)-268(folate)-262(level)-10(s:)-260(3,)-261(6)-259(and)-266(12)-262(months)-263(in)-260(the)-260(first)-263(year)-266(and)]TJ 0.423 -1.398 Td [(at)-261(least)-264(annually)-268(thereafter)-266(so)-266(that)-262(changes)-261(in)-267(status)-262(may)-260(be)-266(detected)]TJ 50.117 1.398 Td (GPP)Tj -52.12 -3.266 Td [(Vitam)-10(in)-260(B12)]TJ /T1_3 1 Tf 1.005 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Check)-265(vitamin)-259(B12)-267(levels)-264(at)-261(regular)-265(interv)-11(als)-261(following)-264(SG,)-266(RYGB)-259(and)-266(malabsorptive)-268(procedures)-272(such)-261(as)-263(BPD/DS)-1606(Grade)-266(B)-262(EL)-256(2)-267(\(2++)-261(to)-263(2)]TJ /T1_4 1 Tf 60.526 0 Td (\025)Tj /T1_1 1 Tf 0.673 0 Td (\))Tj /T1_3 1 Tf -61.773 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Consider)-263(the)-260(follo)-10(wing)-261(frequency)-270(of)-259(monitoring)-268(of)-259(vitamin)-267(B12)-267(levels:)-263(3,)-261(6)-267(and)-259(12)-262(months)-263(in)-267(the)-260(first)-263(year)-266(and)-259(at)]TJ 0.423 -1.398 Td [(least)-264(annually)-268(thereafter)-266(so)-258(that)-269(changes)-261(in)-260(stat)-9(us)-261(may)-260(be)-258(de)-9(tected)]TJ 50.117 1.398 Td (GPP)Tj -52.12 -3.266 Td [(Vitam)-10(in)-260(D,)-262(calcium)-265(and)-266(parathyroid)-262(horm)-10(one)]TJ 1.005 -1.867 Td [(Vitamin)-262(D)]TJ /T1_3 1 Tf T* (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Check)-265(serum)-260(25-hydroxy)-12(vitamin)-267(D)-260(levels)-264(at)-261(regular)-265(intervals)-264(post-surg)-10(ery)]TJ 50.54 0 Td [(Grade)-266(B)-262(EL)-256(2)-267(\(1+)-259(to)-263(3\))]TJ /T1_3 1 Tf -51.115 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Serum)-260(25-hydroxy)-12(vitamin)-267(D)-260(levels)-264(of)-259(75)-262(nmo)-9(l/L)-258(or)-263(greater)-270(are)-262(considered)-266(sufficient.)]TJ 50.54 0 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_3 1 Tf -51.115 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Ensure)-266(total)-257(25-hydro)-14(xyvitamin)-266(D)-260(\(D3)-260(and)-266(D2\))-260(is)-264(measured)-264(if)-265(patient)-266(is)-256(on)-262(vitamin)-267(D2)-263(supplements)-14(,)-258(e.g.,)]TJ 0.423 -1.398 Td [(ergocalcif)-13(erol)]TJ 50.117 1.398 Td (GPP)Tj /T1_3 1 Tf -51.115 -3.266 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Consider)-263(the)-260(follo)-10(wing)-261(frequency)-270(of)-259(monitoring)-268(of)-259(vitamin)-267(D)-260(level)-10(s:)-260(3,)-261(6)-259(and)-266(12)-262(months)-263(in)-260(the)-260(first)-263(year)-266(and)-259(at)]TJ 0.423 -1.398 Td [(least)-264(annually)-268(thereafter)-266(so)-258(that)-269(changes)-261(in)-260(stat)-9(us)-261(may)-260(be)-258(de)-9(tected)]TJ 50.117 1.398 Td (GPP)Tj -51.115 -3.266 Td (Calcium)Tj /T1_3 1 Tf T* (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Check)-265(serum)-260(calcium)-265(levels)-264(at)-268(regular)-265(intervals)]TJ 50.54 0 Td (GPP)Tj /T1_3 1 Tf -51.115 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Consider)-263(the)-260(follo)-10(wing)-261(frequency)-270(of)-259(monitoring)-268(of)-259(serum)-268(calcium)-265(levels:)-263(3,)-268(6)-259(and)-259(12)-262(mon)-9(ths)-254(in)-267(the)-260(first)-263(year)-266(and)]TJ 0.423 -1.398 Td [(at)-261(least)-264(annually)-268(thereafter)-266(so)-266(that)-262(changes)-261(in)-267(status)-262(may)-260(be)-266(detected)]TJ 50.117 1.398 Td (GPP)Tj -51.115 -3.266 Td [(Parathyroid)-266(hormone)]TJ /T1_3 1 Tf T* (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Check)-265(parathyroid)-262(horm)-10(one)-263(\(to)-260(exclude)-268(primary)-265(hyperparathyroidism)-15(\))-254(if)-265(it)-261(has)-263(not)-263(been)-260(che)-10(cked)-258(prior)-267(to)-263(surgery)-1853(GPP)]TJ -1.58 -1.867 Td [(Fat-s)-11(oluble)-259(vitamins)-271(A,)-257(E)-267(and)-259(K)]TJ 1.005 -1.867 Td [(Vitamin)-262(A)]TJ /T1_3 1 Tf T* (\201)Tj /T1_1 1 Tf 0.832 0 Td [(Consider)-270(checking)-265(serum)-260(vitamin)-267(A)-264(levels)-264(if)-265(patient)-258(report)-10(s)-261(steatorrhoea)-268(or)-263(symptoms)-261(of)-267(vitamin)-267(A)-256(deficienc)-15(y,)]TJ 0.166 -1.398 Td [(for)-260(exam)-11(ple,)-257(night)-265(blindness)-266(or)-263(protein)-261(malnutrit)-11(ion)]TJ 50.117 1.398 Td [(Grade)-266(D)-260(EL)-263(4)-259(\(2+)-259(to)-263(4\))]TJ /T1_3 1 Tf -51.115 -3.266 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Check)-265(serum)-260(vitamin)-267(A)-264(levels)-264(at)-261(regular)-265(intervals)-264(followi)-11(ng)-261(malabsorptive)-268(procedures)-272(such)-261(as)-263(BPD/DS)]TJ 50.54 0 Td [(Grade)-266(B)-262(EL)-256(2)-267(\(1+)-259(to)-263(2\))]TJ /T1_3 1 Tf -51.115 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Consider)-263(the)-260(follo)-10(wing)-261(frequency)-270(of)-259(monitoring)-268(of)-259(serum)-268(vitamin)-267(A)-256(level)-10(s)-261(following)-264(malabsorptive)-268(procedures)]TJ 0.423 -1.406 Td [(such)-261(as)-263(BPD/DS:)-267(every)-262(3)-267(months)-263(and)-259(then)-267(annually)-261(once)-264(level)-10(s)-261(are)-262(stable)]TJ 50.117 1.406 Td (GPP)Tj -51.115 -3.266 Td [(Vitamin)-262(E)]TJ /T1_3 1 Tf T* (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Check)-265(serum)-260(vitamin)-267(E)-259(levels)-264(at)-268(regular)-265(intervals)-264(following)-264(malabs)-10(orptive)-265(procedures)-264(such)-261(as)-263(BPD/DS)]TJ 50.54 0 Td [(Grade)-266(B)-262(EL)-256(2)-267(\(1+)-259(to)-263(2+\))]TJ /T1_3 1 Tf -51.115 -1.867 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Consider)-263(monitoring)-268(of)-267(serum)-260(vitamin)-267(E)-259(levels)-264(at)-261(lea)-9(st)-255(annu)-9(ally)-259(following)-264(malabs)-10(orptive)-265(procedures)-264(such)-269(as)]TJ 0.423 -1.406 Td (BPD/DS)Tj 50.117 1.406 Td (GPP)Tj /T1_3 1 Tf -51.115 -3.273 Td (\201)Tj /T1_1 1 Tf 0.575 0 Td [(Check)-265(serum)-260(vitamin)-267(E)-259(levels)-264(if)-265(unexplained)-272(anaemia)-265(or)-263(neuropathy)]TJ 50.54 0 Td [(Grade)-266(D)-260(EL)-263(4)]TJ 7.9999 0 0 7.9999 509.329 39.1181 Tm [(\(Continue)12(s\))]TJ ET 0.137 0.122 0.125 scn /CS0 CS 0.137 0.122 0.125 SCN 0 w 1 j 1 J /GS2 gs 548.787 748.63 -504 0.453 re B* q 1 0 0 1 526.28 761.102 cm -0.51 0 0.51 -12.019 re B* Q BT 0 0 0 scn /GS1 gs /T1_1 1 Tf 6.9999 0 0 6.9999 44.7874 753.1085 Tm (O'KANE)Tj 4.8997 0 0 4.8997 72.1701 753.1085 Tm [(ET)-384(AL)]TJ 6.9999 0 0 6.9999 85.4929 753.1085 Tm (.)Tj /T1_2 1 Tf 65.611 0 Td (7)Tj ET /Document /MC0 BDC q 455.096 759.571 -66.24 -15.6 re W n q /GS2 gs 66.642 0 0 15.744 388.728 743.928 cm /Im0 Do Q EMC Q /Document /MC1 BDC q 463.578 757.474 54.142 -11.282 re W n 1 1 1 scn /GS2 gs 463.578 746.192 54.142 11.282 re f q 1 0 0 1 482.25 747.988 cm /CS1 cs 1 scn /GS1 gs 0 0 m 0 -0.707 -0.157 -1.162 -0.66 -1.444 c -0.66 -1.539 l 2.451 -1.539 l 2.451 -1.444 l 1.948 -1.162 1.792 -0.707 1.792 0 c 1.792 6.03 l 1.792 6.722 1.948 7.177 2.451 7.475 c 2.451 7.554 l -0.66 7.554 l -0.66 7.475 l -0.157 7.177 0 6.722 0 6.03 c 0 0 l h 13.836 -1.539 m 14.275 0.377 l 14.182 0.408 l 13.647 -0.424 12.83 -0.77 11.621 -0.77 c 8.073 -0.77 l 8.073 5.951 l 8.073 6.722 8.261 7.161 8.794 7.475 c 8.794 7.554 l 5.67 7.554 l 5.654 7.475 l 6.141 7.177 6.282 6.737 6.282 6.109 c 6.282 -0.079 l 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5.9998 0 0 5.3325 184.8755 713.9904 Tm (10)Tj 0 Tc 7.9999 0 0 7.9999 195.5338 710.4187 Tm [(The)-471(European)-467(Associa)11(tion)]TJ -18.631 -1.623 Td [(for)-321(the)-324(Study)-319(of)-328(Obesity)-320(taskforce)-320(has)-318(made)-320(detailed)-322(suggestio)12(ns)-325(for)]TJ 0 -1.63 TD [(periopera)10(tive)-397(manageme)13(nt)-398(of)-392(diabetes.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 185.0456 687.9683 Tm (10)Tj 0 Tc 7.9999 0 0 7.9999 195.0803 684.3967 Tm [(The)-393(preoper)12(ative)-397(HbA)]TJ 5.9998 0 0 5.3325 274.507 683.0927 Tm (1c)Tj 7.9999 0 0 7.9999 283.918 684.3967 Tm (is)Tj -29.679 -1.623 Td [(also)-639(a)-638(baseline)-632(from)-636(which)-639(the)-636(impact)-636(of)-640(bariatric)-629(surgery)-635(and)]TJ 0 -1.623 TD [(subseque)13(nt)-362(medicatio)11(n)-362(adjustments)-349(are)-366(assesse)13(d.)-360(This)-360(assessment)-353(is)]TJ 0 -1.63 TD [(essential)-268(in)-279(planning)-265(postoperati)11(ve)-281(diabetes)-266(manageme)13(nt,)-279(especially)-267(if)]TJ 0 -1.623 TD [(withdraw)13(al)-260(of)-257(insulin)-257(is)-255(planned.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 157.3795 635.981 Tm (10)Tj 0 Tc 7.9999 0 0 7.9999 61.5118 619.4266 Tm [(Preope)11(rative)-432(considerati)15(on)-438(of)-427(diabetes)-429(aetiology)-426(is)-432(important)-423(if)]TJ -1.878 -1.63 Td [(this)-405(is)-411(not)-410(already)-400(known,)-400(because)-405(the)-409(expected)-405(impact)-403(of)-406(bariatric)]TJ T* [(surgery)-550(on)-551(glycaemic)-546(control)-547(differs)-546(between)-552(type)-544(1)-555(and)-554(type)-551(2)]TJ T* [(diabetes.)-242(People)-255(with)-250(type)-247(1)-257(diabetes)-245(have)-246(absolute)-248(insulin)-250(deficien)10(cy,)]TJ T* [(and)-554(while)-556(people)-552(with)-561(obesity)-549(and)-554(type)-558(1)-562(diabetes)-549(may)-556(achieve)]TJ 0 -1.63 TD [(improved)-519(glycaemic)-524(control)-526(following)-521(bariatric)-523(surgery,)]TJ 0.0001 Tc 5.9998 0 0 5.3325 246.6708 557.9715 Tm (77)Tj 0 Tc 7.9999 0 0 7.9999 257.7826 554.3998 Tm [(they)-523(will)]TJ -26.412 -1.623 Td [(not)-509(be)-515(expect)12(ed)-515(to)-508(achieve)-508(glycaemic)-510(remission)-503(and)-512(insulin)-505(with-)]TJ 0 -1.623 TD [(drawal.)-512(Furthermore)11(,)-526(in)-520(one)-520(single-cen)16(tre)-522(observatio)12(nal)-523(study,)-512(the)]TJ 0 -1.63 TD [(postopera)14(tive)-1056(occurre)11(nce)-1054(of)-1051(both)-1048(diabetic)-1044(ketoacidosis)-1039(and)]TJ 0 -1.623 TD [(hypoglycae)12(mia)-806(was)-805(observ)12(ed)-806(in)-803(people)-800(with)-802(type)-807(1)-803(diabetes)]TJ T* [(undergoin)13(g)-1056(bariatric)-1047(surgery.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 158.2866 492.9448 Tm (78)Tj 0 Tc 7.9999 0 0 7.9999 173.5937 489.4298 Tm [(Therefor)11(e,)-1055(people)-1048(with)-1050(type)]TJ -15.888 -1.63 Td [(1)-746(diabetes)-741(require)-743(careful)-744(blood)-739(glucose)-743(monitor)12(ing)-747(to)-749(detect)]TJ 0 -1.623 TD [(reducing)-250(insulin)-257(requir)13(ements.)]TJ 1.878 -1.623 Td [(The)-265(presen)12(ce)-266(and)-271(extent)-258(of)-271(diabetes)-259(complicat)13(ions)-268(should)-258(also)-270(be)]TJ -1.878 -1.63 Td [(noted)-798(preoperativ)10(ely)-810(because)-795(long-term)-796(monitoring)-799(of)-803(existing)]TJ 0 -1.623 TD [(microvascu)12(lar)-338(complicat)13(ions)-339(may)-336(still)-329(be)-338(required.)-330(There)-334(is)-333(also)-341(some)]TJ T* [(evidence)-796(in)-803(one)-804(small)-797(case)-803(series)-794(that)-802(the)-799(abrupt)-797(glycaemic)]TJ T* [(improveme)12(nt)-384(following)-380(bariatric)-381(surgery)-380(can)-383(exacerb)12(ate)-387(proliferati)11(ve)]TJ 0 -1.63 TD [(diabetic)-251(retinopathy)14(.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 117.8645 388.97 Tm (79)Tj 0 Tc 7.9999 0 0 7.9999 61.5118 372.4156 Tm [(Finally,)-310(people)-311(without)-312(known)-313(diabetes)-308(should)-308(routinely)-309(undergo)]TJ -1.878 -1.623 Td [(preopera)12(tive)-871(screeni)12(ng)-866(for)-867(diabetes.)-859(Appropria)11(te)-869(tests)-859(include)]TJ T* (HbA)Tj 0.0001 Tc 5.9998 0 0 5.3325 62.2488 345.0897 Tm (1c)Tj 0 Tc 7.9999 0 0 7.9999 71.8866 346.3936 Tm [(and)-412(fasting)-417(plasma)-411(glucose)-410(\(FPG\))-416(and/or)-410(a)-418(discretionar)15(y)-418(oral)]TJ -3.175 -1.623 Td [(glucose)-481(toleran)13(ce)-486(test.)-483(Diabetes)-476(should)-478(be)-487(diagnosed)-473(according)-476(to)]TJ 0 -1.623 TD [(establish)12(ed)-260(criteria.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 113.2724 323.9432 Tm (80)Tj /T1_1 1 Tf 0 Tc 10.0001 0 0 10.0001 46.4882 281.4236 Tm (6.6.2)Tj /T1_0 1 Tf 2.976 0 Td (|)Tj /T1_1 1 Tf 1.054 0 Td [(Dyslipidaem)-10(ia,)-257(live)-8(r)-260(and)-264(renal)-259(fun)-7(ction)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 46.4882 255.4015 Tm [(People)-624(with)-632(pre-exist)13(ing)-634(treated)-627(dyslipida)12(emia)-633(should)-620(undergo)-629(a)]TJ T* [(preopera)12(tive)-390(fasting)-388(lipid)-386(profile,)-385(as)-388(a)-390(baseline)-384(from)-388(which)-384(to)-388(assess)]TJ T* [(the)-502(subseque)13(nt)-504(effect)-499(of)-505(bariatric)-494(surgery)-493(on)-502(dyslipidaem)12(ia)-505(during)]TJ 0 -1.63 TD (follow-up.)Tj 0.0001 Tc 5.9998 0 0 5.3325 81.6378 219.9684 Tm (4,81)Tj 0 Tc 7.9999 0 0 7.9999 61.5118 203.4141 Tm [(The)-322(most)-325(common)-321(liver)-331(abnormali)12(ty)-334(in)-329(this)-327(patient)-320(group)-326(is)-326(non-)]TJ -1.878 -1.623 Td [(alcoholi)-461(fatty)-466(liver)-458(disease)-461(\(NAFLD\))-460(and)-469(bariatric)-459(surgery)-458(results)-461(in)]TJ T* [(pronounced)-316(improve)13(ments.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 142.2425 180.9637 Tm (82)Tj 0 Tc 7.9999 0 0 7.9999 151.7102 177.3921 Tm [(Therefore,)-321(it)-321(is)-326(appropriate)-319(routinely)-316(to)]TJ -13.153 -1.623 Td [(check)-553(liver)-550(function)-552(preopera)12(tively)-558(to)-551(assess)-557(for)-555(the)-551(presence)-552(of)]TJ 0 -1.623 TD [(NAFLD)-250(and)-257(as)-260(a)-255(baseline)-256(for)-258(any)-256(long-term)-250(monito)13(ring.)]TJ /T1_1 1 Tf 10.0001 0 0 10.0001 46.4882 112.422 Tm (6.7)Tj /T1_0 1 Tf 2.177 0 Td (|)Tj /T1_1 1 Tf 1.049 0 Td [(Correct)-9(ion)-260(of)-265(nutritional)-270(deficiencies)]TJ -3.226 -1.298 Td [(preoperativ)-11(ely)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 46.4882 73.4173 Tm [(As)-672(bariatric)-664(surgery)-664(impacts)-663(on)-672(oral)-662(intake)-670(and)-668(absorption)15(,)-675(we)]TJ T* [(recommend)-326(treatm)13(ent)-331(and)-335(correct)12(ion)-334(of)-335(deficien)10(cies)-330(preoperativ)10(ely.)]TJ 5.9998 0 0 5.3325 285.8456 63.9496 Tm (3)Tj 7.9999 0 0 7.9999 46.4882 47.3953 Tm [(See)-254(Section)-258(9.)]TJ /T1_1 1 Tf 10.0001 0 0 10.0001 307.729 723.4014 Tm (7)Tj /T1_0 1 Tf 1.468 0 Td (|)Tj /T1_1 1 Tf 0.1013 Tc 1.151 0 Td [(POSTOPERATIVE)-262(C)3(ARE)-262(AND)]TJ 0.1008 Tc -2.619 -1.298 Td [(BIOCHEMICAL)-262(MONITORING)]TJ /T1_0 1 Tf 0 Tc 7.9999 0 0 7.9999 307.729 684.3967 Tm [(People)-404(should)-407(have)-409(access)-404(to)-409(lifelong)-409(monitoring)-402(following)-408(bariatric)]TJ T* [(surgery)-352(to)-367(ensure)-356(that)-363(nutritiona)16(l)-366(requirement)14(s)-367(are)-359(met,)-364(and)-363(risks)-356(of)]TJ T* [(developi)13(ng)-426(post-baria)17(tric)-427(surgery)]TJ /T1_2 1 Tf 14.584 0 Td (\226)Tj /T1_0 1 Tf 0.574 0 Td [(related)-412(nutritional)-414(deficiencies)-419(are)]TJ -15.158 -1.63 Td (reduced.)Tj 5.9998 0 0 5.3325 337.6062 648.9636 Tm (1)Tj /T1_2 1 Tf 0.576 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.567 0 Td (4,8,10,12)Tj /T1_2 1 Tf 0 Tc 4.091 0 Td (\226)Tj /T1_0 1 Tf 0.576 0 Td (14,83)Tj 7.9999 0 0 7.9999 394.8094 645.392 Tm [(The)-903(type)-913(and)-909(frequen)13(cy)-914(of)-909(nutritional)]TJ -10.885 -1.623 Td [(monito)13(ring)-308(should)-301(reflect)-302(the)-303(bariatric)-296(procedure)-300(and)-306(may)-301(need)-301(to)-310(be)]TJ T* [(individ)13(ualized.)-478(The)-485(follow-up)-475(care)-479(should)-478(remain)-478(with)-476(the)-487(bariatric)]TJ 0 -1.63 TD [(surgery)-366(centre)-364(for)-371(the)-374(first)-374(2)-370(years.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 433.4172 609.9589 Tm (1,8,83)Tj 0 Tc 7.9999 0 0 7.9999 452.8062 606.3872 Tm [(Follow)12(ing)-371(discharge,)-369(people)]TJ -18.135 -1.623 Td [(should)-492(be)-494(offered)-491(lifelong)-494(monitoring)-494(of)-498(nutritional)-485(status)-494(at)-503(least)]TJ 0 -1.623 TD [(annual)14(ly)-1096(as)-1097(part)-1100(of)-1093(shared-car)12(e)-1103(manage)13(ment.)]TJ 5.9998 0 0 5.3325 496.1196 583.9935 Tm (1,8,83)Tj 7.9999 0 0 7.9999 521.2345 580.4219 Tm (Detailed)Tj -26.688 -1.623 Td [(recomm)13(endations)-253(are)-253(listed)-259(in)-144(Table)-256(3.)]TJ /T1_1 1 Tf 10.0001 0 0 10.0001 307.729 528.4345 Tm (7.1)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_1 1 Tf 1.054 0 Td [(Urea)-264(and)-258(electro)-10(lytes,)-265(renal)-265(and)-258(liver)-267(function)]TJ -3.226 -1.304 Td (tests)Tj /T1_0 1 Tf 7.9999 0 0 7.9999 307.729 489.4298 Tm [(Renal)-264(function)-261(should)-265(be)-267(monitored)-262(for)-272(all)-265(procedure)12(s.)-272(Initially)-262(follow-)]TJ 0 -1.63 TD [(ing)-449(surgery,)-453(people)-452(may)-457(have)-452(difficulty)-451(in)-456(maintaini)11(ng)-462(an)-454(adequate)]TJ 0 -1.623 TD [(fluid)-884(intake)-889(and)-894(become)-882(dehydrated.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 454.2802 466.9794 Tm (51)Tj 0 Tc 7.9999 0 0 7.9999 468.34 463.4077 Tm [(Routin)14(e)-897(postopera)14(tive)]TJ -20.076 -1.623 Td [(monito)13(ring)-613(of)-619(liver)-614(function)-609(is)-617(also)-610(appropria)11(te,)]TJ 0.0001 Tc 5.9998 0 0 5.3325 486.7652 453.94 Tm (2,84)Tj 0 Tc 7.9999 0 0 7.9999 503.3196 450.4251 Tm [(to)-615(document)]TJ -24.449 -1.63 Td [(chang)13(es)-584(in)-577(NAFLD,)-578(as)-579(well)-580(as)-579(part)-575(of)-583(general)-575(safety)-574(monitoring)]TJ 0 -1.623 TD [(for)-754(hypoalbum)12(inaemia,)-758(which)-753(may)-754(indicate)-754(underlyin)14(g)-766(infectio)10(n)]TJ T* [(and)-249(inflammat)10(ion.)]TJ /T1_1 1 Tf 10.0001 0 0 10.0001 307.729 372.4156 Tm (7.2)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_1 1 Tf 1.054 0 Td (Haematinics)Tj /T1_0 1 Tf 7.9999 0 0 7.9999 307.729 346.3936 Tm [(T)16(he)30(re)-309(is)-312(a)-326(h)21(ig)26(h)-327(in)26(c)15(id)26(e)17(nc)28(e)-323(o)16(f)-330(i)19(ro)23(n)-320(de)23(f)17(ic)27(ie)22(nc)28(y)-319(a)14(na)28(em)28(ia)-314(fo)26(l)16(lo)26(w)16(in)26(g)-326(ba)28(ri)26(a)14(tr)28(ic)]TJ T* [(s)16(ur)27(g)14(e)17(ry)-227(be)30(c)15(a)14(us)22(e)-238(o)16(f)-238(lo)26(w)-232(di)26(et)24(a)14(ry)-220(ir)26(on)-225(in)26(ta)28(ke)28(,)-243(re)31(du)27(c)15(ed)-225(in)26(te)31(st)23(in)26(a)14(l)-239(a)14(bs)29(o)16(rp)27(ti)26(on)]TJ T* [(a)14(n)21(d,)-236(fo)26(r)-248(s)16(o)16(me)-234(w)16(om)28(en)23(,)-243(me)28(ns)29(tr)21(u)21(at)21(io)29(n.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 431.3763 323.9432 Tm [(15)29(,)20(18)29(,)20(19)29(,)20(35)]TJ /T1_2 1 Tf 0 Tc 5.055 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.557 0 Td [(37)39(,4)25(1)24(,5)25(7)]TJ /T1_2 1 Tf 0 Tc 3.732 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.557 0 Td [(60)29(,)20(72)]TJ /T1_2 1 Tf 0 Tc 2.428 0 Td (\226)Tj /T1_0 1 Tf -0.0242 Tc 0.557 0 Td [(74)-24(,85)]TJ /T1_2 1 Tf 0 Tc 2.419 0 Td (\226)Tj /T1_0 1 Tf 0.0001 Tc 0.557 0 Td (94)Tj 0.0353 Tc 7.9999 0 0 7.9999 322.696 307.3889 Tm [(Vi)5(tamin)-440(B12)-441(absor)7(p)-1(ti)5(on)-440(is)-445(a)7(d)-1(versely)-447(affected)-447(b)6(y)-447(SG,)-441(R)1(YG)6(B)]TJ -1.871 -1.623 Td [(a)7(n)-1(d)-412(BPD/D)9(S)-423(a)7(s)-416(i)-2(t)-418(r)7(eq)6(ui)5(res)-416(an)-419(a)7(cidi)5(c)-418(e)3(nvi)5(ronment)-411(and)-412(p)-1(resence)]TJ 0 -1.623 TD [(of)-756(i)5(n)-1(tr)7(insi)5(c)-758(f)3(actor)-752(p)-1(r)7(o)2(duced)-752(by)-752(th)6(e)-756(gastr)7(ic)-758(p)6(ari)5(et)7(al)-756(cells.)]TJ 0.0422 Tc 5.9998 0 0 5.3325 543.3447 284.9952 Tm (95)Tj 0.0356 Tc 7.9999 0 0 7.9999 307.729 268.4409 Tm [(M)6(an)7(y)-489(people)-493(h)7(ave)-486(about)-489(2)5(-year)-489(s)2(tores)-494(o)2(f)-486(vita)7(m)-3(i)5(n)-490(B12)5(;)-491(th)7(er)7(e-)]TJ 0.0342 Tc 0 -1.63 TD [(fore,)-1675(d)5(e)-6(f)2(iciency)-1674(m)3(ay)-1674(prese)-6(n)5(t)-1674(s)1(everal)-1671(years)-1672(a)-1(fter)]TJ 0.0325 Tc 0 -1.623 TD (surgery.)Tj 0.0489 Tc 5.9998 0 0 5.3325 337.4928 245.9904 Tm [(15,1)7(8)-3(,1)7(9,4)7(0)-3(,4)7(1,47)7(,57)]TJ /T1_2 1 Tf 0 Tc 10.262 0 Td (\226)Tj /T1_0 1 Tf 0.0439 Tc 0.624 0 Td [(59)-8(,65)-8(,)-3(73)-8(,8)-8(6)]TJ /T1_2 1 Tf 0 Tc 5.745 0 Td (\226)Tj /T1_0 1 Tf 0.0433 Tc 0.624 0 Td [(89)-8(,92)-8(,)-3(93)-8(,96)]TJ 0.0351 Tc 7.9999 0 0 7.9999 480.1322 242.4188 Tm [(Vi)5(tamin)-575(B1)5(2)-583(d)6(e)-5(fi-)]TJ 0.0311 Tc -21.551 -1.623 Td [(ci)-6(en)-5(c)-4(y)-593(imp)-5(a)-4(c)-4(t)2(s)-598(a)3(d)-5(v)-5(er)-5(sely)-593(on)-593(th)-5(e)-590(h)-5(a)-4(e)-2(ma)-4(t)-5(o)-2(poi)-6(e)-2(t)-5(i)-6(c)-592(a)-4(nd)-593(ne)-9(rv)-5(ou)-5(s)]TJ 0.0324 Tc 0 -1.63 TD [(systems)-476(a)-3(nd)-479(may)-471(r)-3(esul)-8(t)-471(i)-5(n)-471(m)1(egalob)]TJ 0.0362 Tc 17.079 0 Td [(la)8(stic)-467(ana)8(e)-4(m)5(i)-1(a)-467(a)1(n)7(d)-468(irrever)8(s)3(-)]TJ 0.0346 Tc -17.079 -1.623 Td [(i)4(b)-2(le)-459(neur)6(opath)6(i)-3(es.)]TJ 0.0516 Tc 5.9998 0 0 5.3325 375.5338 206.9858 Tm (95)Tj 0.0338 Tc 7.9999 0 0 7.9999 386.6456 203.4141 Tm [(Vitamin)-463(B)-1(12)-464(levels)-460(are)-460(n)-2(ot)-455(a)-462(g)-2(ood)-463(predic)6(-)]TJ 0.0336 Tc -9.865 -1.623 Td [(tor)-902(of)-906(d)5(ef)-6(iciency)-895(b)-3(ecause)-906(metho)-7(d)5(ological)-900(problems)-900(af)-6(fect)]TJ 0.0352 Tc T* [(sen)6(s)2(iti)5(vity)-411(and)-419(sp)6(ecifici)5(t)-1(y.)]TJ 0.0422 Tc 5.9998 0 0 5.3325 405.9211 180.9637 Tm (97)Tj 0.0332 Tc 7.9999 0 0 7.9999 416.6928 177.3921 Tm [(In)-421(view)-419(of)-425(this,)-422(m)2(ethylm)-5(al)-7(onic)-420(acid)]TJ 0.0355 Tc -13.621 -1.623 Td [(\()5(M)6(MA)7(\))-775(h)-1(as)-771(been)-773(prop)6(osed)-773(a)7(s)-778(a)-772(b)-1(ett)7(e)3(r)-780(i)5(nd)6(icator)7(,)-774(but)-773(th)6(is)]TJ 0.0335 Tc 0 -1.623 TD [(requires)-454(a)-455(sensitive)-460(p)4(lasma)-455(a)-2(ssay)-449(n)]TJ 0.0356 Tc 16.965 0 Td [(ot)-454(r)7(o)-5(u)7(tin)7(ely)-446(avai)5(l)2(able)-451(in)-447(th)7(e)]TJ 0.0339 Tc -16.965 -1.63 Td [(U)5(n)-2(i)4(t)-2(ed)-442(King)5(dom.)]TJ 0.0499 Tc 5.9998 0 0 5.3325 371.4518 141.959 Tm [(98,9)8(9)]TJ 0.034 Tc 7.9999 0 0 7.9999 391.4645 138.3874 Tm [(If)-445(there)-445(i)4(s)-446(d)5(oubt)-448(about)-441(v)-2(itamin)-442(B)6(1)-3(2)-443(d)5(e)-6(f)1(i-)]TJ 0.0347 Tc -10.467 -1.623 Td [(c)7(i)-3(ency)6(,)-406(i)4(t)-398(i)-3(s)-403(b)6(etter)-398(t)-1(o)-402(t)6(reat.)]TJ 0.0516 Tc 5.9998 0 0 5.3325 411.3637 128.9763 Tm (97)Tj -0.0199 Tc 7.9999 0 0 7.9999 322.696 112.422 Tm [(Because)-308(f)-3(olic)-317(acid)-311(is)-316(absorbed)-311(in)-311(the)-315(s)3(mall)-315(bowel,)]TJ -0.0239 Tc 5.9998 0 0 5.3325 489.203 115.9937 Tm (95)Tj 0 Tc 7.9999 0 0 7.9999 498.2739 112.422 Tm [(a)21(b)21(s)16(o)23(r)21(p)21(ti)33(o)23(n)-291(m)18(a)21(y)]TJ -0.0195 Tc -23.818 -1.623 Td [(be)-265(affected)-268(by)-268(RYGB)-267(or)-268(BPD/DS,)-269(but)-268(de)]TJ -0.021 Tc 17.036 0 Td [(ficiency)-269(is)-274(al)-5(so)-274(obs)-5(e)3(rv)-7(ed)-270(fo)-5(ll)-5(ow-)]TJ -0.0198 Tc -17.036 -1.63 Td [(ing)-254(S)4(G)-255(s)3(o)-259(is)-252(m)-1(ore)-258(l)4(ikely)-254(t)1(o)-259(b)1(e)-251(due)-258(to)-251(low)-252(d)1(ietar)-20(y)-240(intake)-251(or)-254(non-adherence)]TJ -0.0202 Tc T* [(with)-262(vitamin)-262(a)1(nd)-262(mineral)-266(s)3(upplementation.)]TJ -0.0234 Tc 5.9998 0 0 5.3325 449.3479 76.989 Tm [(15,18,)6(19,)6(32,34,)6(40,)6(41,47,)6(87,)6(100,101)]TJ 0 Tc 7.9999 0 0 7.9999 322.696 60.4346 Tm [(It)-460(should)-450(be)-452(noted)-458(that)-448(megaloblasti)12(c)-460(and)-455(macrocy)13(tic)-463(anaemi)11(a,)]TJ -1.871 -1.63 Td [(associa)11(ted)-381(with)-370(vitamin)-377(B12)-379(deficien)10(cy,)-377(can)-383(be)-374(masked)-371(by)-384(folic)-377(acid)]TJ ET 0.137 0.122 0.125 scn /CS0 CS 0.137 0.122 0.125 SCN 0 w 1 j 1 J /GS1 gs 550.488 748.63 -504 0.453 re B* q 1 0 0 1 68.995 749.083 cm 0.51 0 -0.51 12.019 re B* Q BT 0 0 0 scn /GS0 gs /T1_1 1 Tf 6.9999 0 0 6.9999 46.4882 753.1085 Tm (6)Tj /T1_0 1 Tf 65.959 0 Td (O'KANE)Tj 4.8997 0 0 4.8997 535.5778 753.1085 Tm [(ET)-372(AL)]TJ 6.9999 0 0 6.9999 548.9006 753.1085 Tm (.)Tj ET /Document /MC0 BDC 1 1 1 scn /GS1 gs 77.499 746.135 54.195 11.338 re f q 1 0 0 1 96.171 747.988 cm /CS1 cs 1 scn /GS0 gs 0 0 m 0 -0.707 -0.157 -1.162 -0.66 -1.444 c -0.66 -1.539 l 2.451 -1.539 l 2.451 -1.444 l 1.948 -1.162 1.791 -0.707 1.791 0 c 1.791 6.03 l 1.791 6.722 1.948 7.177 2.451 7.475 c 2.451 7.554 l -0.66 7.554 l -0.66 7.475 l -0.157 7.177 0 6.722 0 6.03 c 0 0 l h 13.836 -1.539 m 14.275 0.377 l 14.182 0.408 l 13.647 -0.424 12.83 -0.77 11.621 -0.77 c 8.073 -0.77 l 8.073 5.951 l 8.073 6.722 8.261 7.161 8.794 7.475 c 8.794 7.554 l 5.67 7.554 l 5.654 7.475 l 6.141 7.177 6.282 6.737 6.282 6.109 c 6.282 -0.079 l 6.282 -0.724 6.141 -1.146 5.654 -1.444 c 5.67 -1.539 l 13.836 -1.539 l h 28.991 -1.444 m 29.005 -1.539 l 32.148 -1.539 l 32.148 -1.444 l 31.628 -1.146 31.472 -0.675 31.472 0.079 c 31.472 2.215 l 34.237 6.155 l 34.739 6.879 35.163 7.318 35.524 7.475 c 35.524 7.554 l 33.074 7.554 l 33.074 7.475 l 33.514 7.224 33.575 6.611 33.106 5.937 c 31.08 3.015 l 28.849 6.298 l 28.504 6.8 28.566 7.256 28.975 7.475 c 28.975 7.554 l 25.534 7.554 l 25.534 7.475 l 25.944 7.303 26.196 7.067 26.635 6.439 c 29.682 2.088 l 29.682 0.079 l 29.682 -0.675 29.509 -1.146 28.991 -1.444 c 18.045 3.659 m 18.045 6.783 l 21.311 6.783 l 22.803 6.783 23.368 6.549 23.903 5.795 c 23.997 5.826 l 23.808 7.554 l 15.642 7.554 l 15.626 7.475 l 16.114 7.177 16.255 6.737 16.255 6.109 c 16.255 -0.079 l 16.255 -0.724 16.114 -1.146 15.626 -1.444 c 15.642 -1.539 l 24.232 -1.539 l 24.546 0.313 l 24.468 0.345 l 23.918 -0.393 23.259 -0.77 21.783 -0.77 c 18.045 -0.77 l 18.045 2.921 l 20.542 2.921 l 21.61 2.921 22.143 2.748 22.427 2.293 c 22.536 2.293 l 22.536 4.271 l 22.427 4.287 l 22.143 3.832 21.61 3.659 20.542 3.659 c 18.045 3.659 l h -6.988 -1.853 m -6.91 -1.853 l -3.046 7.773 l -2.669 8.7 -2.324 9.156 -1.979 9.359 c -1.979 9.454 l -4.303 9.454 l -4.303 9.359 l -3.816 9.093 -3.706 8.37 -4.036 7.539 c -6.407 1.602 l -9.627 9.485 l -9.705 9.485 l -13.097 1.617 l -15.532 7.806 l -15.814 8.543 -15.735 9.093 -15.281 9.359 c -15.281 9.454 l -18.672 9.454 l -18.672 9.359 l -18.311 9.171 -18.044 8.779 -17.714 7.977 c -13.725 -1.853 l -13.647 -1.853 l -10.286 6.109 l -6.988 -1.853 l f Q EMC /Document /MC1 BDC q 206.441 759.571 -66.24 -15.6 re W n q /GS1 gs 66.642 0 0 15.744 140.088 743.928 cm /Im0 Do Q EMC Q endstreamendobj493 0 obj<>endobj494 0 obj<>stream BT /CS0 cs 0 0 0 scn /GS0 gs /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 723.4014 Tm [(participan)15(ts)-452(in)-449(one)-449(study)-440(conducted)-444(by)-447(Ben-Pora)11(t)-454(et)-451(al.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 508.762 726.973 Tm (40)Tj 0 Tc 7.9999 0 0 7.9999 519.2502 723.4014 Tm [(A)-447(raised)]TJ -26.653 -1.623 Td [(albumin-)12(adjusted)-291(serum)-290(calcium)-293(in)-293(the)-296(presence)-296(of)-293(raised)-296(parathyro)14(id)]TJ 0 -1.623 TD [(hormon)14(e)-536(\(PTH\))-527(may)-528(indicate)-527(primary)-524(hyperpara)14(thyroidism,)-524(and)-526(so)]TJ 0 -1.63 TD [(both)-673(PTH)-679(and)-675(calcium)-676(should)-676(be)-678(measured)-678(preope)13(ratively.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 531.5526 687.9683 Tm (66)Tj 0 Tc 7.9999 0 0 7.9999 543.855 684.3967 Tm (If)Tj -29.729 -1.623 Td [(primary)-446(hyperpar)14(athyroidism)-445(is)-454(suspected,)-449(advice)-453(should)-443(be)-459(sought)]TJ 0 -1.623 TD [(from)-253(a)-255(specialist)-251(in)-258(this)-256(area.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 403.7668 661.9463 Tm (66)Tj /T1_1 1 Tf 0 Tc 10.0001 0 0 10.0001 306.0283 619.4266 Tm (6.3)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_1 1 Tf 1.054 0 Td [(Vitamin)-262(A,)-263(zinc,)-261(copper,)-267(selenium)-267(and)]TJ -3.226 -1.304 Td [(malabsorptive)-269(procedures)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 580.4219 Tm [(The)-542(reported)-548(prevalen)13(ce)-550(of)-555(vitamin)-547(A)-546(deficiency)-543(where)-547(tested)-547(is)]TJ T* (low.)Tj 0.0001 Tc 5.9998 0 0 5.3325 320.3716 570.9542 Tm (29,38,39,43,50)Tj 0 Tc 7.9999 0 0 7.9999 362.9479 567.4392 Tm [(Zinc,)-375(copper)-365(and)-370(selenium)-366(deficiencies)-370(are)-373(not)-367(com-)]TJ -7.115 -1.63 Td [(monly)-446(reported)-456(prior)-448(to)-459(surgery,)]TJ 0.0001 Tc 5.9998 0 0 5.3325 423.2692 557.9715 Tm (30,36,37,67)Tj 0 Tc 7.9999 0 0 7.9999 458.3621 554.3998 Tm [(although)-445(De)-456(Luis)-455(et)-458(al.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 541.9274 557.9715 Tm (33)Tj 0 Tc 7.9999 0 0 7.9999 306.0283 541.4172 Tm [(reporte)13(d)-277(prevalences)-266(of)-278(73.9%)-269(and)-271(63.8%)-276(deficien)10(cy,)-278(respecti)11(vely,)-274(for)]TJ T* [(zinc)-307(and)-313(copper.)-306(We)-306(did)-315(not)-304(consider)-309(that)-306(there)-315(was)-308(strong)-302(evidence)]TJ 0 -1.63 TD [(for)-435(routine)-432(checking)-436(of)-434(vitamin)-433(A,)-441(zinc,)-436(copper)-436(and)-434(selenium)-436(levels)]TJ 0 -1.623 TD [(prior)-249(to)-260(bariatric)-253(surgery)-253(unless)-248(there)-258(is)-255(suspicion)-255(of)-257(deficien)10(cy.)]TJ 1.871 -1.623 Td [(Malabsorpti)15(ve)-430(procedure)12(s)-423(such)-425(as)-423(BPD/DS)-421(are)-423(associated)-419(with)]TJ -1.871 -1.63 Td [(an)-631(increased)-634(incidence)-631(of)-640(vitamin)-639(A,)-640(zinc,)-634(copper)-635(and)-639(selenium)]TJ 0 -1.623 TD [(deficie)11(ncies,)]TJ 0.0001 Tc 5.9998 0 0 5.3325 348.3778 466.9794 Tm (68)Tj /T1_2 1 Tf 0 Tc 1.143 0 Td (\226)Tj /T1_0 1 Tf 0.576 0 Td (74)Tj 7.9999 0 0 7.9999 370.0912 463.4077 Tm [(and)-568(so)-563(consideratio)10(n)-568(may)-563(be)-572(given)-560(to)-572(checki)12(ng)]TJ -8.008 -1.623 Td [(these)-249(preoperativ)10(ely)-258(before)-253(these)-256(procedure)12(s.)]TJ /T1_1 1 Tf 10.0001 0 0 10.0001 306.0283 411.4203 Tm (6.4)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_1 1 Tf 1.054 0 Td (Thiamine)Tj /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 385.3983 Tm [(Few)-468(studies)-465(measure)-465(thiamine)-467(levels)-471(preope)13(ratively.)-471(However,)-466(low)]TJ 0 -1.623 TD [(levels)-371(have)-374(been)-372(reported)-371(in)-378(some)-379(people.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 457.455 375.9873 Tm (36,43)Tj 0 Tc 7.9999 0 0 7.9999 475.54 372.4156 Tm [(We)-377(did)-379(not)-374(consider)]TJ -21.189 -1.623 Td [(there)-251(was)-259(strong)-253(evidence)-251(for)-258(routine)-247(checking)-252(of)-264(thiamin)13(e)-259(levels.)]TJ /T1_1 1 Tf 10.0001 0 0 10.0001 306.0283 320.4283 Tm (6.5)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_1 1 Tf 1.054 0 Td (Magnesium)Tj /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 294.4062 Tm [(Few)-504(studies)-508(have)-501(measured)-508(magne)13(sium)-507(prior)-511(to)-508(surgery.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 514.8282 297.9779 Tm (36,58)Tj 0 Tc 7.9999 0 0 7.9999 533.9904 294.4062 Tm (Low)Tj -28.495 -1.623 Td [(prevale)13(nce)-260(of)-257(magnesiu)12(m)-258(deficiency)-252(is)-262(reported)12(.)]TJ 0.0001 Tc 5.9998 0 0 5.3325 472.9322 284.9952 Tm (36,58)Tj /T1_1 1 Tf 0 Tc 10.0001 0 0 10.0001 306.0283 242.4188 Tm (6.6)Tj /T1_0 1 Tf 2.171 0 Td (|)Tj /T1_1 1 Tf 1.054 0 Td (HbA)Tj 7.4999 0 0 6.666 358.4125 240.7747 Tm (1c)Tj 10.0001 0 0 10.0001 366.2928 242.4188 Tm [(,)-259(lipids,)-266(liver)-262(and)-264(renal)-265(function)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 216.3968 Tm [(These)-318(guidelin)13(es)-321(do)-325(not)-318(specifically)-311(address)-322(the)-317(preoperat)12(ive)-325(medica)12(l)]TJ T* [(assessm)14(ent)-487(of)-491(people)-488(with)-491(type)-488(2)-491(diabetes.)-483(However,)-481(biochemica)11(l)]TJ T* [(monito)13(ring)-492(is)-489(an)-483(important)-487(part)-483(of)-491(preoper)12(ative)-489(and)-490(postope)14(rative)]TJ 0 -1.63 TD [(care,)-297(because)-292(bariatric)-289(surgery)-295(is)-298(used)-295(to)-303(manage)-292(type)-296(2)-300(diabetes)-294(and)]TJ 0 -1.623 TD [(its)-475(associat)11(ed)-480(comorbid)12(ities.)]TJ 5.9998 0 0 5.3325 406.7148 167.9811 Tm (1,10,75,76)Tj 7.9999 0 0 7.9999 438.5196 164.4094 Tm [(Therefore,)-477(a)-475(brief)-479(summary)-466(of)]TJ -16.561 -1.623 Td [(these)-249(important)-253(aspects)-250(of)-257(care)-260(is)-255(included)-255(here.)]TJ /T1_1 1 Tf 10.0001 0 0 10.0001 306.0283 112.422 Tm (6.6.1)Tj /T1_0 1 Tf 2.976 0 Td (|)Tj /T1_1 1 Tf 1.049 0 Td [(Preoper)-11(ative)-262(and)-264(perioperative)-267(manageme)-9(nt)]TJ -4.025 -1.298 Td [(of)-259(diabetes)]TJ /T1_0 1 Tf 7.9999 0 0 7.9999 306.0283 73.4173 Tm [(People)-631(with)-632(known)-632(type)-629(2)-640(diabetes)-627(should)-634(have)-636(an)-631(up-to-dat)11(e)]TJ T* [(preope)13(rative)-851(evaluatio)11(n)-851(of)-845(current)-843(glycaemic)-843(control)-845(including)]TJ 0 -1.63 TD [(measur)15(ement)-431(of)-434(HbA)]TJ 0.0001 Tc 5.9998 0 0 5.3325 383.1306 46.0913 Tm (1c)Tj 0 Tc 7.9999 0 0 7.9999 389.3668 47.3953 Tm [(,)-434(and)-434(glycaemic)-425(control)-427(should)-421(be)-437(optimize)12(d)]TJ ET 0.82 0.827 0.831 scn /GS1 gs 44.787 691.597 242.816 26.022 re f 0.902 0.906 0.91 scn 44.787 642.614 242.816 34.979 re f q 0.06 782.362 595.215 -782.302 re W n q 44.787 471.118 242.816 122.513 re W n q BX /Sh0 sh EX Q Q Q 44.787 331.087 242.816 14.003 re f 44.787 275.131 242.816 55.956 re f 44.787 201.6 242.816 14.003 re f 44.787 166.62 242.816 34.98 re f 0.82 0.827 0.831 scn /CS0 CS 0.82 0.827 0.831 SCN 0 w 1 j 1 J 287.603 106.129 -242.816 0.964 re B* BT 0 0 0 scn /GS0 gs /T1_3 1 Tf 0.141 Tc 7.9999 0 0 7.9999 44.7874 724.5919 Tm [(TA)-8(BL)-5(E)-258(2)]TJ /T1_0 1 Tf 0 Tc 6.017 0 Td [(Preope)11(rative)-255(nutritional)-251(assessment)]TJ /T1_1 1 Tf 7.4999 0 0 7.4999 51.7606 696.5856 Tm [(Preopera)-14(tive)-263(nutritional)-264(assess)-10(ment)]TJ 19.548 1.406 Td [(Grad)-10(e,)-260(evidence)-267(level,)]TJ 0 -1.406 TD [(\(range)-269(of)-261(evidence\))]TJ /T1_0 1 Tf -19.548 -1.965 Td [(Recomm)-11(endations)]TJ /T1_2 1 Tf 0 -1.867 TD (\201)Tj /T1_0 1 Tf 0.575 0 Td [(All)-267(people)-262(should)-263(have)-265(a)]TJ 0.431 -1.398 Td [(comprehensive)-268(nutritional)-271(assessment)]TJ 0 -1.398 TD [(prior)-260(to)-263(bariatric)-264(surg)-9(ery)]TJ 18.543 2.797 Td [(Grade)-266(D)-260(EL)-263(4)]TJ -19.548 -4.664 Td [(Haem)-12(atinics)]TJ /T1_2 1 Tf 1.005 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Check)-265(full)-257(blood)-264(count)-263(includi)-11(ng)]TJ 0.423 -1.398 Td [(haemoglob)-12(in,)-261(ferritin,)-266(folate)-262(and)]TJ T* [(vitamin)-267(B12)-267(levels)]TJ 17.545 2.797 Td [(Grade)-266(B)-262(EL)-263(2)-259(\(1+)-267(to)-263(4\))]TJ -19.548 -4.664 Td [(Vitam)-10(in)-260(D,)-262(calcium)-265(and)-266(parathyroid)-262(horm)-10(one)]TJ /T1_2 1 Tf 1.005 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Check)-265(serum)-260(25-hydroxy)-12(vitamin)-267(D)]TJ 0.423 -1.398 Td (levels)Tj 17.545 1.398 Td [(Grade)-266(B)-262(EL)-263(2)-259(\(2++)-269(to)-256(3\))]TJ /T1_2 1 Tf -18.543 -3.266 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Check)-265(serum)-260(calcium)-265(levels)]TJ 17.968 0 Td [(Grade)-266(D)-260(EL)-263(4)]TJ /T1_2 1 Tf -18.542 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Check)-265(serum/plasma)-270(parathyroid)]TJ 0.423 -1.406 Td [(hormone)-266(levels)]TJ 17.545 1.406 Td [(Grade)-266(B)-262(EL)-263(2)-259(\(2++)-269(to)-256(3\))]TJ /T1_2 1 Tf -18.543 -3.273 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Seek)-262(advice)-268(from)-257(a)-267(specialist)-266(with)]TJ 0.423 -1.399 Td [(expertise)-266(in)-267(primary)]TJ 0 -1.399 TD [(hyperparathyroidi)-14(sm)-258(if)-265(primary)]TJ T* [(hyperparathyroidi)-14(sm)-258(is)-264(suspected)]TJ 17.545 4.195 Td (GPP)Tj -19.548 -6.062 Td [(Vitam)-10(in)-260(A,)-265(zinc,)-261(copper,)-266(selenium)-269(and)-259(malabs)-10(orptive)-265(procedures)]TJ /T1_2 1 Tf 1.005 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Consider)-263(checking)-265(serum)-268(vitamin)-267(A)]TJ 0.423 -1.398 Td [(levels)-264(in)-260(indiv)-9(iduals)-263(going)-265(forward)]TJ 0 -1.398 TD [(for)-260(malabs)-10(orptive)-265(procedures)-264(such)]TJ 0 -1.406 TD [(as)-263(BPD/DS)-268(or)-263(where)-259(vitamin)-267(A)]TJ 0 -1.398 TD [(deficiency)-268(may)-268(be)-258(suspected)]TJ 17.545 5.601 Td (GPP)Tj /T1_2 1 Tf -18.543 -7.468 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Consider)-263(checking)-265(serum)-268(zinc,)-261(copper)]TJ 0.423 -1.398 Td [(and)-259(selenium)-269(levels)-264(in)-267(individuals)]TJ T* [(going)-265(forward)-269(for)-260(malabsorptive)]TJ T* [(procedures)-272(such)-261(as)-263(BPD/DS)-268(or)-256(if)-265(a)]TJ 0 -1.406 TD [(deficiency)-268(is)-264(suspected)]TJ 17.545 5.601 Td (GPP)Tj -19.548 -7.468 Td [(Thi)-9(amine)]TJ /T1_2 1 Tf 1.005 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(There)-260(is)-264(insufficient)-267(evidence)-269(to)]TJ 0.423 -1.398 Td [(support)-268(a)-259(recommendatio)-15(n)-257(to)]TJ 0 -1.398 TD [(screen)-266(an)-259(indiv)-9(idual's)-263(thiamine)-264(levels)]TJ T* [(pre)-260(surg)-9(ery;)-261(however,)-269(some)]TJ T* [(individuals)-265(may)-268(have)-265(low)-257(level)-10(s)]TJ 17.545 5.594 Td [(Grade)-266(D)-260(EL)-263(3)-259(\(2)]TJ /T1_4 1 Tf 6.947 0 Td (\025)Tj /T1_0 1 Tf 0.937 0 Td [(to)-263(3\))]TJ -27.432 -7.461 Td [(Mag)-9(nesium)]TJ /T1_2 1 Tf 1.005 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(There)-260(is)-264(insufficient)-267(evidence)-269(to)]TJ 0.423 -1.406 Td [(support)-268(a)-259(recommendatio)-15(n)-257(to)]TJ T* [(screen)-266(an)-259(indiv)-9(idual's)-263(magnesium)]TJ T* [(level)-267(pre-surgery)]TJ 17.545 4.203 Td (GPP)Tj -19.548 -6.07 Td (HbA)Tj 5.6248 0 0 4.9992 66.6708 204.6047 Tm (1c)Tj 7.4999 0 0 7.4999 72.5102 205.8519 Tm [(,)-258(lipids,)-265(liver)-264(and)-259(renal)-267(function)]TJ /T1_2 1 Tf -1.761 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Routinely)-264(screen)-266(HbA)]TJ 5.6248 0 0 4.9992 134.8157 190.6015 Tm (1c)Tj 7.4999 0 0 7.4999 140.6551 191.8488 Tm [(,)-258(lipid)-268(profile,)]TJ -9.85 -1.398 Td [(liver)-264(and)-259(kidn)-9(ey)-255(function)-271(tests)-261(and)]TJ T* [(treat)-265(as)-263(necessary)]TJ 17.545 2.797 Td (GPP)Tj -19.548 -4.664 Td [(Correcti)-13(on)-262(of)-259(nutritional)-271(deficiencies)-265(preoper)-10(atively)]TJ /T1_2 1 Tf 1.005 -1.867 Td (\201)Tj /T1_0 1 Tf 0.575 0 Td [(Treat)-262(and)-259(correct)-269(nutritional)]TJ 0.423 -1.398 Td [(deficiencies)-272(preoperatively)-274(as)]TJ 0 -1.406 TD [(individuals)-265(have)-265(an)-267(increased)-263(risk)-264(of)]TJ 0 -1.398 TD [(deficiencies)-272(postoperatively)]TJ 17.545 4.203 Td (GPP)Tj -20.478 -6.501 Td [(Abbreviatio)-12(ns:)-389(BPD/DS,)-398(duodenal)-391(switch;)-396(EL,)-386(evidence)-397(level)-396(and)-387(depicts)]TJ T* [(where)-349(the)-350(majority)-357(of)-342(evidence)-360(lies;)-351(GPP,)-346(good)-354(practice)-351(point.)-354(The)-348(range)]TJ T* [(of)-259(evidence)-269(level)-267(is)-264(given)-262(in)-260(brackets.)]TJ ET 0.137 0.122 0.125 scn 0.137 0.122 0.125 SCN /GS1 gs 548.787 748.63 -504 0.453 re B* q 1 0 0 1 526.28 761.102 cm -0.51 0 0.51 -12.019 re B* Q BT 0 0 0 scn /GS0 gs /T1_0 1 Tf 6.9999 0 0 6.9999 44.7874 753.1085 Tm (O'KANE)Tj 4.8997 0 0 4.8997 72.1701 753.1085 Tm [(ET)-384(AL)]TJ 6.9999 0 0 6.9999 85.4929 753.1085 Tm (.)Tj /T1_1 1 Tf 65.611 0 Td (5)Tj ET /Document /MC0 BDC q 455.096 759.571 -66.24 -15.6 re W n q /GS1 gs 66.642 0 0 15.744 388.728 743.928 cm /Im0 Do Q EMC Q /Document /MC1 BDC q 463.578 757.474 54.142 -11.282 re W n 1 1 1 scn /GS1 gs 463.578 746.192 54.142 11.282 re f q 1 0 0 1 482.25 747.988 cm /CS1 cs 1 scn /GS0 gs 0 0 m 0 -0.707 -0.157 -1.162 -0.66 -1.444 c -0.66 -1.539 l 2.451 -1.539 l 2.451 -1.444 l 1.948 -1.162 1.792 -0.707 1.792 0 c 1.792 6.03 l 1.792 6.722 1.948 7.177 2.451 7.475 c 2.451 7.554 l -0.66 7.554 l -0.66 7.475 l -0.157 7.177 0 6.722 0 6.03 c 0 0 l h 13.836 -1.539 m 14.275 0.377 l 14.182 0.408 l 13.647 -0.424 12.83 -0.77 11.621 -0.77 c 8.073 -0.77 l 8.073 5.951 l 8.073 6.722 8.261 7.161 8.794 7.475 c 8.794 7.554 l 5.67 7.554 l 5.654 7.475 l 6.141 7.177 6.282 6.737 6.282 6.109 c 6.282 -0.079 l 6.282 -0.724 6.141 -1.146 5.654 -1.444 c 5.67 -1.539 l 13.836 -1.539 l h 28.991 -1.444 m 29.005 -1.539 l 32.148 -1.539 l 32.148 -1.444 l 31.628 -1.146 31.472 -0.675 31.472 0.079 c 31.472 2.215 l 34.237 6.155 l 34.739 6.879 35.163 7.318 35.524 7.475 c 35.524 7.554 l 33.074 7.554 l 33.074 7.475 l 33.514 7.224 33.575 6.611 33.106 5.937 c 31.08 3.015 l 28.849 6.298 l 28.504 6.8 28.566 7.256 28.975 7.475 c 28.975 7.554 l 25.534 7.554 l 25.534 7.475 l 25.944 7.303 26.196 7.067 26.635 6.439 c 29.682 2.088 l 29.682 0.079 l 29.682 -0.675 29.509 -1.146 28.991 -1.444 c 18.045 3.659 m 18.045 6.783 l 21.311 6.783 l 22.803 6.783 23.368 6.549 23.903 5.795 c 23.997 5.826 l 23.808 7.554 l 15.642 7.554 l 15.626 7.475 l 16.114 7.177 16.255 6.737 16.255 6.109 c 16.255 -0.079 l 16.255 -0.724 16.114 -1.146 15.626 -1.444 c 15.642 -1.539 l 24.232 -1.539 l 24.546 0.313 l 24.468 0.345 l 23.918 -0.393 23.259 -0.77 21.783 -0.77 c 18.045 -0.77 l 18.045 2.921 l 20.542 2.921 l 21.61 2.921 22.143 2.748 22.427 2.293 c 22.536 2.293 l 22.536 4.271 l 22.427 4.287 l 22.143 3.832 21.61 3.659 20.542 3.659 c 18.045 3.659 l h -6.988 -1.853 m -6.91 -1.853 l -3.046 7.773 l -2.669 8.7 -2.324 9.156 -1.979 9.359 c -1.979 9.454 l -4.303 9.454 l -4.303 9.359 l -3.816 9.093 -3.706 8.37 -4.036 7.539 c -6.407 1.602 l -9.627 9.485 l -9.705 9.485 l -13.097 1.617 l -15.532 7.806 l -15.814 8.543 -15.735 9.093 -15.281 9.359 c -15.281 9.454 l -18.672 9.454 l -18.672 9.359 l -18.311 9.171 -18.044 8.779 -17.714 7.977 c -13.725 -1.853 l -13.647 -1.853 l -10.286 6.109 l -6.988 -1.853 l f Q EMC Q endstreamendobj495 0 obj<>endobj496 0 obj<>stream BT /CS0 cs 0 0 0 scn /GS0 gs /T1_0 1 Tf 7.9999 0 0 7.9999 46.4882 723.4014 Tm [(were)-390(circulated)-381(amongst)-390(the)-388(guideline)-389(group)-383(for)-392(iterative)-390(discussion)]TJ 0 -1.623 TD [(and)-306(review.)-305(Following)-302(this,)-308(the)-310(contributing)-303(evidence)-300(and)-306(recommen-)]TJ T* [(dations)-269(were)-270(graded)-269(based)-266(on)-275(Scottish)-266(Intercollegi)9(ate)-274(Guidelines)-267(Net-)]TJ 0 -1.63 TD (work)Tj 0.0001 Tc 5.9998 0 0 5.3325 64.0063 687.9683 Tm (28)Tj 0 Tc 7.9999 0 0 7.9999 76.6488 684.3967 Tm [(\(SIGN\))-716(method)14(ology)-717(\(see)-604(Table)-717(1\))-713(by)-724(two)-712(independen)16(t)]TJ -3.77 -1.623 Td [(reviewers)-367(\(MO)-375(and)-377(HP\).)-376(Draft)-372(recomm)13(endations)-373(togethe)13(r)-383(with)-370(their)]TJ 0 -1.623 TD [(grading)-274(were)-277(then)-283(circulated)-275(within)-274(the)-282(guidelin)13(e)-288(group)-276(in)-279(an)-277(iterative)]TJ 0 -1.63 TD [(process)-347(until)-342(consensus)-339(was)-351(achieved)-338(on)-353(both)-347(the)-346(recommen)15(dations)]TJ 0 -1.623 TD [(and)-335(grading.)-321(Although)-332(we)-329(included)-326(previously)-328(publish)13(ed)-338(guidelin)13(es)-336(in)]TJ T* [(our)-509(literature)-500(review)11(,)-512(we)-506(graded)-503(those)-505(recommend)14(ations)-502(as)-508(being)]TJ 0 -1.63 TD [(expert)-386(opinion)-377(unless)-383(we)-386(had)-384(reviewed)-384(the)-381(original)-383(articles)-385(cited)-383(by)]TJ 0 -1.623 TD [(the)-353(authors.)-350(Just)-349(prior)-356(to)-352(submission)13(,)]TJ /T1_1 1 Tf 16.781 0 Td (\223)Tj /T1_0 1 Tf 0.368 0 Td [(Clinical)-347(practice)-354(guidelin)13(es)-357(for)]TJ -17.15 -1.623 Td [(the)-813(perioperative)-811(nutrition,)-807(metabolic,)-808(and)-816(nonsurgical)-806(support)]TJ T* [(of)-604(patients)-602(undergoin)13(g)-610(bariatric)-601(procedure)12(s)-608(-)-607(2019)-603(update)-602(were)]TJ 0 -1.63 TD [(published)-247(so)-258(were)-256(included.)]TJ /T1_1 1 Tf 11.984 0 Td (\224)Tj /T1_0 1 Tf 5.9998 0 0 5.3325 145.2472 557.9715 Tm (4)Tj /T1_2 1 Tf 10.0001 0 0 10.0001 46.4882 515.3951 Tm (3)Tj /T1_0 1 Tf 1.474 0 Td (|)Tj /T1_2 1 Tf 0.1009 Tc 1.151 0 Td (RESULTS)Tj /T1_0 1 Tf 0 Tc 7.9999 0 0 7.9999 46.4882 489.4298 Tm [(The)-485(searches)-474(identified)-482(601)-481(studies,)-481(510)-481(of)-484(which)-484(were)-482(identified)]TJ T* [(through)-341(database)-345(searches)-339(and)-349(91)-351(from)-346(other)-344(sources.)-344(One)-348(hundred)]TJ 0 -1.623 TD [(and)-384(seventy-o)10(ne)-388(full)-383(papers)-380(were)-383(screened,)-383(and)-384(139)-382(were)-383(included.)]TJ T* [(The)-641(main)-643(reasons)-638(papers)-635(were)-638(excluded)-639(were)-638(that)-646(no)-643(relevant)]TJ 0 -1.63 TD [(nutritional)-407(data)-412(were)-412(reported)-406(or)-416(that)-412(the)-416(study)-404(population)-410(did)-414(not)]TJ 0 -1.623 TD [(include)-552(people)-559(who)-557(had)-554(undergone)-549(bariatric)-558(surgery.)-548(The)-563(32)-557(full)]TJ T* [(papers)-408(removed)-415(with)-413(reasons)-411(for)-413(exclusion)-412(are)-416(listed)-407(as)-416(Supporting)]TJ T* [(Information)-247(in)-144(Table)-256(S3.)]TJ /T1_2 1 Tf 10.0001 0 0 10.0001 46.4882 359.433 Tm (4)Tj /T1_0 1 Tf 1.474 0 Td (|)Tj /T1_2 1 Tf 0.1007 Tc 1.151 0 Td [(SUMM)-5(ARY)-263(O)1(F)-261(T)2(HE)-263(STUDIES)]TJ /T1_0 1 Tf 0 Tc 7.9999 0 0 7.9999 46.4882 333.4109 Tm [(Pre-bariatr)13(ic)-406(surgery)-394(studies)-394(included)-397(seven)-398(cross-se)13(ctional)-395(and)-398(two)]TJ T* [(cohort)-422(studies.)-420(Pre-)-430(and)-427(post-bariatr)16(ic)-434(surgery)-423(studies)-423(included)-418(one)]TJ 0 -1.63 TD [(non-random)15(ized)-552(controlled)-543(trials)-544(\(CTs\),)-548(one)-549(randomized)-541(controlled)]TJ 0 -1.623 TD [(trials)-686(\(RCTs\),)-689(20)-684(cohort)-684(studies,)-687(one)-690(case)-690(control)-682(study,)-682(seven)]TJ T* [(systematic)-283(reviews,)-293(eight)-291(narrative)-285(reviews)-292(and)-292(seven)-291(clinical)-290(practice)]TJ T* [(guidelines.)-548(Post-surg)11(ery)-558(only)-549(studies)-550(included)-553(two)-549(CTs,)-551(six)-560(RCTs,)]TJ 0 -1.63 TD [(30)-521(cohort)-514(studies,)-517(two)-514(case)-520(control)-519(studies,)-517(seven)-511(cross-secti)11(onal)]TJ 0 -1.623 TD [(studies,)-325(one)-336(case)-328(series,)-328(10)-337(case)-328(studies,)-325(one)-336(survey,)-325(nine)-334(systematic)]TJ T* [(reviews,)-421(seven)-426(narrative)-419(reviews)-419(and)-427(10)-429(clinical)-418(practice)-425(guidelines.)]TJ 0 -1.63 TD [(Eight)-508(studies/re)12(views)-506(included)-503(adolescents)-506(only,)-509(and)-505(one)-513(includ)12(ed)]TJ 0 -1.623 TD [(both)-404(adolesce)11(nts)-403(and)-405(adults.)-392(The)-407(rest)-400(of)-406(the)-402(papers)-401(included)-397(adults)]TJ T* [(only.)-448(There)-447(were)-447(45)-450(studies)-444(or)-445(systematic)-446(review)11(s,)-453(which)-441(included)]TJ 0 -1.63 TD [(SG;)-369(74)-365(included)-368(RYGB;)-358(29)-373(included)-361(BPD/DS;)-366(and)-363(17)-373(included)-361(AGB.)]TJ 0 -1.623 TD [(Most)-395(clinical)-396(practice)-390(guidelines)-394(and)-398(narrative)-391(reviews)-398(focused)-389(on)-403(a)]TJ T* [(range)-353(of)-356(procedure)12(s)-352(including)-352(AGB,)-350(SG,)-354(RYGB)-349(and)-356(BPD/DS)11(.)-359(Studies)]TJ 0 -1.63 TD [(were)-312(conduct)14(ed)-317(in)-307(a)-319(variety)-305(of)-314(geographical)-302(areas)-308(including)-309(Australia,)]TJ 0 -1.623 TD [(Canada,)-358(Middle)-361(East,)-364(South)-359(America)-357(and)-363(Asian)-362(countries)-359(\(23)-361(studies)]TJ T* [(in)-300(total\),)-291(but)-299(the)-296(majority)-296(were)-291(conducted)-296(in)-293(Europe)-297(\(73)-297(studies\))-297(or)-296(in)]TJ T* [(the)-296(United)-300(States)-291(\(40)-304(studies\))14(.)-302(Follow-up)-291(in)-300(the)-303(postope)14(rative)-298(studies)]TJ 0 -1.63 TD [(varied)-497(between)-495(6)-498(months)-497(and)-498(15)-500(years.)-497(The)-492(majority)-495(reported)-498(at)]TJ 0 -1.623 TD [(1)-293(year)-288(with)-285(smaller)-285(numbers)-285(reporte)13(d)-291(at)-291(5,)-294(10)-287(or)-289(15)-295(years.)-284(Forty-nine)]TJ T* [(studies)-699(reported)-697(on)-700(a)-709(range)-700(of)-704(micronutr)16(ients;)-702(18)-706(focused)-693(on)]TJ 0 -1.63 TD [(vitamin)-540(D,)-553(calcium)-541(or)-551(bone)-542(health;)-545(17)-543(focused)-545(on)-544(anaemia,)-543(iron,)]TJ 32.655 84.501 Td [(folate)-465(or)-473(vitamin)-469(B12;)-474(eight)-468(focused)-467(on)-473(nutrition)-466(issues)-469(related)-469(to)]TJ 0 -1.623 TD [(neurolo)14(gical)-262(disorders;)-246(and)-257(seven)-256(focused)-254(on)-254(trace)-253(minerals.)]TJ /T1_2 1 Tf 10.0001 0 0 10.0001 307.729 671.414 Tm (5)Tj /T1_0 1 Tf 1.468 0 Td (|)Tj /T1_2 1 Tf 0.1011 Tc 1.151 0 Td [(OVERVIEW)-258(AND)-261(R)-1(ATIONALE)-262(FOR)]TJ 0.1007 Tc -2.619 -1.298 Td (RECOMMENDATIONS)Tj /T1_0 1 Tf 0 Tc 7.9999 0 0 7.9999 307.729 632.4093 Tm [(There)-419(is)-425(a)-425(high)-422(prevalence)-417(of)-427(nutritional)-421(deficie)11(ncies)-423(in)-428(both)-425(adults)]TJ T* [(and)-299(adolesce)11(nts)-304(with)-299(severe)-303(and)-299(complex)-294(obesity.)-299(The)-301(most)-304(commo)13(n)]TJ 0 -1.63 TD 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[(surgery.)-392(In)-397(addition,)-396(two)-394(patient)-391(representativ)12(es)-399(were)-397(included.)-387(The)]TJ 0 -1.63 TD [(membersh)14(ip)-400(therefore)-386(included)-390(six)-397(dietitians)-386(\(MO,)-398(GP,)-395(NW,)-386(DT,)-395(KC)]TJ 0 -1.623 TD [(and)-547(JD\),)-550(two)-542(general)-546(practitio)11(ners)-549(\(HP)-548(and)-547(CH\),)-548(three)-542(physicians)]TJ T* [(\(JP,)-278(RB)-268(and)-278(JM\),)-270(two)-273(chemical)-269(pathologis)11(ts)-275(\(JB)-273(and)-278(MS\),)-272(two)-273(surgeo)12(ns)]TJ 0 -1.63 TD [(\(RWand)-495(KM\))-503(and)-505(two)-500(patient)-505(represent)14(atives)-501(\(AB)-505(and)-505(IM\).)-504(These)]TJ 0 -1.623 TD [(guidelines)-394(aimed)-393(to)-395(address)-392(four)-400(main)-395(areas)-400(of)-399(clinical)-389(managemen)12(t)]TJ T* [(for)-258(patients)-255(underg)14(oing)-256(bariatric)-253(surgery.)]TJ 1.878 -1.623 Td 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4.6661 44.7874 424.7432 Tm (2)Tj 6.9999 0 0 6.9999 47.7921 421.6818 Tm [(Norwich)-269(Medical)-269(School,)-269(University)-271(of)-261(East)]TJ -0.429 -1.433 Td [(Anglia,)-272(Norwich,)-269(UK)]TJ 5.2498 0 0 4.6661 44.7874 401.7826 Tm (3)Tj 6.9999 0 0 6.9999 47.7921 398.6644 Tm [(Faculty)-270(of)-261(Health)-263(and)-270(Human)-261(Scien)-12(ces,)]TJ -0.429 -1.433 Td [(Peninsul)-13(a)-256(Schoo)-12(ls)-259(of)-261(Medici)-11(ne)-256(and)-270(Dentistry,)]TJ 0 -1.425 TD [(Plymouth,)-275(UK)]TJ 5.2498 0 0 4.6661 44.7874 368.7873 Tm (4)Tj 6.9999 0 0 6.9999 47.7921 365.6692 Tm [(Departme)-12(nt)-260(of)-261(Endocrin)-12(ology,)-268(Plymouth)]TJ -0.429 -1.433 Td [(Hospita)-10(ls)-259(NHS)-263(Trust,)-266(Plym)-10(outh,)-265(UK)]TJ 5.2498 0 0 4.6661 44.7874 345.77 Tm (5)Tj 6.9999 0 0 6.9999 47.7921 342.6519 Tm [(Departme)-12(nt)-260(of)-261(Upper)-265(GI)-264(and)-262(Baria)-11(tric)]TJ -0.429 -1.425 Td [(Surgery)-12(,)-260(Musgrove)-271(Park)-259(Hospi)-11(tal,)-265(Taunton)-268(and)]TJ 0 -1.434 TD [(Somerse)-14(t)-253(NH)-11(S)-261(Foundation)-151(Tru)-9(st,)-256(Taun)-11(ton,)-266(UK)]TJ 5.2498 0 0 4.6661 44.7874 312.7747 Tm (6)Tj 6.9999 0 0 6.9999 47.7921 309.6566 Tm [(Fakenham)-270(Weight)-268(Managemen)-15(t)-261(Service,)]TJ -0.429 -1.425 Td [(Fakenha)-13(m)-257(Medica)-12(l)-257(Practice)-14(,)-260(Fakenham,)-271(UK)]TJ 5.2498 0 0 4.6661 44.7874 289.7574 Tm (7)Tj 6.9999 0 0 6.9999 47.7921 286.6393 Tm [(Centre)-265(for)-264(Obes)-10(ity)-258(Resea)-11(rch,)-263(Rayne)-268(Institute,)]TJ -0.429 -1.425 Td [(Departme)-12(nt)-260(of)-261(Med)-9(icine,)-267(University)-271(College)]TJ 0 -1.425 TD [(London,)-266(Lond)-11(on,)-263(UK)]TJ 5.2498 0 0 4.6661 44.7874 256.7621 Tm (8)Tj 6.9999 0 0 6.9999 47.7921 253.644 Tm [(School)-269(of)-261(Biosciences,)-271(Sut)-11(ton)-257(Boni)-10(ngton)]TJ -0.429 -1.425 Td [(Campus,)-269(Univer)-12(sity)-260(of)-261(Nottingh)-13(am,)]TJ 0 -1.433 TD [(Nottingh)-13(am,)-263(UK)]TJ /T1_1 1 Tf 10.0001 0 0 10.0001 209.3102 436.6487 Tm (Summary)Tj /T1_3 1 Tf 9 0 0 9 209.3102 421.6818 Tm [(Bariatric)-306(surgery)-307(is)-310(recognized)-309(as)-306(the)-306(most)-308(clinically)-310(and)-309(cost-effective)-307(treatment)-308(for)]TJ 0 -1.669 TD [(people)-366(with)-373(severe)-368(and)-366(complex)-374(obesity.)-368(Many)-369(people)-366(presenting)-371(for)-372(surgery)-370(have)]TJ T* [(pre-existing)-474(low)-469(vitamin)-477(and)-467(mineral)-478(concentrations.)-474(The)-468(incidence)-476(of)-475(these)-474(may)]TJ 0 -1.663 TD [(increase)-267(after)-277(bariatric)-267(surgery)-275(as)-268(all)-275(procedures)-267(potentially)-273(cause)-272(clinically)-272(significant)]TJ 0 -1.669 TD [(micronutrient)-425(deficiencies.)-429(Therefore,)-432(preparation)-426(for)-429(surgery)-427(and)-423(long-term)-430(nutri-)]TJ 0 -1.663 TD [(tional)-372(monitoring)-379(and)-372(follow-up)-380(are)-376(essential)-375(components)-378(of)-374(bariatric)-380(surgical)-373(care.)]TJ 0 -1.669 TD [(These)-459(guidelines)-460(update)-458(the)-457(2014)-458(British)-459(Obesity)-462(and)-461(Metabolic)-460(Surgery)-457(Society)]TJ T* [(nutritional)-620(guidelines.)-622(Since)-628(the)-621(2014)-629(guidelines,)-626(the)-621(working)-622(group)-626(has)-623(been)]TJ 0 -1.663 TD [(expanded)-297(to)-293(include)-302(healthcare)-298(professionals)-295(working)-300(in)-292(specialist)-302(and)-297(non-specialist)]TJ 0 -1.669 TD [(care)-349(as)-356(well)-351(as)-356(patient)-354(representatives.)-355(In)-350(addition,)-356(in)-349(these)-355(updated)-353(guidelines,)-356(the)]TJ 0 -1.663 TD [(current)-279(evidence)-277(has)-283(been)-275(systematically)-280(reviewed)-281(for)-278(adults)-282(and)-278(adolescents)-280(under-)]TJ 0 -1.669 TD [(going)-386(the)-394(following)-390(procedures:)-395(adjustable)-391(gastric)-391(band,)-390(sleeve)-392(gastrectomy,)-394(Roux-)]TJ 0 -1.663 TD [(en-Y)-438(gastric)-435(bypass)-438(and)-435(biliopancreatic)-441(diversion/duodenal)-434(switch.)-440(Using)-434(methods)]TJ 0 -1.669 TD [(based)-288(on)-284(Scottish)-289(Intercollegiate)-293(Guidelines)-285(Network)-289(methodology,)-293(the)-287(levels)-286(of)-292(evi-)]TJ T* [(dence)-267(and)-272(recommendations)-269(have)-272(been)-269(graded.)-271(These)-264(guidelines)-271(are)-275(comprehensive,)]TJ ET q 1 0 0 1 0 0 cm 0.576 0.584 0.596 scn /GS2 gs 44.787 150.973 242.986 0.454 re f Q BT /T1_1 1 Tf 6.0001 0 0 6.0001 44.7874 139.9181 Tm (Abbreviations:)Tj /T1_3 1 Tf 6.671 0 Td [(25OHD,)-257(25-hydroxyvitamin)-262(D;)-265(AGB,)-255(adjustable)-264(gastric)-258(band;)-259(BOMSS,)-258(British)-261(Obesity)-254(and)-259(Metabolic)-261(Surgery)-259(Society;)-269(BPD/DS,)-259(duodenal)-253(switch;)-264(CT,)-262(non-)-2(randomized)-251(controlled)]TJ -6.671 -1.502 Td [(trials;)-256(EL,)-268(evidence)-257(level;)-264(FPG,)-260(fasting)-261(plasma)-252(glucose;)-261(GPP,)-267(good)-252(practice)-260(point;)-268(OAGB/MGB,)-259(one)-256(anastomosis)-263(gastric)-258(bypass/mini)-253(gastric)-267(bypass;)-250(P)-2(IVKA-II,)-269(protein)-259(induced)-259(by)-261(vitamin)-254(K)]TJ 0 -1.502 TD [(absence)-261(or)-256(antagonism;)-262(PTH,)-265(parathyroid)-256(hormone;)-257(RCT,)-261(randomized)-259(controlled)-257(trial;)-258(ROS,)-263(Royal)-259(Osteoporosis)-260(Society;)-259(RYGB,)-259(Roux-en-Y)-262(gastric)-258(bypa)-2(ss;)-260(SADIs,)-264(single)-263(anastomosis)-253(duodenal)-263(ileal)]TJ 0 -1.493 TD [(bypass)-255(with)-266(sleeve)-260(gastrectomy;)-257(SG,)-260(sleeve)-260(gastrectomy;)-257(SIGN,)-269(Scottish)-254(Intercollegiate)-264(Guidelines)-260(Network.)]TJ 0 -2.003 TD [(Mary)-262(O'Kane)-262(and)-259(Helen)-253(Parretti)-258(contributed)-260(equally)-264(to)-256(the)-265(publication)-257(and)-259(are)-262(considered)-262(joint)-255(first)-258(authors.)]TJ T* [(We)-263(dedicate)-255(our)-261(guidelines)-261(to)-256(Iris)-259(McMillan,)-267(patient)-256(representative,)-263(who)-259(died)-253(just)-261(before)-257(the)-265(guidelines)-261(were)-253(submitted.)]TJ ET q 1 0 0 1 0 0 cm 0.137 0.122 0.125 scn /CS0 CS 0.137 0.122 0.125 SCN 0 w 1 j 1 J /GS2 gs 548.787 741.373 -504 0.51 re B* Q q 1 0 0 1 122.683 741.883 cm 0.137 0.122 0.125 scn /CS0 CS 0.137 0.122 0.125 SCN 0 w 1 j 1 J /GS2 gs 0.51 0 -0.51 11.962 re B* Q q 1 0 0 1 207.383 741.883 cm 0.137 0.122 0.125 scn /CS0 CS 0.137 0.122 0.125 SCN 0 w 1 j 1 J /GS2 gs 0.51 0 -0.51 11.962 re B* Q BT /T1_3 1 Tf 6.9999 0 0 6.9999 44.7874 745.8518 Tm [(Received)-14(:)-333(5)-335(April)-333(2020)-2085(Revised:)-342(21)-338(May)-334(2020)-2077(Accepte)-15(d:)-332(31)-338(May)-334(2020)]TJ 0 -1.928 TD [(DOI:)-342(10.1111/obr.130)-19(87)]TJ ET /Document /MC1 BDC q 1 0 0 1 0 0 cm 486.107 721.417 -66.24 -15.6 re W n q /GS2 gs 66.642 0 0 15.744 419.808 705.768 cm /Im0 Do Q EMC Q /Document /MC2 BDC q 1 0 0 1 0 0 cm 494.589 719.263 54.142 -11.282 re W n 1 1 1 scn /GS2 gs 494.589 707.981 54.142 11.282 re f 1 0 0 1 513.261 709.777 cm /CS1 cs 1 scn /GS1 gs 0 0 m 0 -0.707 -0.157 -1.162 -0.66 -1.444 c -0.66 -1.539 l 2.451 -1.539 l 2.451 -1.444 l 1.948 -1.162 1.792 -0.707 1.792 0 c 1.792 6.03 l 1.792 6.722 1.948 7.177 2.451 7.475 c 2.451 7.554 l -0.66 7.554 l -0.66 7.475 l -0.157 7.177 0 6.722 0 6.03 c 0 0 l h 13.836 -1.539 m 14.275 0.377 l 14.182 0.408 l 13.647 -0.424 12.83 -0.77 11.621 -0.77 c 8.073 -0.77 l 8.073 5.951 l 8.073 6.722 8.261 7.161 8.794 7.475 c 8.794 7.554 l 5.67 7.554 l 5.654 7.475 l 6.141 7.177 6.282 6.737 6.282 6.109 c 6.282 -0.079 l 6.282 -0.724 6.141 -1.146 5.654 -1.444 c 5.67 -1.539 l 13.836 -1.539 l h 28.991 -1.444 m 29.005 -1.539 l 32.148 -1.539 l 32.148 -1.444 l 31.628 -1.146 31.472 -0.675 31.472 0.079 c 31.472 2.215 l 34.237 6.155 l 34.738 6.879 35.163 7.318 35.524 7.475 c 35.524 7.554 l 33.074 7.554 l 33.074 7.475 l 33.514 7.224 33.575 6.611 33.106 5.937 c 31.08 3.015 l 28.849 6.298 l 28.504 6.8 28.566 7.256 28.975 7.475 c 28.975 7.554 l 25.534 7.554 l 25.534 7.475 l 25.944 7.303 26.196 7.067 26.635 6.439 c 29.682 2.088 l 29.682 0.079 l 29.682 -0.675 29.509 -1.146 28.991 -1.444 c 18.045 3.659 m 18.045 6.783 l 21.311 6.783 l 22.803 6.783 23.368 6.549 23.903 5.795 c 23.997 5.826 l 23.808 7.554 l 15.642 7.554 l 15.626 7.475 l 16.114 7.177 16.255 6.737 16.255 6.109 c 16.255 -0.079 l 16.255 -0.724 16.114 -1.146 15.626 -1.444 c 15.642 -1.539 l 24.232 -1.539 l 24.546 0.313 l 24.468 0.345 l 23.918 -0.393 23.259 -0.77 21.783 -0.77 c 18.045 -0.77 l 18.045 2.921 l 20.542 2.921 l 21.61 2.921 22.143 2.748 22.427 2.293 c 22.536 2.293 l 22.536 4.271 l 22.427 4.287 l 22.143 3.832 21.61 3.659 20.542 3.659 c 18.045 3.659 l h -6.988 -1.853 m -6.91 -1.853 l -3.046 7.773 l -2.669 8.7 -2.324 9.156 -1.979 9.359 c -1.979 9.454 l -4.303 9.454 l -4.303 9.359 l -3.816 9.093 -3.706 8.37 -4.036 7.539 c -6.407 1.602 l -9.627 9.485 l -9.705 9.485 l -13.097 1.617 l -15.532 7.806 l -15.814 8.543 -15.735 9.093 -15.281 9.359 c -15.281 9.454 l -18.672 9.454 l -18.672 9.359 l -18.311 9.171 -18.044 8.779 -17.714 7.978 c -13.725 -1.853 l -13.647 -1.853 l -10.286 6.109 l -6.988 -1.853 l f EMC Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 44.787 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 47.792 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 50.797 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 53.802 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 56.806 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 59.811 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 62.816 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 65.82 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 68.882 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 71.887 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 74.891 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 77.896 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 80.901 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 83.905 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 86.91 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 89.915 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 92.92 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 95.924 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 98.929 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 101.934 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 104.939 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 107.943 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 111.005 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 114.009 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 117.014 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 120.019 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 123.024 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 126.028 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 129.033 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 132.038 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 135.042 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 138.047 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 141.052 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 144.057 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 147.061 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 150.066 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 153.128 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 156.132 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 159.137 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 162.142 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 165.146 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 168.151 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 171.156 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 174.161 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 177.165 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 180.17 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 183.175 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 186.179 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 189.184 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 192.189 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 195.25 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 198.255 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 201.26 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 204.264 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 207.269 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 210.274 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 213.279 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 216.283 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 219.288 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 222.293 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 225.298 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 228.302 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 231.307 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 234.312 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 237.316 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 240.378 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 243.383 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 246.387 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 249.392 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 252.397 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 255.402 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 258.406 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 261.411 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 264.416 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 267.42 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 270.425 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 273.43 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 276.435 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 279.439 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 282.501 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 285.505 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 288.51 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 291.515 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 294.52 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 297.524 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 300.529 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 303.534 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 306.539 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 309.543 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 312.548 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 315.553 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 318.557 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 321.562 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 324.624 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 327.628 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 330.633 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 333.638 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 336.642 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 339.647 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 342.652 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 345.657 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 348.661 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 351.666 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 354.671 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 357.676 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 360.68 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 363.685 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 366.69 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 369.751 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 372.756 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 375.761 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 378.765 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 381.77 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 384.775 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 387.779 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 390.784 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 393.789 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 396.794 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 399.798 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 402.803 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 405.808 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 408.813 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 411.874 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 414.879 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 417.883 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 420.888 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 423.893 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 426.898 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 429.902 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 432.907 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 435.912 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 438.916 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 441.921 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 444.926 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 447.931 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 450.935 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 453.997 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 457.001 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 460.006 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 463.011 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 466.016 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 469.02 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 472.025 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 475.03 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 478.035 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 481.039 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 484.044 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 487.049 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 490.053 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 493.058 74.665 1.531 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 496.12 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 499.124 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 502.129 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 505.134 74.665 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B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 544.252 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm /CS0 CS 0 0 0 SCN 0 w 1 j 1 J 547.257 74.665 1.474 -0.51 re B* Q q 1 0 0 1 0 0 cm 0.137 0.122 0.125 scn /CS0 CS 0.137 0.122 0.125 SCN 0 w 1 j 1 J /GS2 gs 44.787 34.469 504 -0.51 re B* Q q 1 0 0 1 524.806 23.981 cm 0.137 0.122 0.125 scn /CS0 CS 0.137 0.122 0.125 SCN 0 w 1 j 1 J /GS2 gs 0 0 m 0 9.978 l 0.454 9.978 l 0.454 0 l B* Q BT /T1_3 1 Tf 6.9999 0 0 6.9999 44.7874 64.1763 Tm [(This)-264(is)-265(an)-255(ope)-10(n)-258(access)-270(article)-263(unde)-11(r)-261(the)-259(terms)-270(of)-261(the)-267(Creative)-268(Commons)-272(Attribution)-268(Licen)-11(se,)-260(which)-267(permits)-265(use,)-267(distributio)-14(n)-258(and)-262(reprodu)-12(ction)-263(in)-262(any)-263(me)-2(dium)-12(,)]TJ 0 -1.433 TD [(provided)-273(the)-259(origina)-11(l)-257(work)-265(is)-265(properly)-263(cited)-13(.)]TJ 0 -1.425 TD [(\251)-263(2020)-263(The)-264(Autho)-11(rs.)]TJ /T1_4 1 Tf 9.525 0 Td [(Obesity)-266(Revie)-11(ws)]TJ /T1_3 1 Tf 7.054 0 Td [(published)-263(by)-266(John)-267(Wiley)-265(&)-264(Sons)-259(Ltd)-269(on)-263(behalf)-263(of)-261(Worl)-11(d)-258(Obesity)-268(Feder)-11(ation)]TJ /T1_4 1 Tf -16.579 -2.883 Td [(Obesity)-339(Re)-10(views.)]TJ /T1_3 1 Tf 7.427 0 Td [(2020)-12(;1)]TJ /T1_5 1 Tf 3.134 0 Td (\226)Tj /T1_3 1 Tf 0.575 0 Td (23.)Tj 41.33 0 Td [(wileyonlinel)-13(ibrary.com/)-13(journal/obr)]TJ /T1_1 1 Tf 18.96 0 Td (1)Tj ET endstreamendobj504 0 obj<>endobj505 0 obj<>endobjxref 0 3 0000000000 65535 f 0000419983 00000 n 0000425409 00000 n 19 1 0000425781 00000 n 23 1 0000426140 00000 n 25 1 0000426487 00000 n 30 1 0000426881 00000 n 32 1 0000427228 00000 n 35 1 0000427633 00000 n 38 1 0000428027 00000 n 41 1 0000428386 00000 n 45 1 0000428814 00000 n 48 1 0000429197 00000 n 50 1 0000429568 00000 n 53 1 0000429951 00000 n 57 1 0000430367 00000 n 62 1 0000430786 00000 n 64 1 0000431169 00000 n 66 1 0000431540 00000 n 68 1 0000431887 00000 n 96 1 0000432438 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