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LETTER TO THE EDITOR |
Division of Endocrinology
Diabetology and Metabolism
Centre Hospitalier Universitaire Vaudois
Lausanne
Switzerland
E-mail: vittorio.giusti{at}chuv.ch
Dear Sir:
We are grateful for Ledoux and Larger's interest in our article, which was published recently in the Journal (1). Ledoux and Larger's assumption that standard multivitamin supplementation can prevent nutritional deficiencies after gastric bypass surgery is hazardous and based only on their contrasting studies (2, 3), which are not supported by the international literature.
In their article published in 2006, Ledoux et al (2) concluded the following: "...multivitamin preparation did not correct the serum concentrations of vitamin A and E. Specific supplementation with vitamin A and E are thus required after RYGBP, and intramuscular supplementation, especially for vitamin B-12 could be required." This assertion confirms our study's results rather than Ledoux and Larger's letter.
Moreover, in their recent study (3), in which the prevalence of nutritional deficiencies was prospectively evaluated in patients undergoing gastric bypass and treated with standard multivitamins (Elevit B9; Bayer Health Care AG, Puteaux Cedex, France), Ledoux's team validated the inefficacy of multivitamin supplementation as follows: "However, vitamin B-12 and iron deficits need specific supplementation." More important, in this study the authors report also that: "...clinical symptoms suggestive of nutrition deficits were recorded in 59% of patients." Additionally, despite the use of standard multivitamin substitution, more than one-half of the patients necessitated vitamin B-12 treatment, 10% developed anemia, 6% had a vitamin A deficit, and 8% had a vitamin B-6 insufficiency. How is it possible to affirm that standard multivitamins can prevent nutritional deficiencies with such results? I believe, rather, that these data support the importance of specific nutritional substitution and the lack of efficacy of standard multivitamin supplementation.
The inefficacy of Elevit B9 in Ledoux et al's study (2), which was used to prevent nutritional deficiencies, was not unexpected. In fact, Poitou et al (4), in their recent review, analyzed the main forms of multivitamin and multimineral supplements habitually used after bariatric surgery in Europe and conclude that management of nutritional deficiencies after gastric bypass requires rigorous medical follow-up and specific vitamin supplements. More importantly, Poitou et al also evaluated Elevit B9, and affirmed the following: "...in France, no marketed supplement available covers all the requirements. In addition, one does not know the proportion of each vitamin or minerals introduced which is really absorbed, the principal site of absorption remaining the excluded duodenum."
A similar review, conducted in the United States by Parkes (5), evaluated multivitamin supplements specifically developed by several companies for bariatric surgery patients. Parkes concluded that, despite the use of these supplement prescriptions, "frequent monitoring of nutritional status and additional supplementation, as needed, can aid in preventing severe clinical deficiencies."
Colossi et al (6) shared the same opinion after they evaluated the prevalence of nutritional deficiencies in 210 patients who underwent gastric bypass. They concluded that, "this study provides further evidence of the necessity of routine supplementation of vitamins and minerals using multivitamins, starting by the 30th day after bariatric surgery and persisting for the rest of the patient's life. Certainly, this routine does not eliminate the need for complementary supply of some specific nutrients based on periodic clinical and laboratory evaluation...".
Vargas-Ruiz et al (7), in their prospective study that assessed adherence to standard multivitamin treatment after gastric bypass, concluded that "routine schema of vitamin supplementation is not sufficient to prevent iron and vitamin B-12 deficiencies in most patients." Similar conclusions are reported by Love and Billett (8) in their review article. In 1991, Brolin et al (9) documented the inefficacy of multivitamin prophylaxis in preventing all nutritional deficiencies.
Surprisingly, of the abovementioned studies (1, 2, 4-9), only the study by Love and Billett (8) was reported in Ledoux et al's bibliography (3), which indicates the bias and nonobjectivity of the author concerning nutritional deficiencies after bariatric surgery, especially concerning the efficacy of standard multivitamin supplements.
We will consider the criticisms of our work in an effort to improve the quality of our future publications. Nevertheless, we note that the patient's exclusion criteria and biological assessments of nutritional deficiencies are provided in Figure 1 and Table 1 of the manuscript and are detailed in the text. The schemas used are habitually accepted by many international journals. Our work is admittedly a retrospective study, with the known limits of this type of design. The objective of our study was to simply evaluate the prevalence and type of nutritional deficiencies experienced after gastric bypass and not to investigate the causes and origins of such deficiencies.
In conclusion, the international literature data suggest that standard multivitamin supplements are ineffective at preventing nutritional deficiencies after gastric bypass, so I am unable to agree with Ledoux and Larger's assumption.
ACKNOWLEDGMENTS
No conflicts of interest were reported.
REFERENCES
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