Assessment of Preoperative Multivitamin Use on the Impact on Micronutrient Deficiencies in Metabolic Bariatric Surgery Patients

Assessment of Preoperative Multivitamin Use on the Impact on Micronutrient Deficiencies in Metabolic Bariatric Surgery Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of Preoperative Multivitamin Use on the Impact on Micronutrient Deficiencies in Metabolic Bariatric Surgery Patients Johannes Sander, Bart Torensma, Jacqueline Siepe, Torsten Schorp, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5918872/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Apr, 2025 Read the published version in Obesity Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Background Most patients achieve successful weight loss following metabolic bariatric surgery (MBS), but they face an increased risk of micronutrient deficiencies due to altered gastrointestinal physiology and dietary restrictions. This study evaluated the impact of a specialized multivitamin on blood serum levels before MBS. Methods A prospective, within-patient comparison trial was conducted between January and July 2023 at a large bariatric clinic. Differences in serum micronutrient levels between baseline and the three-month follow-up were assessed, along with changes in the prevalence of micronutrient deficiencies. Results Of 120 patients recruited, 99 (82.5%) completed the three-month follow-up. Significant changes were observed in 14 of 22 serum parameters (63.6%). Eleven parameters, including iron, vitamin K1, zinc, CRP, hemoglobin, hematocrit, MCV, calcium, folic acid, vitamin B1, and vitamin D, showed significant increases (p < 0.001). Conversely, magnesium, phosphate, and albumin levels significantly decreased (p < 0.001). Among 22 parameters, deficiencies were identified in 18 (81.8%), with prevalence rates ranging from 1.0% (copper) to 88.8% (vitamin D). After three months, significant reductions in deficiency prevalence were observed for iron, folic acid, and vitamin D. However, phosphate deficiency increased significantly, from 2.1% to 19.8% (p < 0.001). Conclusion Micronutrient deficiencies are prevalent in patients with obesity. Preoperative specialized multivitamin supplementation effectively reduces key deficiencies, particularly in iron, folic acid, and vitamin D. Future research should address residual deficiencies and evaluate long-term outcomes of prolonged supplementation. metabolic bariatric surgery micronutrient deficiencies multivitamin supplementation preoperative care obesity Key Points Micronutrient deficiencies are highly prevalent in patients undergoing MBS, with vitamin D and iron among the most affected. Specialized multivitamin supplementation significantly improves serum levels of key micronutrients preoperatively. Persistent deficiencies in some micronutrients warrant further investigation into optimized supplementation strategies. Introduction Obesity is a significant contributor to a broad spectrum of metabolic disorders, including type 2 diabetes, cardiovascular disease, dyslipidemia, hypertension, and certain cancers [1,2]. Additionally, it is associated with various psychological challenges in specific individuals [3]. Given the inconclusive evidence regarding the long-term efficacy of medical treatments and lifestyle modifications, metabolic bariatric surgery (MBS) had been proposed as an effective intervention to achieve sustained weight loss in patients with severe obesity [4–6]. While most patients achieved successful weight loss following MBS, they faced an increased risk of micronutrient deficiencies due to altered gastrointestinal physiology and dietary restrictions [7–9]. Nutritional guidelines for MBS patients emphasized the long-term use of specialized postoperative multivitamins to prevent these deficiencies [10–12]. Extensive research had demonstrated the safety and efficacy of multivitamins, tailored specifically to meet the nutritional needs of bariatric patients [13–18]. In addition to an increased risk for developing deficiencies after surgery, micronutrient deficiencies were already highly prevalent in patients with obesity compared to those with a healthy weight [9,19–24]. Several factors contribute to this increased prevalence, including limited dietary diversity [25], dilution effects caused by increased serum volume, fat and muscle mass, and larger liver size; and obesity-related comorbidities such as liver steatosis [26], diabetes [27], inflammation [28,29], and hormonal dysregulation [30,31]. Moreover, inadequate intake or absorption of specific vitamins and minerals could disrupt the intricate balance between micronutrients, potentially compounding deficiencies. Micronutrients interact in complex ways, where a deficiency in one may affect the absorption or metabolism of others, potentially compounding nutritional challenges. For instance, low vitamin D levels can impair calcium absorption, increasing the risk of bone disorders. Consequently, nutritional guidelines emphasized the importance of comprehensive nutritional assessments before bariatric surgery, including preoperative screening for deficiencies and other health parameters [10–12]. Preoperative assessments includes screening for micronutrient deficiencies, diabetes, dyslipidemia, and renal function, with identified deficiencies corrected as clinically indicated before surgery. Despite this, preoperative screening often focuses on a limited subset of micronutrients, leaving many potential deficiencies undetected. For example, common assessments typically include vitamin D, iron or vitamin B12, while nutrient deficiencies such as zinc are often overlooked due to cost, time limitations, or clinical guidelines. Clinical studies have evaluated the safety and efficacy of post-bariatric specialized multivitamins tailored to the nutritional needs of various types of surgeries [7,32,33]. To our knowledge, there are no studies on the effect of specialized multivitamin supplementation on correcting blood serum values before MBS. This study aimed to evaluate the impact of a specialized multivitamin on blood serum levels before MBS. Methods Study Design This was a prospective, within-patient comparison trial conducted between January 2023 and July 2023 at a large bariatric clinic. Patients met the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) criteria after multidisciplinary screening and consented to undergo primary metabolic bariatric surgery. The study received approval from the institutional ethics committee (Ethical Board Registration Number: BLINDED ) and complied with the ethical standards of the 1964 Declaration of Helsinki. Written informed consent was obtained from all participants before their inclusion in the study. Study Objectives All patients received a specialized multivitamin developed for pre-operative intake ( WLS Start) for three months in addition to standard care, which included nutritional, physical, and psychological therapy. The primary objective was to determine the within-patient differences in serum blood levels of micronutrients between baseline and the three-month follow-up. The secondary objective was to evaluate the percentage change in the prevalence of micronutrient deficiencies within patients between baseline and three months. Inclusion and Exclusion Criteria Patients aged 18 to 65 years with a body mass index (BMI) ≥ 40 kg/m², or a BMI ≥ 35 kg/m² with associated medical problems such as type 2 diabetes mellitus (T2DM), hypertension, obstructive sleep apnea syndrome (OSAS), or hypercholesterolemia, were included in the study. Patients with a history of gastrointestinal (GI) diseases, such as celiac disease or inflammatory bowel disease (IBD), addiction behavior, suspected compliance issues, renal or hepatic insufficiency, or those unable to swallow the supplement, were excluded. Data Collection This data collection process provided a comprehensive assessment of the impact of WLS Start supplementation. Data were collected after approval for MBS, at baseline, before initiating supplementation, and three months later. Information collected included demographic characteristics such as gender, age, and BMI; associated medical problems, including T2DM, hypertension, OSAS, and hypercholesterolemia; baseline use of vitamins and supplements; and any adverse effects or complaints related to supplement use. Lab assessment Peripheral blood samples were collected and allowed to clot at room temperature for 30 minutes. The samples were then centrifuged at 4000 rpm for 10 minutes at 4 °C, and the resulting serum was aliquoted and stored at −80 °C until analysis. All laboratory analyses were conducted following standardized operating procedures to ensure accuracy and reproducibility. The following parameters were assessed, with deficiencies defined based on the specified reference ranges: Hemoglobin: 12–16 g/dL Mean Corpuscular Volume (MCV): 82–98 fL Iron: 9.0–30.4 µmol/L Ferritin: 10–291 ng/mL Folic Acid: 6.0–17.0 ng/mL Vitamin B12: 211-911 pg/ml C-Reactive Protein (CRP): <0.5 mg/L Vitamin D (25-OH): 25–130 µg/L Parathyroid Hormone (PTH): 15–65 pg/mL Calcium: 2.15–2.58 mmol/L Albumin: 35–53 g/L Vitamin B1: 28–85 µg/L Zinc: 600–1200 µg/L Phosphate: 0.87–1.45 mmol/L Magnesium: 0,65-1,07 mmol/l Vitamin A: 0.3–0.7 mg/L Vitamin E: 5–18 mg/L Vitamin K: K1 0,13-1,19 µg/l K2 (MK-4) 0,1-0,86 µg/l K2 (MK-7) 0,1-0,82 µg/l Copper: 11-22 µmol/l These parameters were selected to evaluate the nutritional and biochemical status of the participants comprehensively. Any values falling outside the specified reference ranges were classified as deficiencies/hypervitaminoses and further analyzed in the context of the study. Composition of the Supplement WLS Start (FitForMe, the Netherlands] was administered once daily. The supplement contains the following micronutrients and dosages, with the respective percentage of the recommended dietary allowance (RDA) (full description Appendix 1). This formulation is based on an elaborate literature review specifically designed to address the unique nutritional needs of patients preparing for MBS. It provided higher concentrations of essential micronutrients, such as vitamin B12, vitamin D, iron, and zinc, to mitigate the risk of deficiencies common in patients with obesity. The supplement was manufactured and administered following regulatory standards to ensure consistency and safety. Statistical analysis Descriptive and inferential statistical methods were applied. The normality of the data was assessed using the Kolmogorov–Smirnov test, Q–Q plots, and Levene’s test for equality of variances. Categorical variables were presented as counts and percentages (n, %). At the same time, continuous data were expressed as mean ± standard deviation (SD) for normally distributed variables and as median with interquartile range (IQR) for skewed distributions. Within-patient comparisons of categorical variables were analyzed using the McNemar test. For continuous data, independent samples and paired Student’s t-tests were employed for normally distributed variables, while the Wilcoxon signed-rank test was used for non-normally distributed variables. Univariate and multivariable logistic regression analyses were performed using a backward selection method to identify and adjust for potential confounding factors. Statistical significance was defined as a p-value ≤ 0.05. All statistical analyses were conducted using R software version 4.1.3. Sample size The sample size was calculated using OpenEpi.com based on a clinically relevant reduction in ferritin deficiencies of 50%, assuming a baseline deficiency prevalence of 14% (SD: 15%), a 95% confidence interval (CI), and 80% power. The required sample size was determined to be 73 patients. Accounting for an anticipated drop-out rate at 3 months primarily due to non-adherence to multivitamin supplementation, the total sample size for the study was set at 120 patients. Results Baseline characteristics A total of 120 patients were recruited for the study, of whom 99 (82.5%) completed the three-month follow-up period. The majority of participants were female (60.8%), with a mean age of 42.3 ± 11.81 years. The mean body mass index (BMI) at baseline was 47.4 ± 7.1 kg/m². Participants presented with various associated medical problems. The prevalence of hypertension was 49.2%, dyslipidemia 57.5%, type 2 diabetes mellitus (T2DM) 21.7%, hypothyroidism 23.3%, asthma 15.0%, depression 52.5%, gastroesophageal reflux disease (GERD) 49.2%, and obstructive sleep apnea syndrome (OSAS) 32.5%. No participants had a diagnosis of coronary artery disease. Preoperative supplement use At baseline, 19.9% of participants reported using over-the-counter (OTC) multivitamins or individual supplements. Furthermore, 11.6% used vitamin D, 2.5% vitamin B, 0.8% vitamin C, 1.6% vitamin K, 5.8% zinc, 3.3% magnesium and 2.5% selenium. Changes in blood levels Across the 22 measured parameters, no cases of hypervitaminosis were observed during the study. Fourteen parameters (63.6%) exhibited statistically significant changes in serum levels between baseline and follow-up. Eleven parameters (50.0%) showed a significant increase in mean values, including iron, vitamin K1, zinc, C-reactive protein (CRP), hemoglobin, hematocrit, mean corpuscular volume (MCV), calcium, folic acid, vitamin B1, and vitamin D. Conversely, Three parameters (13.6%) displayed significant minimal decreased in mean values with a (mean differences, 95%CI) for magnesium (-0.01 [-0.03; 0.00]), phosphate (-1.12 [-0.17;-0.07], and albumin (-0.89 [-1.42; -0.35]) (p=<0.001). The four parameters with the most significant mean changes were iron (2.12; 95% CI: 1.12–3.12, p<0.001), folic acid (10.92; 95% CI: 9.54–12.29, p<0.001), vitamin B1 (9.94; 95% CI: 4.85–15.03, p<0.001), and vitamin D (11.07; 95% CI: 9.38–12.76, p<0.001) (Table 1). Deficiencies Among the 22 assessed parameters, deficiencies were identified in 18 (81.2%) parameters, with prevalence rates ranging from 1.0% (copper) to 88.8% (vitamin D) of the patients. No deficiencies were observed in vitamin K2 (MK4), vitamin B1, vitamin B12, or parathyroid hormone. At the 3-month follow-up, deficiencies were identified in 16 assessed parameters, with prevalence rates ranging from 1% to 50% of patients After three months, 3 out of 22 micronutrients demonstrated a significant reduction in deficiency prevalence between baseline and follow-up. Iron deficiency decreased from 30.5% to 15.8% (p=0.003). Folic acid deficiency showed a substantial decline, from 41.5% to 7.4% (p=<0.001), and vitamin D deficiency improved significantly from 88.8% to 50.0% (p=<0.001). However, phosphate deficiency increased significantly, rising from 2.1% at baseline to 19.8% at follow-up (p=<0.001)(from 2 to 19 patients) (Table 2). Correcting for confounding factor When correcting for sex and BMI, significant differences emerged in the patterns of serum changes and deficiencies. For male participants with a BMI <50, 27.3% of parameters, including calcium, phosphate, albumin, folic acid, vitamin B12, and vitamin D, showed significant changes (p50, only three parameters (13.6%) showed significant increases: zinc, folic acid, and vitamin D, with zinc not being significant in the lower BMI group (Table 3). Among female participants with a BMI <50, 27.3% of parameters showed significant changes, including hematocrit, MCV, phosphate, folic acid, vitamin B12, and vitamin D (p50 exhibited more widespread changes, with 40.9% of parameters showing significant differences, including iron, CRP, hemoglobin, hematocrit, MCV, calcium, folic acid, vitamin D, and parathyroid hormone (PTH) (p50, decreasing from 43.5% to 17.4% (p<0.001). The increase in phosphate deficiency was significant only among women with a BMI <50, rising from 0.0% (n=0) to 16.2% (n=6) (p=0.031). No such trend was observed in groups with higher BMI categories. None of the other potential confounding variables, such as BMI treated as a continuous variable or the use of preoperative over-the-counter (OTC) supplements, significantly influenced the observed changes in deficiencies. Nausea and side-effect of supplement use There was no significant association between supplement use and nausea (p=0.377). The majority of participants (67.7%) reported no nausea. Mild nausea was noted in 15 participants (15.2%), while 17.2% (17 participants) experienced nausea without vomiting. During the supplementation period, 11.1% of participants reported mild side effects, including headache, bloating, flatulence, or an unpleasant taste. These effects were transient and did not necessitate discontinuation of the supplement. However, as dietary patterns and other lifestyle factors were not monitored, it remains unclear whether these side effects were exclusively attributable to the supplement . Discussion This prospective study assessed the impact of specialized preoperative supplementation in patients with severe obesity undergoing metabolic and bariatric surgery (MBS), focusing on identifying micronutrient deficiencies and evaluating the effectiveness of supplementation in addressing these deficiencies. The deficiencies were identified in 81.2%, with statistically significant changes observed in 63.6% between baseline and follow-up. Research on the use of specialized preoperative multivitamins in MBS patients are not known. A systematic review by Gudzune et al. (2013), which included 21,345 eligible patients, reported that presurgical testing for micronutrient deficiencies was performed in fewer than 25% of cases. Over a 36-month follow-up, the prevalence of micronutrient deficiencies increased across all MBS types, ranging from 20–88% [ 34 ]. More recently, a systematic review by Tang et al. examined 27 studies addressing micronutrient repletion before MBS, assessing micronutrient status both pre- and post-MBS. The interventions varied widely, including chronic oral supplementation with multivitamins (n = 21), megadoses of oral supplements (n = 1), intramuscular injections (n = 1), intravenous infusions (n = 1), and combined oral and injectable approaches (n = 3). The authors concluded that proactive micronutrient repletion schedules before MBS appear safe and feasible but noted variability in efficacy depending on the specific micronutrient, dose, duration, and delivery method (e.g., oral vs. infusion) [ 32 ]. Our results reported using OTC supplements prior to this study. However, this subgroup did not significantly reduce the prevalence of measured deficiencies or had a confounding effect on the changed micronutrient. The study group's active use of specialized supplementation (WLS Start) significantly reduced the prevalence of deficiency in 3 out of 22 micronutrients between baseline and the 3-month follow-up. However, deficiencies in 16 micronutrients persisted, potentially placing patients at a disadvantage when undergoing surgery. With 3 months, the study period was relatively short. Possibly, with longer use of preoperative supplementation, better blood serum values could have been reported. Since there were no hypervitaminosis, there is an opportunity for prolonged use. In the case of magnesium (-0.01) and albumin (-0.89), we observed a minimal yet statistically significant reduction in serum levels. However, this did not impact deficiency rates, as none of the patients experienced clinical deficiencies, rendering these changes clinically irrelevant. Conversely, phosphate levels showed a mean decrease of -0.12, accompanied by a significant increase in deficiency prevalence, rising from 3.8–23.1%. The observed increase in phosphate deficiencies in our study may potentially be linked to the use of ascorbic acid supplementation over the three-month period. Ascorbic acid, particularly in higher doses, can contribute to metabolic acidosis, which in turn may initially result in transiently elevated serum phosphate levels. However, the resulting acidosis can lead to a compensatory increase in renal phosphate excretion over time, ultimately reducing serum phosphate concentrations [ 35 ]. This mechanism aligns with our findings of decreased phosphate levels and increased deficiency prevalence, but further research is needed to confirm this hypothesis and evaluate the extent to which ascorbic acid supplementation may contribute to phosphate imbalances in this population. Impact of Fewer Deficiencies in Vitamin D, Iron, and Folic Acid Reducing deficiencies in vitamin D, iron, and folic acid is crucial for MBS patients due to their essential roles in metabolic and physiological processes. Vitamin D deficiency, common in severe obesity and often exacerbated after MBS, plays a critical role in calcium absorption, bone health, immune function, and reducing systemic inflammation. A recent systematic review by Giustina et al. (2023) emphasized the importance of assessing vitamin D levels both preoperatively and postoperatively in all patients undergoing MBS. The review further recommends high-dose vitamin D supplementation pre- and postoperative, irrespective of the surgical procedure type, to address these deficiencies effectively [ 36 ]. Addressing this deficiency preoperatively minimizes the risks of postoperative complications such as bone demineralization and poor wound healing. Iron deficiency, linked to anemia and fatigue, is often exacerbated by reduced intake and malabsorption after surgery. Adequate iron levels support hemoglobin synthesis and oxygen transport, which are essential for healing. Similarly, folic acid is vital for DNA synthesis, red blood cell production, and tissue repair, reducing risks of megaloblastic anemia and supporting recovery and support rapid cell turnover required during tissue repair after surgery. In our study, iron had the most pronounced effect among women with a BMI > 50, decreasing from 43.5–17.4%. Studies suggested that elevated body weight may impact endometrial function, contributing to heavier menstrual blood loss. While the relationship between obesity and endometrial cancer is widely recognized, there is limited knowledge regarding the frequency of heavy menstrual bleeding among obese adolescents and adult women [ 37 , 38 ]. Clinical Implications of Improved Nutritional Status Fewer deficiencies and higher levels of key micronutrients underscore the importance of tailored preoperative supplementation in optimizing nutritional status before MBS. Adequate levels of vitamin D, iron, folic acid, vitamin B1, and zinc help mitigate pre-existing deficiencies that can impair recovery and long-term outcomes. Improved preoperative nutrition not only enhances surgical recovery but also prepares patients for better management of postoperative deficiencies, often exacerbated by altered gastrointestinal physiology. Rationale for Preoperative Supplementation More evidence is necessary to support the effectiveness of specialized preoperative multivitamins tailored to MBS patients in preventing postoperative deficiencies. However, many deficiencies are already present preoperatively due to limited dietary diversity, dilution effects from increased serum volume, expanded fat and muscle mass, and conditions like liver steatosis, diabetes, and chronic inflammation [ 9 , 25 – 31 ]. If unaddressed, these deficiencies are likely to worsen postoperatively due to reduced nutrient intake and absorption. Preoperative supplementation addressing existing deficiencies can potentially reduce risks during recovery, establish adherence to supplementation regimens, and optimize outcomes by supporting immune function wound healing, and may have a protective effect against hair loss with levels of zinc, folic acid, ferritin, and protein intake that closely associated with the risk of hair loss, highlighting the importance of optimizing these factors before surgery, and overall metabolic health. Known and Potential Risks and Benefits The risks of supplementation in this study are minimal, as the intervention occurs entirely before MBS. The primary risk remains the development of micronutrient deficiencies, which this study aims to mitigate through specialized multivitamins. Although dosages are relatively high, they remain within safe limits and are well-tolerated by patients with severe obesity due to dilution effects, increased serum volume, and altered metabolism linked to obesity-related associated medical problems. The three-month supplementation period was a conservative approach. No cases of hypervitaminosis were observed, supporting the safety of this approach, while still being able to improve blood serum values before surgery. Limitations This study has several limitations that should be considered. A washout period was not applied, meaning that the effects of any prior supplementation or dietary habits could not be fully isolated from the intervention. Despite this, deficiencies were still present preoperatively in many participants, underscoring the need for tailored nutritional optimization prior to MBS. Additionally, while the preoperative setting was particularly relevant for identifying and addressing deficiencies, the absence of a true control group limits the ability to attribute observed changes solely to the intervention. Potential confounding factors, such as differences in metabolism, associated medical problems, or baseline nutritional statuses, may also have influenced the results, since we could not correct for all the factors due to low incidence. The relatively short study duration of three months may not fully capture the long-term implications of preoperative supplementation, particularly for deficiencies that take longer to resolve or have extended effects on surgical outcomes. Finally, the study’s focus on a specific preoperative bariatric population in a single healthcare setting may limit the generalizability of findings to other populations or healthcare systems. These limitations highlight the need for future studies with robust designs, including randomized controlled trials, washout periods, longer follow-up durations, and more detailed monitoring of adherence and external supplement use, to validate these findings and better understand the long-term benefits of preoperative supplementation. Conclusion This study highlights the prevalence of micronutrient deficiencies in patients with obesity and demonstrates the effectiveness of preoperative specialized multivitamin supplementation in reducing key deficiencies, including iron, folic acid, and vitamin D. Significant improvements in serum levels of critical nutrients such as vitamin B1 and zinc further underscore the benefits of tailored preoperative supplementation. Future research is warranted to address residual deficiencies in other micronutrient and evaluate long-term outcomes associated with prolonged pre-operative supplementation. Studies should also assess the effects after MBS and determine the burden of postoperative deficiencies after preoperative supplement use. Declarations Ethical Approval: All procedures involving human participants were performed according to the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent: Informed consent was obtained from all individual participants included in the study. Conflicts of interest: All the authors declare that they have no conflict of interest. Funding: None Author Contribution JS and BT wrote manuscriptBT analyzed dataFB and EA supervisedAll authors reviewed the manuscript, provided feedback and approved. 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Preoperative Micronutrient Repletion Strategies in Metabolic and Bariatric Surgery: A Systematic Review. Journal of the Academy of Nutrition and Dietetics. 2024;S2212267224008645. Kamal FA, Fernet LY, Rodriguez M, Kamal F, Da Silva NK, Kamal OA, et al. Nutritional Deficiencies Before and After Bariatric Surgery in Low- and High-Income Countries: Prevention and Treatment. Cureus [Internet]. 2024 [cited 2024 Nov 27]; Available from: https://www.cureus.com/articles/233173-nutritional-deficiencies-before-and-after-bariatric-surgery-in-low--and-high-income-countries-prevention-and-treatment Gudzune KA, Huizinga MM, Chang H-Y, Asamoah V, Gadgil M, Clark JM. Screening and Diagnosis of Micronutrient Deficiencies Before and After Bariatric Surgery. OBES SURG. 2013;23:1581–9. Salcedo-Betancourt JD, Moe OW. The Effects of Acid on Calcium and Phosphate Metabolism. IJMS. 2024;25:2081. Giustina A, Di Filippo L, Facciorusso A, Adler RA, Binkley N, Bollerslev J, et al. Vitamin D status and supplementation before and after Bariatric Surgery: Recommendations based on a systematic review and meta-analysis. Rev Endocr Metab Disord. 2023;24:1011–29. McDonald ME, Bender DP. Endometrial Cancer. Obstetrics and Gynecology Clinics of North America. 2019;46:89–105. Calle EE. Overweight, Obesity, and Mortality from Cancer in a Prospectively Studied Cohort of U.S. Adults. The new england journal of medicine. 2003; Tables Table 1 Change in blood level before and after 3 months of use of the supplement. Variable N Mean change 95% Confidence Interval p-value Iron 95 2.12 [1.12; 3.12] <0.001 Magnesium 95 -0.01 [-0.03; 0.00] 0.023 Vitamin A 99 0.01 [-0.03; 0.05] 0.579 Vitamin E 99 0.15 [-0.68; 0.97] 0.726 Vitamin K1 98 0.10 [-0.01; 0.22] 0.073 Vitamin K2 (MK4) 98 -0.03 [-0.14; 0.07] 0.528 Vitamin K2 (MK7) 98 0.01 [-0.08; 0.11] 0.747 Copper 99 -0.09 [-0.61; 0.43] 0.744 Zinc 92 61.19 [21.98; 100.41] 0.003 CRP 59 2.16 [0.02; 4.30] 0.048 Hemoglobin 99 0.37 [0.11; 0.63] 0.005 Hematocrit 99 0.01 [0.01; 0.02] <0.001 MCV 99 1.06 [0.54; 1.59] <0.001 Calcium 95 0.06 [0.04; 0.09] <0.001 Phosphate 96 -0.12 [-0.17; -0.07] <0.001 Albumin 96 -0.89 [-1.42; -0.35] 0.001 Ferritin 96 -8.16 [-17.10; 0.77] 0.073 Folic Acid 94 10.92 [9.54; 12.29] <0.001 Vitamin B1 95 9.94 [4.85; 15.03] <0.001 Vitamin B12 95 -13.40 [-45.56; 18.76] 0.410 Vitamin D 80 11.07 [9.38; 12.76] <0.001 Parathyroid Hormon 96 -6.85 [-12.02; -1.68] 0.010 MCV = Mean Corpuscular Volume, CRP= C-Reactive Protein Table 2 Change of deficiencies Variable Proportion Baseline Proportion Follow-UP p-value Iron 29/95 (30.5%) 15/95 (15.8%) 0.003 Magnesium 3/95 (3.2%) 3/95 (3.2%) 1.000 Vitamin A 2/99 (2.0%) 5/99 (5.1%) 0.375 Vitamin E 1/99 (1.0%) 0/99 (0%) 1.000 Vitamin K1 3/98 (3.1%) 7/98 (7.1%) 0.219 Vitamin K2 (MK4) 0/98 (0%) 0/98 (0%) n.a. Vitamin K2 (MK7) 3/98 (3.1%) 8/98 (8.2%) 0.180 Copper 1/99 (1.0%) 1/99 (1.0%) 1.000 Zinc 2/92 (2.2%) 4/92 (4.3%) 0.688 CRP 25/59 (42.4%) 19/59 (32.2%) 0.146 Hemoglobin 3/99 (3.0%) 0/99 (0%) 0.250 Hematocrit 2/99 (2.0%) 0/99 (0%) 0.500 MCV 16/99 (16.2%) 11/99 (11.1%) 0.125 Calcium 5/95 (5.3%) 1/95 (1.1%) 0.125 Phosphate 2/96 (2.1%) 19/96 (19.8%) <0.001 Albumin 15/96 (15.6%) 22/96 (22.9%) 0.039 Ferritin 2/96 (2.0%) 0/96 (0%) 0.500 Folic Acid 39/94 (41.5%) 7/94 (7.4%) <0.001 Vitamin B1 0/95 (0%) 0/95 (0%) n.a. Vitamin B12 0/95 (0%) 1/95 (1.1%) 1.000 Vitamin D 71/80 (88.8%) 40/80 (50.0%) <0.001 Parathyroid Hormon 0/96 (0%) 1/96 (1.0%) 1.000 MCV = Mean Corpuscular Volume, CRP= C-Reactive Protein Table 3: Correcting for confounding factors BMI < 50 and Male gender* Variable Mean change 95% Confidence Interval p-value Iron 1.27 [-0.39; 2.94] 0.128 Magnesium -0.01 [-0.03; 0.01] 0.261 Vitamin A -0.02 [-0.10; 0.06] 0.671 Vitamin E -1.32 [-2.73; 0.09] 0.066 Vitamin K1 0.03 [-0.16; 0.21] 0.770 Vitamin K2 (MK4) -0.12 [-0.36; 0.13] 0.341 Vitamin K2 (MK7) -0.09 [-0.23; 0.04] 0.153 Copper 0.17 [-0.79; 1.14] 0.714 Zinc 41.04 [-42.89;124.97] 0.324 CRP 2.91 [-0.29; 6.11] 0.071 Hemoglobin 0.17 [-0.08; 0.42] 0.169 Hematocrit 0.00 [-0.00; 0.01] 0.240 MCV 0.44 [-0.44; 1.33] 0.312 Calcium 0.06 [ 0.03; 0.09] <0.001 Phosphate -0.18 [-0.28;-0.08] 0.001 Albumin -1.63 [-2.42;-0.85] <0.001 Ferritin -4.54 [-27.07;18.00] 0.682 Folic Acid 10.24 [ 7.67;12.82] <0.001 Vitamin B1 8.74 [ 2.49;14.99] 0.008 Vitamin B12 -37.40 [-93.48;18.68] 0.181 Vitamin D 11.04 [ 7.76;14.33] 50 and Male gender* Variable Mean change 95% Confidence Interval p-value Iron 2.01 [-0.05; 4.07] 0.054 Magnesium -0.03 [-0.07; 0.01] 0.183 Vitamin A 0.02 [-0.11; 0.15] 0.760 Vitamin E 0.81 [-1.36; 2.98] 0.420 Vitamin K1 0.17 [-0.04; 0.38] 0.102 Vitamin K2 (MK4) -0.09 [-0.30; 0.13] 0.375 Vitamin K2 (MK7) 0.04 [-0.13; 0.20] 0.613 Copper 0.12 [-0.65; 0.89] 0.733 Zinc 149.20 [47.84;250.56] 0.009 CRP 1.97 [-0.39; 4.34] 0.088 Hemoglobin 0.21 [-0.22; 0.64] 0.296 Hematocrit -0.00 [-0.03; 0.02] 0.605 MCV 0.30 [-1.21; 1.81] 0.664 Calcium 0.05 [-0.03; 0.12] 0.188 Phosphate -0.13 [-0.28; 0.02] 0.083 Albumin -0.74 [-2.49; 1.01] 0.363 Ferritin -26.80 [-67.42;13.82] 0.170 Folic Acid 11.04 [ 6.74;15.34] <0.001 Vitamin B1 7.16 [-7.31;21.63] 0.292 Vitamin B12 24.20 [-55.37;103.77] 0.509 Vitamin D 14.30 [ 8.42;20.18] <0.001 Parathyroid Hormon -2.34 [-21.52;16.84] 0.789 *Other potential confounding variables, including BMI as a continuous variable, did not significantly alter the observed outcomes in terms of changes in deficiencies. MCV = Mean Corpuscular Volume, CRP= C-Reactive Protein Table 4: Correcting for confounding factors BMI < 50 and Women gender* Variable Mean change 95% Confidence Interval p-value Iron 1.68 [-0.06; 3.43] 0.058 Magnesium -0.01 [-0.03; 0.01] 0.382 Vitamin A 0.03 [-0.02; 0.09] 0.234 Vitamin E 0.35 [-0.78; 1.49] 0.533 Vitamin K1 0.14 [-0.06; 0.34] 0.164 Vitamin K2 (MK4) 0.06 [-0.11; 0.23] 0.454 Vitamin K2 (MK7) -0.03 [-0.09; 0.03] 0.297 Copper -0.01 [-0.71; 0.69] 0.976 Zinc 34.03 [-15.60;83.66] 0.173 CRP 0.30 [-3.58; 4.17] 0.876 Hemoglobin 0.72 [ 0.16; 1.28] 0.013 Hematocrit 0.02 [ 0.01; 0.02] <0.001 MCV 2.32 [ 1.45; 3.18] <0.001 Calcium 0.06 [ 0.02; 0.10] 0.003 Phosphate -0.15 [-0.22;-0.08] <0.001 Albumin -0.76 [-1.70; 0.17] 0.106 Ferritin -6.11 [-15.60; 3.38] 0.200 Folic Acid 10.92 [ 8.62;13.22] <0.001 Vitamin B1 19.94 [11.29;28.60] <0.001 Vitamin B12 -30.19 [-72.09;11.71] 0.153 Vitamin D 7.26 [ 4.06;10.46] 50 and Women gender* Variable Mean change 95% Confidence Interval p-value Iron 3.31 [ 1.37; 5.25] 0.002 Magnesium -0.01 [-0.04; 0.01] 0.305 Vitamin A 0.02 [-0.03; 0.07] 0.447 Vitamin E 1.07 [-0.92; 3.06] 0.278 Vitamin K1 0.12 [-0.10; 0.33] 0.274 Vitamin K2 (MK4) 0.02 [-0.12; 0.17] 0.774 Vitamin K2 (MK7) 0.14 [-0.16; 0.44] 0.353 Copper -0.52 [-1.80; 0.76] 0.408 Zinc 40.62 [-42.83;124.06] 0.322 CRP 3.24 [ 1.49; 4.99] 0.002 Hemoglobin 0.46 [ 0.16; 0.76] 0.004 Hematocrit 0.02 [ 0.01; 0.03] <0.001 MCV 1.38 [ 0.42; 2.33] 0.007 Calcium 0.08 [ 0.05; 0.12] <0.001 Phosphate -0.03 [-0.13; 0.06] 0.515 Albumin -0.31 [-1.24; 0.62] 0.497 Ferritin -1.09 [-11.05; 8.88] 0.823 Folic Acid 11.51 [ 9.23;13.80] <0.001 Vitamin B1 6.39 [-4.44;17.22] 0.234 Vitamin B12 -3.09 [-84.87;78.70] 0.938 Vitamin D 11.50 [ 9.31;13.69] <0.001 Parathyroid Hormon -12.85 [-24.02;-1.69] 0.026 *Other potential confounding variables, including BMI as a continuous variable, did not significantly alter the observed outcomes in terms of changes in deficiencies. MCV = Mean Corpuscular Volume, CRP= C-Reactive Protein Additional Declarations No competing interests reported. Supplementary Files Appendix1PreVit.docx Cite Share Download PDF Status: Published Journal Publication published 08 Apr, 2025 Read the published version in Obesity Surgery → Version 1 posted Editorial decision: Revision requested 14 Feb, 2025 Reviews received at journal 11 Feb, 2025 Reviews received at journal 11 Feb, 2025 Reviewers agreed at journal 05 Feb, 2025 Reviewers agreed at journal 04 Feb, 2025 Reviewers invited by journal 04 Feb, 2025 Editor assigned by journal 04 Feb, 2025 Submission checks completed at journal 30 Jan, 2025 First submitted to journal 28 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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13:08:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5918872/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5918872/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11695-025-07853-1","type":"published","date":"2025-04-08T16:05:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80558612,"identity":"06cff2ea-1079-4c4a-898c-0d508c5b4ef7","added_by":"auto","created_at":"2025-04-14 16:15:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1565181,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5918872/v1/e835dd36-d8bb-4103-91ab-6e79a8b075f2.pdf"},{"id":75299839,"identity":"33f8ad0f-e728-4e29-b565-a4f23c61ab90","added_by":"auto","created_at":"2025-02-03 07:27:30","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15204,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1PreVit.docx","url":"https://assets-eu.researchsquare.com/files/rs-5918872/v1/072d24b87687b24c2e68d71c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of Preoperative Multivitamin Use on the Impact on Micronutrient Deficiencies in Metabolic Bariatric Surgery Patients","fulltext":[{"header":"Key Points","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eMicronutrient deficiencies are highly prevalent in patients undergoing MBS, with vitamin D and iron among the most affected.\u003c/li\u003e\n \u003cli\u003eSpecialized multivitamin supplementation significantly improves serum levels of key micronutrients preoperatively.\u003c/li\u003e\n \u003cli\u003ePersistent deficiencies in some micronutrients warrant further investigation into optimized supplementation strategies.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Introduction","content":"\u003cp\u003eObesity is a significant contributor to a broad spectrum of metabolic disorders, including type 2 diabetes, cardiovascular disease, dyslipidemia, hypertension, and certain cancers [1,2]. Additionally, it is associated with various psychological challenges in specific individuals [3]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven the inconclusive evidence regarding the long-term efficacy of medical treatments and lifestyle modifications, metabolic bariatric surgery (MBS) had been proposed as an effective intervention to achieve sustained weight loss in patients with severe obesity [4\u0026ndash;6]. While most patients achieved successful weight loss following MBS, they faced an increased risk of micronutrient deficiencies due to altered gastrointestinal physiology and dietary restrictions [7\u0026ndash;9]. Nutritional guidelines for MBS patients emphasized the long-term use of specialized postoperative multivitamins to prevent these deficiencies [10\u0026ndash;12].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExtensive research had demonstrated the safety and efficacy of multivitamins, tailored specifically to meet the nutritional needs of bariatric patients [13\u0026ndash;18].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition to an increased risk for developing deficiencies after surgery, micronutrient deficiencies were already highly prevalent in patients with obesity compared to those with a healthy weight [9,19\u0026ndash;24]. Several factors contribute to this increased prevalence, including limited dietary diversity [25], dilution effects caused by increased serum volume, fat and muscle mass, and larger liver size; and obesity-related comorbidities such as liver steatosis [26], diabetes [27], inflammation [28,29], and hormonal dysregulation [30,31].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoreover, inadequate intake or absorption of specific vitamins and minerals could disrupt the intricate balance between micronutrients, potentially compounding deficiencies. Micronutrients interact in complex ways, where a deficiency in one may affect the absorption or metabolism of others, potentially compounding nutritional challenges. For instance, low vitamin D levels can impair calcium absorption, increasing the risk of bone disorders. Consequently, nutritional guidelines emphasized the importance of comprehensive nutritional assessments before bariatric surgery, including preoperative screening for deficiencies and other health parameters [10\u0026ndash;12].\u003c/p\u003e\n\u003cp\u003ePreoperative assessments includes screening for micronutrient deficiencies, diabetes, dyslipidemia, and renal function, with identified deficiencies corrected as clinically indicated before surgery. Despite this, preoperative screening often focuses on a limited subset of micronutrients, leaving many potential deficiencies undetected. For example, common assessments typically include vitamin D, iron or vitamin B12, while nutrient deficiencies such as zinc are often overlooked due to cost, time limitations, or clinical guidelines.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical studies have evaluated the safety and efficacy of post-bariatric specialized multivitamins tailored to the nutritional needs of various types of surgeries [7,32,33].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo our knowledge, there are no studies on the effect of specialized multivitamin supplementation on correcting blood serum values before MBS.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study aimed to evaluate the impact of a specialized multivitamin on blood serum levels before MBS.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a prospective, within-patient comparison trial conducted between January 2023 and July 2023 at a large bariatric clinic. Patients met the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) criteria after multidisciplinary screening and consented to undergo primary metabolic bariatric surgery. The study received approval from the institutional ethics committee (Ethical Board Registration Number: \u003cstrong\u003eBLINDED\u003c/strong\u003e) and complied with the ethical standards of the 1964 Declaration of Helsinki. Written informed consent was obtained from all participants before their inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients received a specialized multivitamin developed for pre-operative intake \u003cem\u003e(\u003c/em\u003eWLS Start) for three months in addition to standard care, which included nutritional, physical, and psychological therapy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe primary objective\u003c/strong\u003e was to determine the within-patient differences in serum blood levels of micronutrients between baseline and the three-month follow-up.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe secondary objective\u003c/strong\u003e was to evaluate the percentage change in the prevalence of micronutrient deficiencies within patients between baseline and three months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients aged 18 to 65 years with a body mass index (BMI) \u0026ge; 40 kg/m\u0026sup2;, or a BMI \u0026ge; 35 kg/m\u0026sup2; with associated medical problems such as type 2 diabetes mellitus (T2DM), hypertension, obstructive sleep apnea syndrome (OSAS), or hypercholesterolemia, were included in the study. Patients with a history of gastrointestinal (GI) diseases, such as celiac disease or inflammatory bowel disease (IBD), addiction behavior, suspected compliance issues, renal or hepatic insufficiency, or those unable to swallow the supplement, were excluded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis data collection process provided a comprehensive assessment of the impact of \u003cem\u003eWLS Start\u003c/em\u003e supplementation. Data were collected after approval for MBS, at baseline, before initiating supplementation, and three months later. Information collected included demographic characteristics such as gender, age, and BMI; associated medical problems, including T2DM, hypertension, OSAS, and hypercholesterolemia; baseline use of vitamins and supplements; and any adverse effects or complaints related to supplement use.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLab assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePeripheral blood samples were collected and allowed to clot at room temperature for 30 minutes. The samples were then centrifuged at 4000 rpm for 10 minutes at 4 \u0026deg;C, and the resulting serum was aliquoted and stored at \u0026minus;80 \u0026deg;C until analysis. All laboratory analyses were conducted following standardized operating procedures to ensure accuracy and reproducibility.\u003c/p\u003e\n\u003cp\u003eThe following parameters were assessed, with deficiencies defined based on the specified reference ranges:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eHemoglobin:\u003c/strong\u003e 12\u0026ndash;16 g/dL\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMean Corpuscular Volume (MCV):\u003c/strong\u003e 82\u0026ndash;98 fL\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIron:\u003c/strong\u003e 9.0\u0026ndash;30.4 \u0026micro;mol/L\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFerritin:\u003c/strong\u003e 10\u0026ndash;291 ng/mL\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFolic Acid:\u003c/strong\u003e 6.0\u0026ndash;17.0 ng/mL\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVitamin B12:\u003c/strong\u003e 211-911 pg/ml\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eC-Reactive Protein (CRP):\u003c/strong\u003e \u0026lt;0.5 mg/L\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVitamin D (25-OH):\u003c/strong\u003e 25\u0026ndash;130 \u0026micro;g/L\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eParathyroid Hormone (PTH):\u003c/strong\u003e 15\u0026ndash;65 pg/mL\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCalcium:\u003c/strong\u003e 2.15\u0026ndash;2.58 mmol/L\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAlbumin:\u003c/strong\u003e 35\u0026ndash;53 g/L\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVitamin B1:\u003c/strong\u003e 28\u0026ndash;85 \u0026micro;g/L\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eZinc:\u003c/strong\u003e 600\u0026ndash;1200 \u0026micro;g/L\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePhosphate:\u003c/strong\u003e 0.87\u0026ndash;1.45 mmol/L\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMagnesium:\u003c/strong\u003e 0,65-1,07 mmol/l\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVitamin A:\u003c/strong\u003e 0.3\u0026ndash;0.7 mg/L\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVitamin E:\u003c/strong\u003e 5\u0026ndash;18 mg/L\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVitamin K:\u003c/strong\u003e K1 0,13-1,19 \u0026micro;g/l \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eK2\u0026nbsp;\u003c/strong\u003e(MK-4) 0,1-0,86 \u0026micro;g/l\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eK2\u003c/strong\u003e (MK-7) 0,1-0,82 \u0026micro;g/l\u0026nbsp;\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eCopper:\u003c/strong\u003e 11-22 \u0026micro;mol/l\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese parameters were selected to evaluate the nutritional and biochemical status of the participants comprehensively. Any values falling outside the specified reference ranges were classified as deficiencies/hypervitaminoses and further analyzed in the context of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComposition of the Supplement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWLS Start\u0026nbsp;(FitForMe, the Netherlands] was administered once daily. The supplement contains the following micronutrients and dosages, with the respective percentage of the recommended dietary allowance (RDA) (full description Appendix 1).\u003c/p\u003e\n\u003cp\u003eThis formulation is based on an elaborate literature review specifically designed to address the unique nutritional needs of patients preparing for MBS. It provided higher concentrations of essential micronutrients, such as vitamin B12, vitamin D, iron, and zinc, to mitigate the risk of deficiencies common in patients with obesity. The supplement was manufactured and administered following regulatory standards to ensure consistency and safety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive and inferential statistical methods were applied. The normality of the data was assessed using the Kolmogorov\u0026ndash;Smirnov test, Q\u0026ndash;Q plots, and Levene\u0026rsquo;s test for equality of variances. Categorical variables were presented as counts and percentages (n, %). At the same time, continuous data were expressed as mean \u0026plusmn; standard deviation (SD) for normally distributed variables and as median with interquartile range (IQR) for skewed distributions.\u003c/p\u003e\n\u003cp\u003eWithin-patient comparisons of categorical variables were analyzed using the McNemar test. For continuous data, independent samples and paired Student\u0026rsquo;s t-tests were employed for normally distributed variables, while the Wilcoxon signed-rank test was used for non-normally distributed variables. Univariate and multivariable logistic regression analyses were performed using a backward selection method to identify and adjust for potential confounding factors. Statistical significance was defined as a p-value \u0026le; 0.05. All statistical analyses were conducted using\u0026nbsp;R software version 4.1.3.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size was calculated using OpenEpi.com based on a clinically relevant reduction in ferritin deficiencies of 50%, assuming a baseline deficiency prevalence of 14% (SD: 15%), a 95% confidence interval (CI), and 80% power. The required sample size was determined to be 73 patients. Accounting for an anticipated drop-out rate at 3 months primarily due to non-adherence to multivitamin supplementation, the total sample size for the study was set at 120 patients.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 120 patients were recruited for the study, of whom 99 (82.5%) completed the three-month follow-up period. The majority of participants were female (60.8%), with a mean age of 42.3 \u0026plusmn; 11.81 years. The mean body mass index (BMI) at baseline was 47.4 \u0026plusmn; 7.1 kg/m\u0026sup2;.\u003c/p\u003e\n\u003cp\u003eParticipants presented with various associated medical problems. The prevalence of hypertension was 49.2%, dyslipidemia 57.5%, type 2 diabetes mellitus (T2DM) 21.7%, hypothyroidism 23.3%, asthma 15.0%, depression 52.5%, gastroesophageal reflux disease (GERD) 49.2%, and obstructive sleep apnea syndrome (OSAS) 32.5%. No participants had a diagnosis of coronary artery disease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreoperative supplement use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt baseline, 19.9% of participants reported using over-the-counter (OTC) multivitamins or individual supplements. Furthermore, 11.6% used vitamin D, 2.5% vitamin B, 0.8% vitamin C, 1.6% vitamin K, 5.8% zinc, 3.3% magnesium and 2.5% selenium.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChanges in blood levels\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcross the 22 measured parameters, no cases of hypervitaminosis were observed during the study. Fourteen parameters (63.6%) exhibited statistically significant changes in serum levels between baseline and follow-up. Eleven parameters (50.0%) showed a significant increase in mean values, including iron, vitamin K1, zinc, C-reactive protein (CRP), hemoglobin, hematocrit, mean corpuscular volume (MCV), calcium, folic acid, vitamin B1, and vitamin D. Conversely, Three parameters (13.6%) displayed significant minimal decreased in mean values with a (mean differences, 95%CI) for magnesium (-0.01 [-0.03; 0.00]), phosphate (-1.12 [-0.17;-0.07], and albumin (-0.89 [-1.42; -0.35]) (p=\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eThe four parameters with the most significant mean changes were iron (2.12; 95% CI: 1.12\u0026ndash;3.12, p\u0026lt;0.001), folic acid (10.92; 95% CI: 9.54\u0026ndash;12.29, p\u0026lt;0.001), vitamin B1 (9.94; 95% CI: 4.85\u0026ndash;15.03, p\u0026lt;0.001), and vitamin D (11.07; 95% CI: 9.38\u0026ndash;12.76, p\u0026lt;0.001) (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeficiencies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 22 assessed parameters, deficiencies were identified in 18 (81.2%) parameters, with prevalence rates ranging from 1.0% (copper) to 88.8% (vitamin D) of the patients. No deficiencies were observed in vitamin K2 (MK4), vitamin B1, vitamin B12, or parathyroid hormone.\u003c/p\u003e\n\u003cp\u003eAt the 3-month follow-up, deficiencies were identified in 16 assessed parameters, with prevalence rates ranging from 1% to 50% of patients\u003c/p\u003e\n\u003cp\u003eAfter three months, 3 out of 22 micronutrients demonstrated a significant reduction in deficiency prevalence between baseline and follow-up. \u003cstrong\u003eIron\u003c/strong\u003e deficiency decreased from 30.5% to 15.8% (p=0.003). \u003cstrong\u003eFolic\u003c/strong\u003e acid deficiency showed a substantial decline, from 41.5% to 7.4% (p=\u0026lt;0.001), and \u003cstrong\u003evitamin\u003c/strong\u003e \u003cstrong\u003eD\u003c/strong\u003e deficiency improved significantly from 88.8% to 50.0% (p=\u0026lt;0.001). However, \u003cstrong\u003ephosphate\u003c/strong\u003e deficiency increased significantly, rising from 2.1% at baseline to 19.8% at follow-up (p=\u0026lt;0.001)(from 2 to 19 patients) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrecting for confounding factor\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen correcting for sex and BMI, significant differences emerged in the patterns of serum changes and deficiencies. For male participants with a BMI \u0026lt;50, 27.3% of parameters, including calcium, phosphate, albumin, folic acid, vitamin B12, and vitamin D, showed significant changes (p\u0026lt;0.001). In males with BMI \u0026gt;50, only three parameters (13.6%) showed significant increases: zinc, folic acid, and vitamin D, with zinc not being significant in the lower BMI group (Table 3).\u003c/p\u003e\n\u003cp\u003eAmong female participants with a BMI \u0026lt;50, 27.3% of parameters showed significant changes, including hematocrit, MCV, phosphate, folic acid, vitamin B12, and vitamin D (p\u0026lt;0.001). In contrast, women with a BMI \u0026gt;50 exhibited more widespread changes, with 40.9% of parameters showing significant differences, including iron, CRP, hemoglobin, hematocrit, MCV, calcium, folic acid, vitamin D, and parathyroid hormone (PTH) (p\u0026lt;0.001) (Table 4).\u003c/p\u003e\n\u003cp\u003eRegarding deficiencies, iron had the most pronounced effect among women with a BMI \u0026gt;50, decreasing from 43.5% to 17.4% (p\u0026lt;0.001). The increase in phosphate deficiency was significant only among women with a BMI \u0026lt;50, rising from 0.0% (n=0) to 16.2% (n=6) (p=0.031). No such trend was observed in groups with higher BMI categories.\u003c/p\u003e\n\u003cp\u003eNone of the other potential confounding variables, such as BMI treated as a continuous variable or the use of \u003cstrong\u003epreoperative over-the-counter (OTC)\u003c/strong\u003e supplements, significantly influenced the observed changes in deficiencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNausea and side-effect of supplement use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no significant association between supplement use and nausea (p=0.377). The majority of participants (67.7%) reported no nausea. Mild nausea was noted in 15 participants (15.2%), while 17.2% (17 participants) experienced nausea without vomiting.\u003c/p\u003e\n\u003cp\u003eDuring the supplementation period, 11.1% of participants reported mild side effects, including headache, bloating, flatulence, or an unpleasant taste. These effects were transient and did not necessitate discontinuation of the supplement. However, as dietary patterns and other lifestyle factors were not monitored, it remains unclear whether these side effects were exclusively attributable to the supplement\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective study assessed the impact of specialized preoperative supplementation in patients with severe obesity undergoing metabolic and bariatric surgery (MBS), focusing on identifying micronutrient deficiencies and evaluating the effectiveness of supplementation in addressing these deficiencies.\u003c/p\u003e \u003cp\u003eThe deficiencies were identified in 81.2%, with statistically significant changes observed in 63.6% between baseline and follow-up.\u003c/p\u003e \u003cp\u003eResearch on the use of specialized preoperative multivitamins in MBS patients are not known. A systematic review by Gudzune et al. (2013), which included 21,345 eligible patients, reported that presurgical testing for micronutrient deficiencies was performed in fewer than 25% of cases. Over a 36-month follow-up, the prevalence of micronutrient deficiencies increased across all MBS types, ranging from 20\u0026ndash;88% [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMore recently, a systematic review by Tang et al. examined 27 studies addressing micronutrient repletion before MBS, assessing micronutrient status both pre- and post-MBS. The interventions varied widely, including chronic oral supplementation with multivitamins (n\u0026thinsp;=\u0026thinsp;21), megadoses of oral supplements (n\u0026thinsp;=\u0026thinsp;1), intramuscular injections (n\u0026thinsp;=\u0026thinsp;1), intravenous infusions (n\u0026thinsp;=\u0026thinsp;1), and combined oral and injectable approaches (n\u0026thinsp;=\u0026thinsp;3). The authors concluded that proactive micronutrient repletion schedules before MBS appear safe and feasible but noted variability in efficacy depending on the specific micronutrient, dose, duration, and delivery method (e.g., oral vs. infusion) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur results reported using OTC supplements prior to this study. However, this subgroup did not significantly reduce the prevalence of measured deficiencies or had a confounding effect on the changed micronutrient.\u003c/p\u003e \u003cp\u003eThe study group's active use of specialized supplementation (WLS Start) significantly reduced the prevalence of deficiency in 3 out of 22 micronutrients between baseline and the 3-month follow-up. However, deficiencies in 16 micronutrients persisted, potentially placing patients at a disadvantage when undergoing surgery. With 3 months, the study period was relatively short. Possibly, with longer use of preoperative supplementation, better blood serum values could have been reported. Since there were no hypervitaminosis, there is an opportunity for prolonged use.\u003c/p\u003e \u003cp\u003eIn the case of magnesium (-0.01) and albumin (-0.89), we observed a minimal yet statistically significant reduction in serum levels. However, this did not impact deficiency rates, as none of the patients experienced clinical deficiencies, rendering these changes clinically irrelevant. Conversely, phosphate levels showed a mean decrease of -0.12, accompanied by a significant increase in deficiency prevalence, rising from 3.8\u0026ndash;23.1%. The observed increase in phosphate deficiencies in our study may potentially be linked to the use of ascorbic acid supplementation over the three-month period. Ascorbic acid, particularly in higher doses, can contribute to metabolic acidosis, which in turn may initially result in transiently elevated serum phosphate levels. However, the resulting acidosis can lead to a compensatory increase in renal phosphate excretion over time, ultimately reducing serum phosphate concentrations [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This mechanism aligns with our findings of decreased phosphate levels and increased deficiency prevalence, but further research is needed to confirm this hypothesis and evaluate the extent to which ascorbic acid supplementation may contribute to phosphate imbalances in this population.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eImpact of Fewer Deficiencies in Vitamin D, Iron, and Folic Acid\u003c/h2\u003e \u003cp\u003eReducing deficiencies in vitamin D, iron, and folic acid is crucial for MBS patients due to their essential roles in metabolic and physiological processes.\u003c/p\u003e \u003cp\u003eVitamin D deficiency, common in severe obesity and often exacerbated after MBS, plays a critical role in calcium absorption, bone health, immune function, and reducing systemic inflammation. A recent systematic review by Giustina et al. (2023) emphasized the importance of assessing vitamin D levels both preoperatively and postoperatively in all patients undergoing MBS. The review further recommends high-dose vitamin D supplementation pre- and postoperative, irrespective of the surgical procedure type, to address these deficiencies effectively [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAddressing this deficiency preoperatively minimizes the risks of postoperative complications such as bone demineralization and poor wound healing.\u003c/p\u003e \u003cp\u003eIron deficiency, linked to anemia and fatigue, is often exacerbated by reduced intake and malabsorption after surgery. Adequate iron levels support hemoglobin synthesis and oxygen transport, which are essential for healing. Similarly, folic acid is vital for DNA synthesis, red blood cell production, and tissue repair, reducing risks of megaloblastic anemia and supporting recovery and support rapid cell turnover required during tissue repair after surgery.\u003c/p\u003e \u003cp\u003eIn our study, iron had the most pronounced effect among women with a BMI\u0026thinsp;\u0026gt;\u0026thinsp;50, decreasing from 43.5\u0026ndash;17.4%. Studies suggested that elevated body weight may impact endometrial function, contributing to heavier menstrual blood loss. While the relationship between obesity and endometrial cancer is widely recognized, there is limited knowledge regarding the frequency of heavy menstrual bleeding among obese adolescents and adult women [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications of Improved Nutritional Status\u003c/h2\u003e \u003cp\u003eFewer deficiencies and higher levels of key micronutrients underscore the importance of tailored preoperative supplementation in optimizing nutritional status before MBS. Adequate levels of vitamin D, iron, folic acid, vitamin B1, and zinc help mitigate pre-existing deficiencies that can impair recovery and long-term outcomes. Improved preoperative nutrition not only enhances surgical recovery but also prepares patients for better management of postoperative deficiencies, often exacerbated by altered gastrointestinal physiology.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eRationale for Preoperative Supplementation\u003c/h2\u003e \u003cp\u003eMore evidence is necessary to support the effectiveness of specialized preoperative multivitamins tailored to MBS patients in preventing postoperative deficiencies.\u003c/p\u003e \u003cp\u003eHowever, many deficiencies are already present preoperatively due to limited dietary diversity, dilution effects from increased serum volume, expanded fat and muscle mass, and conditions like liver steatosis, diabetes, and chronic inflammation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26 CR27 CR28 CR29 CR30\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. If unaddressed, these deficiencies are likely to worsen postoperatively due to reduced nutrient intake and absorption.\u003c/p\u003e \u003cp\u003ePreoperative supplementation addressing existing deficiencies can potentially reduce risks during recovery, establish adherence to supplementation regimens, and optimize outcomes by supporting immune function wound healing, and may have a protective effect against hair loss with levels of zinc, folic acid, ferritin, and protein intake that closely associated with the risk of hair loss, highlighting the importance of optimizing these factors before surgery, and overall metabolic health.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eKnown and Potential Risks and Benefits\u003c/h2\u003e \u003cp\u003eThe risks of supplementation in this study are minimal, as the intervention occurs entirely before MBS. The primary risk remains the development of micronutrient deficiencies, which this study aims to mitigate through specialized multivitamins. Although dosages are relatively high, they remain within safe limits and are well-tolerated by patients with severe obesity due to dilution effects, increased serum volume, and altered metabolism linked to obesity-related associated medical problems.\u003c/p\u003e \u003cp\u003eThe three-month supplementation period was a conservative approach. No cases of hypervitaminosis were observed, supporting the safety of this approach, while still being able to improve blood serum values before surgery.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations that should be considered. A washout period was not applied, meaning that the effects of any prior supplementation or dietary habits could not be fully isolated from the intervention. Despite this, deficiencies were still present preoperatively in many participants, underscoring the need for tailored nutritional optimization prior to MBS.\u003c/p\u003e \u003cp\u003eAdditionally, while the preoperative setting was particularly relevant for identifying and addressing deficiencies, the absence of a true control group limits the ability to attribute observed changes solely to the intervention. Potential confounding factors, such as differences in metabolism, associated medical problems, or baseline nutritional statuses, may also have influenced the results, since we could not correct for all the factors due to low incidence.\u003c/p\u003e \u003cp\u003eThe relatively short study duration of three months may not fully capture the long-term implications of preoperative supplementation, particularly for deficiencies that take longer to resolve or have extended effects on surgical outcomes.\u003c/p\u003e \u003cp\u003eFinally, the study\u0026rsquo;s focus on a specific preoperative bariatric population in a single healthcare setting may limit the generalizability of findings to other populations or healthcare systems.\u003c/p\u003e \u003cp\u003eThese limitations highlight the need for future studies with robust designs, including randomized controlled trials, washout periods, longer follow-up durations, and more detailed monitoring of adherence and external supplement use, to validate these findings and better understand the long-term benefits of preoperative supplementation.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the prevalence of micronutrient deficiencies in patients with obesity and demonstrates the effectiveness of preoperative specialized multivitamin supplementation in reducing key deficiencies, including iron, folic acid, and vitamin D. Significant improvements in serum levels of critical nutrients such as vitamin B1 and zinc further underscore the benefits of tailored preoperative supplementation.\u003c/p\u003e \u003cp\u003eFuture research is warranted to address residual deficiencies in other micronutrient and evaluate long-term outcomes associated with prolonged pre-operative supplementation. Studies should also assess the effects after MBS and determine the burden of postoperative deficiencies after preoperative supplement use.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical Approval:\u003c/h2\u003e\n\u003cp\u003eAll procedures involving human participants were performed according to the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003ch2\u003eInformed Consent:\u003c/h2\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003ch2\u003eConflicts of interest:\u003c/h2\u003e\n\u003cp\u003eAll the authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eJS and BT wrote manuscriptBT analyzed dataFB and EA supervisedAll authors reviewed the manuscript, provided feedback and approved.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eData can be requested with the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGuh DP, Zhang W, Bansback N, Amarsi Z, Birmingham CL, Anis AH. The incidence of co-morbidities related to obesity and overweight: A systematic review and meta-analysis. BMC Public Health. 2009;9:88. \u003c/li\u003e\n\u003cli\u003eKhaodhiar L, McCowen KC, Blackburn GL. Obesity and its comorbid conditions. Clinical Cornerstone. 1999;2:17\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eBremner J, Moazzami K, Wittbrodt M, Nye J, Lima B, Gillespie C, et al. Diet, Stress and Mental Health. Nutrients. 2020;12:2428. \u003c/li\u003e\n\u003cli\u003eCottam S, Cottam D, Cottam A, Zaveri H, Surve A, Richards C. The Use of Predictive Markers for the Development of a Model to Predict Weight Loss Following Vertical Sleeve Gastrectomy. OBES SURG. 2018;28:3769\u0026ndash;74. \u003c/li\u003e\n\u003cli\u003eDouketis JD, Macie C, Thabane L, Williamson DF. Systematic review of long-term weight loss studies in obese adults: clinical significance and applicability to clinical practice. Int J Obes. 2005;29:1153\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eIkramuddin S, Korner J, Lee W-J, Connett JE, Inabnet WB, Billington CJ, et al. Roux-en-Y Gastric Bypass vs Intensive Medical Management for the Control of Type 2 Diabetes, Hypertension, and Hyperlipidemia: The Diabetes Surgery Study Randomized Clinical Trial. JAMA. 2013;309:2240. \u003c/li\u003e\n\u003cli\u003eMohapatra S, Gangadharan K, Pitchumoni CS. Malnutrition in obesity before and after bariatric surgery. Disease-a-Month. 2020;66:100866. \u003c/li\u003e\n\u003cli\u003eLupoli R, Lembo E, Saldalamacchia G, Avola CK, Angrisani L, Capaldo B. Bariatric surgery and long-term nutritional issues. WJD. 2017;8:464. \u003c/li\u003e\n\u003cli\u003eVan Rutte PWJ, Aarts EO, Smulders JF, Nienhuijs SW. Nutrient Deficiencies Before and After Sleeve Gastrectomy. OBES SURG. 2014;24:1639\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eMechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, et al. Clinical Practice Guidelines For The Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures \u0026ndash; 2019 Update: Cosponsored By American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society For Metabolic \u0026amp; Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Endocrine Practice. 2019;25:1\u0026ndash;75. \u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Kane M, Parretti HM, Pinkney J, Welbourn R, Hughes CA, Mok J, et al. British Obesity and Metabolic Surgery Society Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery\u0026mdash;2020 update. Obesity Reviews. 2020;21:e13087. \u003c/li\u003e\n\u003cli\u003eParrott J, Frank L, Rabena R, Craggs-Dino L, Isom KA, Greiman L. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients. Surgery for Obesity and Related Diseases. 2017;13:727\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eDogan K, Aarts EO, Koehestanie P, Betzel B, Ploeger N, De Boer H, et al. Optimization of Vitamin Suppletion After Roux-En-Y Gastric Bypass Surgery Can Lower Postoperative Deficiencies: A Randomized Controlled Trial. Medicine. 2014;93:e169. \u003c/li\u003e\n\u003cli\u003eHeusschen L, Berendsen AAM, Cooiman MI, Deden LN, Hazebroek EJ, Aarts EO. Optimizing Multivitamin Supplementation for Sleeve Gastrectomy Patients. OBES SURG. 2021;31:2520\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eHeusschen L, Schijns W, Ploeger N, Deden LN, Hazebroek EJ, Berends FJ, et al. The True Story on Deficiencies After Sleeve Gastrectomy: Results of a Double-Blind RCT. OBES SURG. 2020;30:1280\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eHoman J, Schijns W, Aarts EO, van Laarhoven CJHM, Janssen IMC, Berends FJ. An optimized multivitamin supplement lowers the number of vitamin and mineral deficiencies three years after Roux-en-Y gastric bypass: a cohort study. Surgery for Obesity and Related Diseases. 2016;12:659\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eSmelt HJM, Van Loon S, Pouwels S, Boer A-K, Smulders JF, Aarts EO. Do Specialized Bariatric Multivitamins Lower Deficiencies After Sleeve Gastrectomy? OBES SURG. 2020;30:427\u0026ndash;38. \u003c/li\u003e\n\u003cli\u003eSchijns W, Schuurman LT, Melse-Boonstra A, Van Laarhoven CJHM, Berends FJ, Aarts EO. Do specialized bariatric multivitamins lower deficiencies after RYGB? Surgery for Obesity and Related Diseases. 2018;14:1005\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eAl-Mutawa A, Al-Sabah S, Anderson AK, Al-Mutawa M. Evaluation of Nutritional Status Post Laparoscopic Sleeve Gastrectomy\u0026mdash;5-Year Outcomes. OBES SURG. 2018;28:1473\u0026ndash;83. \u003c/li\u003e\n\u003cli\u003eErnst B, Thurnheer M, Schmid SM, Schultes B. Evidence for the Necessity to Systematically Assess Micronutrient Status Prior to Bariatric Surgery. OBES SURG. 2009;19:66\u0026ndash;73. \u003c/li\u003e\n\u003cli\u003eFrame‐Peterson LA, Megill RD, Carobrese S, Schweitzer M. Nutrient Deficiencies Are Common Prior to Bariatric Surgery. Nut in Clin Prac. 2017;32:463\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eKrzizek E-C, Brix JM, Herz CT, Kopp HP, Schernthaner G-H, Schernthaner G, et al. Prevalence of Micronutrient Deficiency in Patients with Morbid Obesity Before Bariatric Surgery. OBES SURG. 2018;28:643\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eMoiz\u0026eacute; V, Deulofeu R, Torres F, De Osaba JM, Vidal J. Nutritional Intake and Prevalence of Nutritional Deficiencies Prior to Surgery in a Spanish Morbidly Obese Population. OBES SURG. 2011;21:1382\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003ePeterson LA, Cheskin LJ, Furtado M, Papas K, Schweitzer MA, Magnuson TH, et al. Malnutrition in Bariatric Surgery Candidates: Multiple Micronutrient Deficiencies Prior to Surgery. OBES SURG. 2016;26:833\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eDamms-Machado A, Weser G, Bischoff SC. Micronutrient deficiency in obese subjects undergoing low calorie diet. Nutr J. 2012;11:34. \u003c/li\u003e\n\u003cli\u003eTargher G, Bertolini L, Scala L, Cigolini M, Zenari L, Falezza G, et al. Associations between serum 25-hydroxyvitamin D3 concentrations and liver histology in patients with non-alcoholic fatty liver disease. Nutrition, Metabolism and Cardiovascular Diseases. 2007;17:517\u0026ndash;24. \u003c/li\u003e\n\u003cli\u003ePalomer X, Gonz\u0026aacute;lez‐Clemente JM, Blanco‐Vaca F, Mauricio D. Role of vitamin D in the pathogenesis of type 2 diabetes mellitus. Diabetes Obesity Metabolism. 2008;10:185\u0026ndash;97. \u003c/li\u003e\n\u003cli\u003eCepeda-Lopez AC, Aeberli I, Zimmermann MB. Does Obesity Increase Risk for Iron Deficiency? A Review of the Literature and the Potential Mechanisms. International Journal for Vitamin and Nutrition Research. 2010;80:263\u0026ndash;70. \u003c/li\u003e\n\u003cli\u003eAusk KJ, Ioannou GN. Is Obesity Associated With Anemia of Chronic Disease? A Population‐based Study. Obesity. 2008;16:2356\u0026ndash;61. \u003c/li\u003e\n\u003cli\u003eKahn SE, Hull RL, Utzschneider KM. Mechanisms linking obesity to insulin resistance and type 2 diabetes. Nature. 2006;444:840\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eKumar R, Mal K, Razaq MK, Magsi M, Memon MK, Memon S, et al. Association of Leptin With Obesity and Insulin Resistance. Cureus [Internet]. 2020 [cited 2024 Dec 19]; Available from: https://www.cureus.com/articles/47751-association-of-leptin-with-obesity-and-insulin-resistance\u003c/li\u003e\n\u003cli\u003eTang X, Reidlinger DP, Crichton M, Craggs-Dino L, Fayet-Moore F, Marshall S. Preoperative Micronutrient Repletion Strategies in Metabolic and Bariatric Surgery: A Systematic Review. Journal of the Academy of Nutrition and Dietetics. 2024;S2212267224008645. \u003c/li\u003e\n\u003cli\u003eKamal FA, Fernet LY, Rodriguez M, Kamal F, Da Silva NK, Kamal OA, et al. Nutritional Deficiencies Before and After Bariatric Surgery in Low- and High-Income Countries: Prevention and Treatment. Cureus [Internet]. 2024 [cited 2024 Nov 27]; Available from: https://www.cureus.com/articles/233173-nutritional-deficiencies-before-and-after-bariatric-surgery-in-low--and-high-income-countries-prevention-and-treatment\u003c/li\u003e\n\u003cli\u003eGudzune KA, Huizinga MM, Chang H-Y, Asamoah V, Gadgil M, Clark JM. Screening and Diagnosis of Micronutrient Deficiencies Before and After Bariatric Surgery. OBES SURG. 2013;23:1581\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eSalcedo-Betancourt JD, Moe OW. The Effects of Acid on Calcium and Phosphate Metabolism. IJMS. 2024;25:2081. \u003c/li\u003e\n\u003cli\u003eGiustina A, Di Filippo L, Facciorusso A, Adler RA, Binkley N, Bollerslev J, et al. Vitamin D status and supplementation before and after Bariatric Surgery: Recommendations based on a systematic review and meta-analysis. Rev Endocr Metab Disord. 2023;24:1011\u0026ndash;29. \u003c/li\u003e\n\u003cli\u003eMcDonald ME, Bender DP. Endometrial Cancer. Obstetrics and Gynecology Clinics of North America. 2019;46:89\u0026ndash;105. \u003c/li\u003e\n\u003cli\u003eCalle EE. Overweight, Obesity, and Mortality from Cancer in a Prospectively Studied Cohort of U.S. Adults. The new england journal of medicine. 2003; \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eChange in blood level before and after 3 months of use of the supplement.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eMean change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e95% Confidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eIron\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[1.12; 3.12]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eMagnesium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[-0.03; 0.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.023\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eVitamin A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[-0.03; 0.05]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.579\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eVitamin E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[-0.68; 0.97]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.726\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eVitamin K1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[-0.01; 0.22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eVitamin K2 (MK4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[-0.14; 0.07]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.528\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eVitamin K2 (MK7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[-0.08; 0.11]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.747\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eCopper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[-0.61; 0.43]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.744\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eZinc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e61.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[21.98; 100.41]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e2.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[0.02; 4.30]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.048\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eHemoglobin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[0.11; 0.63]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eHematocrit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[0.01; 0.02]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eMCV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[0.54; 1.59]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eCalcium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[0.04; 0.09]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003ePhosphate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[-0.17; -0.07]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eAlbumin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[-1.42; -0.35]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eFerritin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-8.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[-17.10; 0.77]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eFolic Acid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e10.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[9.54; 12.29]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eVitamin B1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e9.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[4.85; 15.03]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eVitamin B12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-13.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[-45.56; 18.76]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.410\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eVitamin D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e11.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[9.38; 12.76]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003eParathyroid Hormon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-6.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e[-12.02; -1.68]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMCV = Mean Corpuscular Volume, CRP= C-Reactive Protein\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 Change of deficiencies\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"629\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProportion Baseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProportion Follow-UP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eIron\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e29/95 (30.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e15/95 (15.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eMagnesium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e3/95 (3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e3/95 (3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eVitamin A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e2/99 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e5/99 (5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.375\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eVitamin E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e1/99 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e0/99 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eVitamin K1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e3/98 (3.1%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e7/98 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.219\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eVitamin K2 (MK4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e0/98 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e0/98 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eVitamin K2 (MK7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e3/98 (3.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e8/98 (8.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.180\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eCopper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e1/99 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e1/99 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eZinc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e2/92 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e4/92 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.688\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e25/59 (42.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e19/59 (32.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.146\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eHemoglobin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e3/99 (3.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e0/99 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.250\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eHematocrit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e2/99 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e0/99 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.500\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eMCV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e16/99 (16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e11/99 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eCalcium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e5/95 (5.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e1/95 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003ePhosphate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e2/96 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e19/96 (19.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eAlbumin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e15/96 (15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e22/96 (22.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eFerritin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e2/96 (2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e0/96 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.500\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eFolic Acid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e39/94 (41.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e7/94 (7.4%) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eVitamin B1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e0/95 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e0/95 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003en.a.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eVitamin B12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e0/95 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e1/95 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eVitamin D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e71/80 (88.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e40/80 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 200px;\"\u003e\n \u003cp\u003eParathyroid Hormon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 171px;\"\u003e\n \u003cp\u003e0/96 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 169px;\"\u003e\n \u003cp\u003e1/96 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMCV = Mean Corpuscular Volume, CRP= C-Reactive Protein\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eTable 3: Correcting for confounding factors BMI \u0026lt; 50 and Male gender*\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"left\" dir=\"ltr\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"609\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eMean change\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e95% Confidence Interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eIron\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.39; 2.94]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.128\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eMagnesium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.03; 0.01]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.261\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.10; 0.06]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.671\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-2.73; 0.09]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin K1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.16; 0.21]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.770\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin K2 (MK4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.36; 0.13]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.341\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin K2 (MK7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.23; 0.04]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.153\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCopper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.79; 1.14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.714\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eZinc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e41.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-42.89;124.97]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.324\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;2.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.29; 6.11]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eHemoglobin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.08; 0.42]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.169\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eHematocrit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.00; 0.01]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.240\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eMCV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.44; 1.33]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.312\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCalcium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 0.03; 0.09]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003ePhosphate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.28;-0.08]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eAlbumin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-1.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-2.42;-0.85]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFerritin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-4.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-27.07;18.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.682\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFolic Acid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e10.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 7.67;12.82]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin B1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;8.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 2.49;14.99]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin B12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-37.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-93.48;18.68]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.181\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e11.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 7.76;14.33]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eParathyroid Hormon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-4.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-13.48; 4.61]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.323\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eCorrecting for confounding factors BMI \u0026gt; 50 and Male gender*\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"left\" dir=\"ltr\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"609\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eMean change\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e95% Confidence Interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eIron\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.05; 4.07]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eMagnesium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.07; 0.01]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.183\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.11; 0.15]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.760\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-1.36; 2.98]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.420\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin K1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.04; 0.38]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin K2 (MK4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.30; 0.13]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.375\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin K2 (MK7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.13; 0.20]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.613\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCopper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.65; 0.89]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.733\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eZinc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e149.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[47.84;250.56]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e0.009\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;1.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.39; 4.34]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.088\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eHemoglobin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.22; 0.64]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.296\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eHematocrit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.03; 0.02]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.605\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eMCV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-1.21; 1.81]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.664\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCalcium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.03; 0.12]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.188\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003ePhosphate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.28; 0.02]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eAlbumin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-2.49; 1.01]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.363\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFerritin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-26.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-67.42;13.82]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFolic Acid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e11.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 6.74;15.34]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin B1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;7.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-7.31;21.63]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.292\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin B12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e24.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-55.37;103.77]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.509\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e14.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 8.42;20.18]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eParathyroid Hormon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-2.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-21.52;16.84]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.789\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp dir=\"LTR\"\u003e\u003cem\u003e*Other potential confounding variables, including BMI as a continuous variable, did not significantly alter the observed outcomes in terms of changes in deficiencies.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003eMCV = Mean Corpuscular Volume, CRP= C-Reactive Protein\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eTable 4: Correcting for confounding factors BMI \u0026lt; 50 and Women gender*\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"left\" dir=\"ltr\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"609\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eMean change\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e95% Confidence Interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eIron\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;1.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.06; 3.43]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eMagnesium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.03; 0.01]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.382\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.02; 0.09]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.234\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.78; 1.49]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.533\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin K1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.06; 0.34]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.164\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin K2 (MK4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.11; 0.23]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.454\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin K2 (MK7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.09; 0.03]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.297\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCopper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.71; 0.69]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.976\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eZinc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e34.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-15.60;83.66]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.173\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-3.58; 4.17]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.876\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eHemoglobin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 0.16; 1.28]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eHematocrit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 0.01; 0.02]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eMCV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;2.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 1.45; 3.18]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCalcium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 0.02; 0.10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003ePhosphate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.22;-0.08]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eAlbumin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-1.70; 0.17]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFerritin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-6.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-15.60; 3.38]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.200\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFolic Acid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e10.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 8.62;13.22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin B1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e19.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[11.29;28.60]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin B12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-30.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-72.09;11.71]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.153\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;7.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 4.06;10.46]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eParathyroid Hormon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-5.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-12.95; 1.37]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.110\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eCorrecting for confounding factors BMI \u0026gt; 50 and Women gender*\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"left\" dir=\"ltr\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"609\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eMean change\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e95% Confidence Interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eIron\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;3.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 1.37; 5.25]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eMagnesium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.04; 0.01]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.305\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.03; 0.07]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.447\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.92; 3.06]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.278\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin K1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.10; 0.33]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.274\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin K2 (MK4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.12; 0.17]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.774\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin K2 (MK7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.16; 0.44]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.353\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCopper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-1.80; 0.76]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.408\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eZinc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e40.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-42.83;124.06]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.322\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;3.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 1.49; 4.99]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eHemoglobin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 0.16; 0.76]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eHematocrit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 0.01; 0.03]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eMCV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 0.42; 2.33]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e0.007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eCalcium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 0.05; 0.12]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003ePhosphate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-0.13; 0.06]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.515\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eAlbumin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-1.24; 0.62]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.497\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFerritin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-11.05; 8.88]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.823\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFolic Acid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e11.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 9.23;13.80]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin B1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;6.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-4.44;17.22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.234\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin B12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-3.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-84.87;78.70]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.938\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eVitamin D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e11.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[ 9.31;13.69]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp dir=\"LTR\"\u003eParathyroid Hormon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp dir=\"LTR\"\u003e-12.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp dir=\"LTR\"\u003e[-24.02;-1.69]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp dir=\"LTR\"\u003e\u003cem\u003e*Other potential confounding variables, including BMI as a continuous variable, did not significantly alter the observed outcomes in terms of changes in deficiencies.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003eMCV = Mean Corpuscular Volume, CRP=\u0026nbsp;C-Reactive Protein\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"metabolic bariatric surgery, micronutrient deficiencies, multivitamin supplementation, preoperative care, obesity","lastPublishedDoi":"10.21203/rs.3.rs-5918872/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5918872/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nMost patients achieve successful weight loss following metabolic bariatric surgery (MBS), but they face an increased risk of micronutrient deficiencies due to altered gastrointestinal physiology and dietary restrictions. This study evaluated the impact of a specialized multivitamin on blood serum levels before MBS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nA prospective, within-patient comparison trial was conducted between January and July 2023 at a large bariatric clinic. Differences in serum micronutrient levels between baseline and the three-month follow-up were assessed, along with changes in the prevalence of micronutrient deficiencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nOf 120 patients recruited, 99 (82.5%) completed the three-month follow-up. Significant changes were observed in 14 of 22 serum parameters (63.6%). Eleven parameters, including iron, vitamin K1, zinc, CRP, hemoglobin, hematocrit, MCV, calcium, folic acid, vitamin B1, and vitamin D, showed significant increases (p \u0026lt; 0.001). Conversely, magnesium, phosphate, and albumin levels significantly decreased (p \u0026lt; 0.001). Among 22 parameters, deficiencies were identified in 18 (81.8%), with prevalence rates ranging from 1.0% (copper) to 88.8% (vitamin D). After three months, significant reductions in deficiency prevalence were observed for iron, folic acid, and vitamin D. However, phosphate deficiency increased significantly, from 2.1% to 19.8% (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003cbr\u003e\nMicronutrient deficiencies are prevalent in patients with obesity. Preoperative specialized multivitamin supplementation effectively reduces key deficiencies, particularly in iron, folic acid, and vitamin D. Future research should address residual deficiencies and evaluate long-term outcomes of prolonged supplementation.\u003c/p\u003e","manuscriptTitle":"Assessment of Preoperative Multivitamin Use on the Impact on Micronutrient Deficiencies in Metabolic Bariatric Surgery Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-03 07:19:25","doi":"10.21203/rs.3.rs-5918872/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-14T19:09:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-11T22:34:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-11T14:31:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190206934421378296647777902050608325723","date":"2025-02-05T07:22:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204679043722284487819856573347442998630","date":"2025-02-05T00:16:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-02-04T15:31:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-04T15:15:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-30T08:07:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Obesity Surgery","date":"2025-01-28T12:56:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7dcaa50f-d30f-4127-8aef-cf73b9f6347e","owner":[],"postedDate":"February 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-14T16:08:42+00:00","versionOfRecord":{"articleIdentity":"rs-5918872","link":"https://doi.org/10.1007/s11695-025-07853-1","journal":{"identity":"obesity-surgery","isVorOnly":false,"title":"Obesity Surgery"},"publishedOn":"2025-04-08 16:05:10","publishedOnDateReadable":"April 8th, 2025"},"versionCreatedAt":"2025-02-03 07:19:25","video":"","vorDoi":"10.1007/s11695-025-07853-1","vorDoiUrl":"https://doi.org/10.1007/s11695-025-07853-1","workflowStages":[]},"version":"v1","identity":"rs-5918872","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5918872","identity":"rs-5918872","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}