Hair Loss Among Bariatric Surgery Patients

| November 11, 2010

by Silvia Leite Faria, MS; orlando Pereira Faria, MD; Renato Diniz Lins, MD; and Heloisa Rodrigues de Gouvea

Ms. Faria is a nutritionist from Gastrocirurgia de Brasília, Brasília, Brazil and is also in private practice; Dr. Pereira Faria is a chief surgeon, Gastrocirurgia de Brasília, Brasília, Brazil; Dr. Lins is a medical doctor from Gastrocirurgia de Brasília, Brasília; and Ms. Rodrigues de Gouvêa is a nutritionist and trainee from Gastrocirurgia de Brasília, Brasília, Brazil.

Financial Disclosure: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2010;7(11):18–20Abstract
The best treatment available for morbid obesity is bariatric surgery. This procedure, however, may lead to nutritional deficiencies due to reduced food intake, the scope of the surgery itself, rapid weight loss, inadequate absorption of nutrients, and the lack of adherence to supplement programs. This article provides an extensive review of current literature relating to hair loss in bariatric patients. A description of current methods of treatments is included.

Introduction
Morbid obesity is a refractory disease related to diets and medication.[1] Bariatric surgery is seen as the only effective treatment in such cases.[2,3] Currently, surgical treatment of obesity is divided into the following two groups: 1) restrictive surgical procedures and 2) mixed surgical procedures, with the restrictive factor described as having more or less of a disabsorptive component. Malnutrition is a risk associated with all bariatric procedures, and hair loss is a frequent complaint that may be associated with nutritional factors, such as lower caloric intake and/or lower absorption of important nutrients for the maintenance and growth of hair.[4]

Hair loss can seriously impact the lives of individuals and may lead to anxiety, low self-esteem, psychosocial problems, and depression. As a consequence, hair loss can be a stress factor for this population.[5,6] The aim of this article is to provide a comprehensive review of the literature on hair loss in patients undergoing bariatric surgery and provide clinicians with a description of the causes and recommended treatments.

Literature Search
A broad review of the Medline and Pubmed databases for articles published between the years 1983 and 2009 was conducted, selecting articles related to humans. The key words used in the electronic search included the following: hair loss replacement systems, bariatric surgery, alopecia, nutritional deficiencies, biotin, zinc, iron, vitamin B12, and essential fatty acids.
A total of 41 articles were found, of which 30 were selected. Among these, 15 were reviews, four compilations of guidelines, eight original articles, two clinical case studies, and one statement of the original article. Articles that addressed other causes of hair loss, outside of the area of nutrition, were excluded. Besides scientific articles, 10 chapters from books and one monograph were also examined.

Causes and Treatments of Hair Loss
The most likely causes of hair loss were found to be related to age, sex, disease, and genetic factors. It is therefore important to gather history of each patient who presents with hair loss regarding any current illness, recent illnesses, auto-immune diseases, family history of hair loss, food intake, medications, and the use of cosmetics harmful to the hair.[5]

Hair follicles have two stages: the anagen (hair growth) stage and the telogen (inactive) phase. All hairs begin their cycle in the anagen phase, grow for a period of time and move into the telogen phase, which lasts about 100 to 120 days. Then the hair falls out. This process, if accelerated, is called telogen effluvium and is the cause of hair loss in bariatric patients.[7]

The causes for telogen effluvium are drugs, surgery, fever, childbirth, diseases related to the thyroid, such as hyper- and hypothyroidism, rapid weight loss, anorexia, low protein intake, iron and zinc deficiency, and toxicity of heavy metals.[4–6] In bariatric surgery, telogen effluvium may be associated with patients who are nonadherent to the supplement program or who have had rapid weight loss, difficulty in feeding themselves, or have poor dietary habits (e.g., food intolerances, especially with protein sources).[4]

Hair loss after bariatric surgery often occurs between the third and sixth month after surgery and can last 6 to 12 months or more. In the first six months, this framework can be reversed without intervention, although there is no consensus on treatment for these cases.[8] After six months postsurgery, nutritional causes are involved in hair loss.4 In both cases, there is no harm to the follicle, so the hair can grow back.[9]

The nutrients possibly related to hair loss are protein, iron, zinc, essential fatty acids, vitamin B12, and biotin.

Protein. Protein-energy deficiency is associated with increased hair loss.[4,5] A protein deficiency can manifest itself through the reduction of hepatic proteins including albumin, loss of muscle mass, asthenia (weakness), and alopecia.[10]

Among the factors contributing to protein deficiency are the following: insufficient chewing, since food needs to be better digested in order to compensate for the mechanical barrier imposed by the weight loss surgery (WLS);[10] reduction of the availability of pepsin, renin, and hydrochloric acid due to the isolation of the distal stomach, thus limiting protein digestion;[11] anorexia; frequent episodes of vomiting; diarrhea; food intolerances; depression; fear of weight regain; abuse of alcohol or drugs; and socioeconomic status. Thus, all patients after surgery are at risk of developing protein deficiency in connection with restrictive and disabsorptive procedures.[10]

Patients who undergo Roux-en-Y gastric bypass (RYGB) usually have a low-calorie diet of 500 to 800kcal per day. Despite a calorie-protein increase during the first year, such intakes remain at insufficient levels.[11]

According to Marcason,[12] the minimum recommended protein intake for bariatric patients is 60g per day, with emphasis on proteins of high biological value (HBV).[12,13] However, in general, the recommended intake is 80g of protein for women and 100g for men per day or 1.5g/kg ideal weight.[11,14] In cases of more disabsorptive surgery, such as biliopancreatic diversion (BPD), there is a raised malabsorption of protein. It is therefore recommended that patients intake at least 90g of protein.[15]

It is believed that a reduction in the availability of protein can cause thinning of the hair, difficulty in the normal hair growth process, and diffuse alopecia.[16] In relation to essential amino acids, their deficiency can affect growth and differentiation of hair, since they compose 27 percent of the protein content of hair.[16]

Among all essential amino acids, a deficiency of L-lysine, in particular, can contribute to hair loss while “full body supplies of L-lysine” improve hair growth after periods of decline and improve the levels of iron in the body. Its bioavailable form is primarily found in fish, meat and eggs and a decrease in consumption of these foods may cause a negative balance of this amino acid affecting hair growt.[17] Thus, a supplementation of 1.5–2g of L-lysine is recommended.[4]

Iron. Iron is the micronutrient most related to hair loss. Its deficiency, in cases without anemia, was related to hair loss for the first time in the early 60s.[18]

In WLS, specifically RYGB, a decreased intake of foods rich in iron occur. Decreased absorption also occurs, since iron absorption is more efficient in the duodenum and adjacent parts of the jejunum, which are isolated in RYGB. Concomitant with this is a decrease in the reduction process of iron to its most bioavailable form, due to lower production of hydrochloric acid.[10]

For women, iron deficiency is more prevalent among those who are in a fertile age, and serum ferritin levels below 40Ìg are strongly associated with hair loss.[4,10,19] Kantor et al[20] related low concentrations of serum ferritin and hemoglobin with hair loss. Researchers have observed in cases of telogen effluvium that a significant number of people respond well when treated with iron. In a study by Rushton et al,[21] researchers correlated low serum ferritin with hair loss among women treatment for six months with daily supplementation of 72mg of iron, and 1.5g of L-lysine decreased the percentage of hairs in the telogen phase as well as the hair loss in 39 percent and increased levels of serum ferritin.
Iron supplementation  recommended for patients with hair loss is 320mg of ferrous fumarate or gluconate or 65mg of elemental iron twice a day, with a volume of approximately 25 percent ingested  being absorbed.[18,22] Parenteral infusion must be prescribed for bariatric patients who are refractory to iron supplementation or have anemia related to iron deficiency or hemoglobin serum levels below 11g/dL.[23]

Biotin. A biotin deficiency can cause depigmentation of hair and diffuse alopecia, since this vitamin plays an important role in the development of the hair follicles.[16,24] It is believed that supplementation or topical use of biotin can prevent hair loss and accelerate growth after a period of decline.[4]

Such biotin deficiency related to hair loss was initially observed in patients undergoing total parenteral nutrition (TPN) without prolonged biotin. After starting their supplementation of biotin, patients undergoing TPN improved rapidly in terms of hair loss.[9]

In 2001, Bruginsky[25] evaluated 118 patients and found that 17 percent of women reported alopecia due to surgery. Also, these women presented with inadequate intake of several nutrients, such as folic acid, retinol, fiber, vitamin C, and biotin. In a period of 30 days, the growth of hair in 100 percent of cases was observed after supplementation of 100mcg of biotin and other nutrients, such as folic acid, inositol, choline, B complex, that are known to boost the action of biotin.

One must consider that the daily 1 to 2mg of biotin may provide clinical support to cases of hair loss not responding to other types of treatment.[17] Daily consumption of 2.5mg was established as a safe limit of intake of biotin, the no observed adverse effects level (NOAEL).[24]

Zinc. Zinc has several functions and is an important factor for growth and development of hair. Its uptake can be assisted by the presence of glucose and amino acids in the intestinal tract and its deficiency can cause growth retardation, diarrhea, alopecia, skin lesions, and loss of appetite, among others problems.[26,27]

In cases of hair loss, a supplementation of 15mg/day of zinc chelate is recommended.[28] The upper level is 40mg of zinc; a supplementation of 50mg over long periods can lead to copper deficiency.[10]

Essential fatty acids. Some studies have observed deficiency of essential fatty acids (linoleic and linolenic acids) in patients after RYGB and adjustable gastric banding (AGB) since these procedures alter the digestion of lipids and, as a consequence, the uptake of essencial fatty acids.[10,15,29] In relation to BPD and duodenal switch (DS), only 28 percent of ingested fat is absorbed.[29]

In patients with biotin deficiency, levels of linoleic acid lower than normal were observed. In cases of functional deficiency of biotin (due to lack of carboxylase) associated to hair loss, supplementation with polyunsaturated fatty acids may reduce this symptom, suggesting that hair loss can be caused by impairment of elongation of polyunsaturated fatty acids as a result of reduced activity of acetyl-CoA carboxylase.[24]

For patients post-RYGB, flaxseed oil (15mL) is recommended.[15] The recommended dose of linolenic acid is 0.5 to 1.0 percent of energy intake and linoleic acid is from 3 to 5 percent. These amounts can be reached with two capsules of 1g of linseed oil and two tablespoons of extra virgin olive oil.[22]

Vitamin B12. It is known that the human body has stores of vitamin B12, on average, for 3 to 5 years dependent on one’s daily intake. However, since patients undergoing RYGB have lower production of hydrochloric acid and of the intrinsic factor, both of which are needed for its absorption in the terminal ileum, there may be deficiency of vitamin B12 if the supplementation is not adequate. Thus, RYGB patients have digestion, release, and absorption difficulties of vitamin B12.[10]

Brolin et al[30] observed deficiency of vitamin B12 in patients six months after bariatric surgery, becoming more common after one year.[10] Deficiency in B12 may alter the pigmentation of hair. This alteration can be reversed with B12 supplementation.[16] The supplementation of vitamin B12 must be at least 350 to 500Ìg/day orally in its crystalline for, but patients may need a monthly intramuscular supplement of 1000Ìg.[10,22]

Recommendations
Patients who present with hair loss six months postsurgery should follow the following recommendation daily: intake 80g of protein for women and 100g for men (with sufficient amounts of L-lysine, 1.5 to 2g/day), add 15 mL of flaxseed oil, 2.5g of biotin, one or two multivitamin capsules with minerals (thus providing 200 percent of DRIs), 350 to 500Ìg/day of B12 in its crystalline form, and 320mg of ferrous fumarate or gluconate or 65mg of elemental iron twice daily. (Table 1) The supplementation of zinc recommended in this article is already present in sufficient doses in multivitamins that contain minerals.

Conclusion
Patients undergoing WLS may have hair loss after surgery due to the lower intake and inadequate absorption of protein, iron, biotin, zinc, vitamin B 12, and essential fatty acids. These patients need an adequate supplementation in order to prevent complications from evolving. Further randomized studies on hair loss in bariatric patients are needed in order to know, with accuracy, the adequate levels of supplementation of these nutrients to be administered.

References
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2.    Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683–2693.
3.    Folli F, Pontiroli AE, Schwesinger WH. Metabolic aspects of bariatric surgery. Med Clin N Am. 2007;91:393–414.
4.    Jacques J. Micronutrition for the Weight Loss Surgery Patient. Edgemont, PA: Matrix Medical Communications; 2006:146–147.
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7.    Pereira JM. Analysis of spontaneously eliminated hair. . Na Bras Dermatol.1996;71(6):517–524.
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20.    Kantor J, Kessler LJ, Brooks DG, et al. Decreased serum ferritin is associated with alopecia in women. J Invest Dermatol. 2003;121(5):985–988.
21.    Rushton DH, Norris MJ, Dover R, et al. Causes of hair loss and the developments in hair rejuvenation. Int J Cosmet Sci. 2002;24:17–23.
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25.    Bruginsky A. Biotin supplementation as a treatment for alopecia post gastroplasty. [Monograph]. Sao Paulo: Brazilian Institute of Homeopathic Studies. Specialization in Orthomolecular Nutrition and longevity. São Paulo, 2001:38.
26.    Yuyama LKO, Yonekura L, Aguiar JPL, Rodrigues ML, Cozzolino SM. Zinco. In: Cozzolino SM, ed. Biodisponibilidade de Nutrientes. Second Edition. São Paulo: Manole; 2007:549.
27.    Institute of Medicine (IOM). Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chomium, Cooper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium and Zinc. Washington, DC: National Academy Press; 2001:420–441.
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29.    Slater GH, Ren CF, Siegel N, et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004;8:48–55.
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