title: Guidelines on vitamin D replacement in bariatric surgery: Identification and systematic appraisal.
abstract: BACKGROUND
  Bariatric surgery is the most effective therapeutic option to reduce weight in morbidly obese individuals, but it results in a number of mineral and vitamin deficiencies. Clinical Practice Guidelines (CPGs) attempt to balance those benefits and harms to provide guidance to physicians and patients.
  
  
  OBJECTIVE
  We compare and evaluate the quality of the evidence and of the development process of current CPGs that provide recommendations on vitamin D replacement in patients undergoing bariatric surgery, using a validated tool.
  
  
  METHODS
  We searched 4 databases, with no time restriction, to identify relevant and current CPGs. Two reviewers assessed eligibility and abstracted data, in duplicate. They evaluated the quality of CPGs development process using the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) tool that consists of 6 domains. A content expert verified those assessments.
  
  
  RESULTS
  We identified 3 eligible CPGs: (1) the Endocrine Society (ES) guidelines (2010); (2) the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), and the American Society for Metabolic & Bariatric Surgery (ASMBS) guidelines (update 2013); and (3) the Interdisciplinary European (IE) guidelines on Metabolic and Bariatric Surgery (latest update 2014). The ES and the AACE/TOS/ASMBS guidelines recommended high doses of vitamin D, varying from 3000IU daily to 50,000IU 1-3 times weekly. Vitamin D doses were not mentioned in the IE guidelines. The recommendations were based on a low quality of evidence, if any, or limited to a single high quality trial, for some outcomes. In terms of quality, only the IE guidelines described their search methodology but none of the CPGs provided details on evidence selection and appraisal. None of the three CPGs rigorously assessed the preferences of the target population, resource implications, and the applicability of these guidelines. According to the AGREE II tool, we rated the ES guidelines as average in quality, and the other two as low in quality.
  
  
  CONCLUSIONS
  Current CPGs recommendations on vitamin D supplementation in bariatric surgery differ between societies. They do not fulfill criteria for optimal guideline development, in part possibly due to limited resources, and are based on expert opinion. Thus, the pressing need for high quality randomized trials to inform CPGs, to be developed based on recommended standards.
authors.affiliation: Division of Endocrinology, Calcium Metabolism and Osteoporosis Program, WHO, Collaborating Center for Metabolic Bone Disorders, American University of Beirut Medical Center, Beirut, Lebanon; Scholars in HeAlth Research Program (SHARP), American University of Beirut Medical Center, Beirut, Lebanon. Electronic address: mc39@aub.edu.lb.
authors.forename: Marlene Toufic
authors.initials: MT
authors.lastname: Chakhtoura
authors.affiliation: Scholars in HeAlth Research Program (SHARP), American University of Beirut Medical Center, Beirut, Lebanon.
authors.forename: Nancy
authors.initials: N
authors.lastname: Nakhoul
authors.affiliation: Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.
authors.forename: Elie A
authors.initials: EA
authors.lastname: Akl
authors.affiliation: Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Christos S
authors.initials: CS
authors.lastname: Mantzoros
authors.affiliation: Division of Endocrinology, Calcium Metabolism and Osteoporosis Program, WHO, Collaborating Center for Metabolic Bone Disorders, American University of Beirut Medical Center, Beirut, Lebanon.
authors.forename: Ghada A
authors.initials: GA
authors.lastname: El Hajj Fuleihan
mesh_terms: D050110:Bariatric Surgery / Q000009:adverse effects*; D019587:Dietary Supplements; D017408:Guidelines as Topic; D006801:Humans; D009767:Obesity, Morbid / Q000601:surgery; D011183:Postoperative Complications / Q000188:drug therapy* / Q000378:metabolism; D014807:Vitamin D / Q000008:administration & dosage / Q000627:therapeutic use*; D014808:Vitamin D Deficiency / Q000188:drug therapy* / Q000209:etiology*; D014815:Vitamins / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D014815:Vitamins; D014807:Vitamin D
keywords: Appraisal tool; Bariatric surgery; Clinical practice guidelines; Quality of evidence; Vitamin D replacement
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