What vitamin deficiency is indicated by burning lips after significant weight loss following bariatric surgery?

Burning Lips After Bariatric Surgery: Vitamin B2 (Riboflavin) Deficiency

Burning lips after significant weight loss following bariatric surgery is most characteristic of vitamin B2 (riboflavin) deficiency, though zinc deficiency should also be strongly considered as it presents with similar oral symptoms including glossitis and taste changes. 1

Primary Deficiency: Zinc

Zinc deficiency is the most likely cause of burning lips post-bariatric surgery, presenting with:

• Glossitis (inflammation of the tongue and oral mucosa) 1
• Taste changes and altered taste acuity 1
• Poor wound healing 1
• Hair loss 1

Zinc deficiency occurs occasionally after sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB), and more commonly following biliopancreatic diversion with duodenal switch (BPD/DS). 1 Risk factors include length of time after surgery and limb length in bypass procedures. 1

Secondary Consideration: B-Complex Vitamins

While the guidelines focus primarily on B12, thiamine, and folate monitoring, riboflavin (B2) deficiency classically causes burning sensations of the lips, tongue, and oral mucosa (angular cheilitis, glossitis). 1 However, this specific deficiency is not extensively discussed in bariatric surgery guidelines, likely because it's included in standard multivitamin supplementation. 1

Vitamin B12 deficiency can also contribute to oral symptoms:

• Glossitis and oral mucosal changes 1
• Neurological symptoms including numbness and tingling 1
• Deficiency may not appear until 2+ years post-surgery due to body stores 1

Diagnostic Algorithm

When a patient presents with burning lips post-bariatric surgery:

1. Check serum zinc levels immediately - this is the most specific test for the presenting symptom 1
2. Assess for other zinc deficiency signs: taste changes, hair loss, poor wound healing 1
3. Check vitamin B12 levels and methylmalonic acid (MMA) if B12 is borderline (180-350 pg/mL) 1
4. Evaluate copper levels concurrently - high-dose zinc supplementation can cause copper deficiency and vice versa 1
5. Review multivitamin adherence - non-compliance is a common cause of multiple deficiencies 1

Treatment Approach

For zinc deficiency with normal or borderline copper levels:

• Prescribe two Forceval tablets daily for 3 months 1
• Recheck zinc and copper levels after 3 months 1
• Maintain zinc-to-copper ratio of 8-15 mg zinc to 1 mg copper when supplementing 1

For severe zinc deficiency with normal copper:

• High-dose zinc supplementation for 3 months 1
• Monitor copper levels closely - if copper falls, refer for specialist advice 1

For concurrent zinc and copper deficiency:

• Two Forceval tablets daily for 3 months 1
• Recheck both levels after treatment 1

Critical Monitoring Requirements

All bariatric surgery patients require:

• Zinc monitoring at 3,6, and 12 months post-surgery, then at least annually 1
• Copper monitoring concurrently with zinc, especially in patients on high-dose zinc 1
• Full blood count and ferritin at the same intervals 1
• Vitamin B12 levels at 3,6, and 12 months, then annually 1

Common Pitfalls to Avoid

Do not supplement zinc without checking copper levels - these minerals have antagonistic absorption, and supplementing one can precipitate deficiency of the other. 1 This is particularly important as copper deficiency causes severe neuromuscular abnormalities and myeloneuropathy. 1

Do not assume multivitamin supplementation is adequate - standard multivitamins may not contain sufficient zinc for post-bariatric surgery patients, particularly after malabsorptive procedures. 1

Do not delay treatment while awaiting lab results if clinical suspicion is high - oral symptoms with zinc deficiency can progress, and empiric treatment with balanced supplementation (Forceval) is safe. 1

Prevention Strategy

Lifelong supplementation requirements post-bariatric surgery include: 1

• 1-2 adult multivitamin-plus-mineral supplements daily 1
• Specific attention to zinc content in chosen supplement 1
• Regular monitoring even with supplementation adherence 1