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*Please Note: The OAC Blog is not a substitute for medical advice. If you have any questions regarding the information in this blog series, please be sure to speak with a healthcare professional regarding your concerns.
The decision to have bariatric surgery is a life-changing one. After surgery, there are many adjustments that have to be made to support health and success long term. Some of these adjustments will always be nutritional, such as new portions, new foods, more protein, less sugar, etc. All of these and more will become a routine part of life for those who have chosen surgery to treat obesity.
Using dietary supplements – vitamins and minerals (and sometimes protein or others) – to guard against low nutrient levels is usually recommended to some degree after all bariatric surgery procedures. This blog series will cover some of the basic recommendations by procedure. However, if you have had or are considering bariatric surgery, it is important that you follow the specific recommendations given to you by your program doctor or dietitian.
Adjustable Gastric Banding (LAGB)
Because the LAGB is only restrictive, people may think they do not need to supplement. However, it is still recommended for the following reasons:
- It is common for individuals to have low levels of some vitamins and minerals before surgery.
- After surgery, you are eating a lot less, so it is harder to get all the nutrition you need from your food alone.
For these reasons, the most recent recommendations on nutrition after LAGB are to take a daily adult multivitamin with minerals that has iron, folic acid and thiamine (B1). They also recommend Calcium (citrate) 1200 to 1500 milligrams daily and vitamin D at a level of at least 3000 IU per day. For vitamin D it is important that a doctor check your levels and make sure you are in a healthy range.
Sleeve Gastrectomy (VSG) and Gastric Bypass (RNY)
In a sleeve gastrectomy, a large portion of the stomach is removed leaving a thin, tube-like stomach. In a gastric bypass the stomach is made much smaller and the top portion of the intestines are bypassed (meaning food does not go through that part anymore). Because more of the digestive system is changed with these surgeries, there is more of a risk for problems with nutrition.
While the procedures are different, current information would indicate that the nutritional problems that can occur are fairly similar. The recommendations include 2 adult multivitamins plus minerals (each containing iron, folic acid, and thiamine), 1200 to 1500 milligrams of calcium as calcium citrate, 45-60 milligrams of elemental iron (total from multivitamin and other supplements), enough vitamin B12 to maintain normal levels and vitamin D at a level of at least 3000 IU per day. For both B12 and vitamin D it is important that a doctor check your levels and make sure you are in a healthy range. It is also important to note that levels of iron above 45mg per day are above the upper limit of safety for adults – so you should not take more than a total of 45mg per day unless your doctor as told you to and is supervising your treatment. It is also typically recommended that VSG and RNY patients start with a chewable (or liquid or powder) product for at least six months.
Conclusion
If you walk into a health food store or drug store, you will literally find hundreds of kinds and forms of vitamins and minerals. Because some will be ok for bariatric surgery patients and some are not, it is best to ask your surgeon or dietitian for their recommendations (most will give them to you before or soon after your surgery). If you decide to change what you are taking (more, less, different products), it is important to tell your surgeon or dietitian what you are doing so that they have the right information to monitor your health.
If you have trouble taking vitamins for any reason, you should also get help with this – nutritional deficiencies can take a while to appear, but they can be serious when they do, so prevention is important. And finally – make sure you get in for your regular lab work. Deficiencies can happen even in those doing everything “right.” If we find deficiencies early, they tend to be easy to treat – but if we find them late, there can be serious problems. So testing is almost as important as taking your vitamins for your long-term health.
About the Author
Dr. Jacques, a frequent author in the OAC’s quarterly publication, Your Weight Matters Magazine, is a Naturopathic Doctor with more than a decade of expertise in medical nutrition. Her greatest love is empowering patients to better their own health. Dr. Jacques is a member of the OAC National Board of Directors.
I’m planning to have WLS in November and I’ve just started researching about bariatric vitamins. I’ve seen another company that says I don’t have to take certain things like calcium and iron separate because this company has combined them in to one multivitamin. I would prefer to take the least amount of vitamins as possible, but it seems other companies recommend I take them separate. I want to start a complete regimen as soon as possible and save as much money as I can. Can you please help me with my questions?
Hi Roxie –
The first rule is that you should get a recommendation from your doctor and not from a company. Typically if you have had a purely restrictive procedure like a gastric band, then you can mix iron and calcium. However if you have a procedure like a sleeve gastrectomy, gastric bypass or duodenal switch, it is usually recommended that you take your calcium as calcium citrate and that you take iron and calcium separate from each other. This includes not taking your iron with calcium rich foods like yogurt.
It is definitely good that you are asking these questions now so that you can be prepared for what you need to do. Even if the program is a little more complicated than you want or costs a bit more, it’s important to remember that this is not something you are doing that is simply a bit of added protection – vitamin deficiencies from bariatric surgery can be serious and prevention is an important part of assuring your long term health and well being. If you are concerned about what you have to take, make an appointment in advance with the program dietitian to talk about it. That way you can have a solid plan that you feel good about before your surgery.
In Health,
Dr Jacques
Hello Roxie, I prefer to take my vitamins separate. I am 2 1/2 years post RNY. I started out using 2 multi vitamins, additional B-1, B-12, Calcium, 2 D-3. I can’t remember what else. At 2 years, I had to DECREASE to 1 multi vitamin, decreased B-1, and decreased the D-3. I think when you have adjustments like that, it would be harder if the vitamins were combined. Just a thought though. It was also nice to see the pills decrease, whatever they were. Good luck to you.
Thank you I’m trying to get all the info I can regarding this. I’m serious about the gastric bypass that’s the one the Dr recommends because of 4 tubal pregnancy surgeries I’ve had in the past. And insurance won’t cover the sleeve. Anyways thanks for info and wouldn’t mind more info on any of this.
Robin,
Thank you for your comment. We are excited to present this information as we know many individuals want to be informed about the topic. Please check back next week for Dr. Jacques’ next post, which will focus on the importance of follow-up care and how to identify deficiencies.
Thanks
James
What is a healthy Vitamin D level for someone who has had gastric bypass surgery? I’m at the mid year point for my yearly follow up appointment with my surgeon and had my primary doctor order a 25-hydroxy vitamin D test just to find out where I am. I’ve found many sites that give a normal range but didn’t know if it should be any different for someone who has had surgery.
Hi Steve,
A healthy vitamin D level should be the same for both bariatric surgery and non-bariatric surgery patients. Right now, it is pretty hotly debated what that number should be. Most people agree that you should be at least at a level of 30 ng/mL for healthy bones. A range of 30-100 ng/mL is what the Endocrine Society calls “sufficient”. Above 150 is considered to be toxic by most experts.
I hope this helps!
In Health,
Dr Jacques
Have you seen that menstrating females require a little more iron than 45-60 mg to maintain normal levels long term??
Hi Dawn,
It is not uncommon that menstruating women may need more iron than the current recommendations for prevention. The current recommendations are based on our knowledge to date, but individuals can be different in terms of iron intake from food, loss, absorption and storage. Sometimes people do fine at these levels, sometimes they are even fine with less – but others definitely need more.
That said, it is important to know that iron – while very much needed in certain amounts by the body – can also be very toxic when taken in excess. The Upper Limit of Safety (UL) for iron is 45mg per day – the bottom end of the current recommendation for prevention after bariatric surgery. So it is important that people not take over that level unless they are under the care of a doctor who can monitor treatment.
In Health,
Dr Jacques
Had RNY 7 years ago, my doctor said I need to take injections of b-12 for the rest of my life. I noticed you didn’t mention this. Lack of the intrinsic factor causes the DEF. + he said the absorption is not there with my surgery. Comment?
Hi Margaret,
In most cases it is really not necessary to have injections of B12. even in pernicious anemia (a condition where people don’t make intrinsic factor or where it is destroyed by antibodies) we typically control their B12 with oral or sublingual tablets. The typical dose for an oral or sublingual should be over 750 micrograms (mcg) per day – most people will use 1000 mcg. It is inexpensive and easy to get. The nutritional guidelines for bariatric surgery recommend using injections in those who cannot maintain normal range B12 levels with an oral or sublingual supplement. If you are going to switch, you should tell your doctor and plan to have a test in 3-6 months to make sure your levels are holding. You should try to stay above 400.
I hope this helps.
In Health,
Dr Jacques
Roxie,
As said a lot depends on the procedure you are having. Simple fact, get used to taking vitamins. They become a mainstay of our health and well being. Especially if you have a malabsorption type procedure like a DS! Also with the calcium citrate being kept separate from the iron, you may consider pairing the iron with vit. C.it helps increase the irons bioavailability.
There is a lot to learn and digest ( no pun intended) but it is an excellent journey.
K
Kenny and Roxane-
Thank you so much for the advice! And Dr. Jaques! I’m really happy to say that I’ve found a great vitamin regimen from Bari Life Bariatric Supplements. I’m still up for trying different regimens before I get started, but after A LOT of research and after talking with my doctor it turns out that Bari Life vitamins do give all patients everything they need-the dosage varies by surgical procedure. The iron and calcium is combined into their tablets and powder vitamins and the reason that you can take them together is because it’s non-heme iron. You can’t take calcium with heme iron (iron from meat). Apparently, non-heme iron is the iron found in all supplements and it can very well be absorbed with calcium. I will do whatever is best for my health, but I want to save money too!=P so taking them together is definitely the option for me, since it is an option!
Hi Roxie,
First, let me say the I am always very happy when patients find something they can take. It’s always better to take something over nothing – which is what many people end up doing if they don’t find a workable solution.
That said, I have taught nutrition to surgeons and bariatric health professionals for over a decade and I always think it’s important to continue to do that. It sounds like your doctor is interested in these things so you might want to encourage him or her to look a little more closely at the research on the interactions between iron and calcium. The truth is that some of the research is conflicting – but even new studies show that calcium will clearly reduce the absorption of non-heme iron (iron salts) by 38-50%. In individuals with non-bypassed intestines studies seem to show that over long periods of time (3-12 months) the body will usually absorb enough iron to compensate. However, in a procedure like a gastric bypass, most of the area where iron is normally absorbed is now not contacted by food or supplements. Because of this, the likelihood of iron deficiency and malabsorption over time is greatly increased compared to normal, and competition between the minerals is very hard to overcome. The 2010 guidelines from The Endocrine Society that directly address concerns about bone health support this by saying the following:
“Iron deficiency may also be exacerbated as a result of a nutrient-nutrient inhibitory absorptive interaction between iron and calcium, another mineral that should be given routinely during the postoperative period. Most studies, but not all studies, show that nonheme- and heme-iron absorption is inhibited up to 50–60% when consumed in the presence of calcium supplements or with dairy products. Calcium at doses of 300–600 mg has a direct dose-related inhibiting effect on iron absorption.” (J Clin Endocrinol Metab 95: 4823–4843, 2010)
At the end of the day, the important thing is to be careful. Do what your doctor has suggested, keep yourself informed, continue to take care of yourself and eat well, and make sure you have your regular labs done so that you can catch any deficiencies early – your doctor should be monitoring ferritin in addition to an iron panel, so that you catch a deficiency early if one arises.
Thank you for participating in the conversation.
In Health,
Dr Jacques