Vitamin and mineral supplementation is essential to optimal health and vitality following bariatric surgery.  Obtaining all of the vitamin and minerals from food alone is difficult before surgery, but after surgery there are special challenges that make supplementation a must.  Smaller quantities of food are eaten, bringing in smaller quantities of vitamins and minerals.  The breakdown of food into its small absorbable components is compromised without the benefit of the acidic churning environment of the larger stomach.  Food also has a decreased length of small intestine to pass through, lowering the opportunities for absorption.  Lastly, most people experience a decreased appetite for the first months.  Making healthful food choices, consistently taking the vitamin and mineral supplements recommended by your surgeon and nutritionist, and completing lab tests at the recommended intervals will help to keep you full of energy and on the way to a healthful weight loss. 

To help you in choosing the right supplements for your individual needs, let’s take a look at the more common deficient nutrients individually and then how to choose supplements in general.  The most common nutrition deficiencies are iron and Vitamin B-12.  Other nutrients to monitor are protein, calcium and folic acid.  The rates of deficiencies found in studies and reported here are higher than those generally experienced by Barix patients.

Iron

Iron has many important functions/roles in the body, including oxygen transportation, immune function, and exercise performance.  The recommended dietary allowances for iron are 15 mg for women and 10 mg for men. 

Studies indicate that up to 33% of gastric bypass patients develop an iron deficiency.  There are three main reasons why this occurs.  The primary absorption site for iron is in the first section of the small intestine, which has been bypassed by the surgery.  Iron is also better absorbed in an acid environment; this has also been limited by the surgery.  And lastly, red meat contains the best-absorbed form of iron (heme iron) and this is often limited due to pouch size and tolerance.  In addition to the physiological reasons for decreased iron absorption, iron supplementation is poorly absorbed and has side effects of nausea and constipation for many.  Iron supplementation for those with an iron deficiency typically returns iron levels to normal.  Taking iron supplements on an empty stomach with a Vitamin C supplement may increase absorption.  Do not take calcium supplements or multivitamins with iron supplements.  Do not routinely take iron supplements unless your lab values indicate a need and your physician directs you to do so. 

There are two types of iron found in foods, heme iron and non-heme iron.  Heme iron is much better absorbed.  Forty percent of the heme iron from food is absorbed compared to 10% of the non-heme iron.  Because iron is absorbed well in an acid environment, the tomato base in spaghetti increases the absorption of the iron in the ground beef.  Cooking in an iron skillet can also increase the available iron in a food.  

Foods Containing Heme Iron

Food	Mg Iron in 3 oz serving
Bone meal	74.0
Caviar	10.8
Calves Liver	8.0
Mussels	5.3
Oysters	5.0
Snails	3.2
Bacon	3.0
Beef	3.0
Veal	2.9
Pork	2.7
Chicken	1.5
Haddock	1.0

Foods Containing Non-heme Iron

Food	Mg  Iron in 3 oz serving
Seaweed	81.0
Wheat Germ	8.5
Molasses, blackstrap	8.1
Chickpeas	6.2
Prunes	3.2
Spinach	3.0
Bread, whole wheat	2.3
Bread, white, enriched	2.3
Cheddar cheese	0.9
Milk	0.0

Vitamin B 12

Vitamin B 12 functions in the formation of the protective sheath around nerve cells; in the metabolism of carbohydrate, protein and fat; in the production of amino acids and fats; in the replication of genetic code within each cell and in the formation of neurotransmitters.  Adults require 3 micrograms a day.  Vitamin B 12 requires intrinsic factor, a substance in gastric juices, for absorption. 

Studies indicate that 37% of people develop a Vitamin B 12 deficiency after surgery.  In a pre-surgical stomach, gastric juices free Vitamin B 12 from foods.  It then binds with intrinsic factor in the stomach prior to moving through to the lower small intestine for absorption.  This process is much less efficient after surgery, leading to a lower absorption rate for Vitamin B 12. 

Oral supplementation with Vitamin B 12 is somewhat effective.  However, because the Vitamin B 12 must bind with intrinsic factor, in a less than optimal process, absorption is compromised.  Vitamin B 12 injections are an option; however require a trip to the doctor on a regular basis.  A cost efficient, effective solution is a liquid or dissolvable tablet taken sublingually (under the tongue).  Wal-Mart carries Spring Valley Liquid Sublingual B-Complex for less than $6.00 for a two-month supply.   Supplementation for Vitamin B 12 will be recommended by your physician if your Vitamin B 12 levels get close to or below the low end of the acceptable range.  An untreated Vitamin B 12 deficiency can lead to irreversible nerve damage. 

Folic Acid

Lab values for folic acid are elevated in patients that routinely take the recommend vitamin and mineral supplements.  The surgeon and nutritionist can tell by your folic acid lab value if you have been taking your vitamins as recommended.  Deficiencies are only seen when multivitamin and mineral supplements are not taken on a routine basis.  Anyone desiring to become pregnant should keep a close eye on folic acid levels. 

Calcium

Calcium functions as a component of bones and teeth; a component of cell membranes; it is essential for muscle relaxation; it maintains a regular heartbeat; it is necessary for the transmission of nerve impulses; and it is needed for blood clotting.  Requirements range from 800-1500 mg daily.  Hypertension, osteoporosis, and metabolic bone disease can result from a deficiency.  Calcium is absorbed in the small intestinal area that is bypassed after the surgery, leading to a possible decrease in absorption.  Calcium absorption and deficiencies following gastric exclusion are not well defined.  Due to the lack of comprehensive studies regarding calcium adequacy following gastric exclusion surgery and the fact that low bone mass affects 44 million Americans, it is important to obtain a daily calcium intake of 1200 mg from food or supplemental sources. 

Calcium supplements are either in the form of calcium citrate or calcium carbonate.  Either form is an effective supplement.  Calcium carbonate is found in many calcium supplements.  It is less expensive, has twice the elemental calcium by weight than calcium citrate and appears to be absorbed almost as well if taken with food. 

Calcium carbonate is also a common form of supplement.  It is absorbed well in a non-acid environment, which occurs in the first section of small intestine below the pouch.  The pills will be larger than calcium carbonate because calcium citrate contains half as much elemental calcium.  

Food Sources of Calcium

Food	Amount	Calcium (mg)
Yogurt, plain	1 cup	415
Sardines	2 ounces	372
Milk, nonfat	1 cup	302
Milk, nonfat, dry	1/3 cup	279
Cheese, cheddar	1 ounce	204
Salmon, canned with bones	3 ounces	167
Tofu	1 cake	154
Cottage Cheese	1 cup	146
Oysters	½ cup	113
Mustard Greens, cooked	½ cup	97
Orange	1 medium	54
Broccoli, cooked	½ cup	50
Navy beans, cooked	½ cup	48
Apricots, dried	½ cup	44

Protein

Adequate protein is essential for health.  Protein functions in the building of tissue; fluid balance; acid-base balance; the formation of antibodies; as a part of hormones; transporting of proteins; blood clotting; and as structural proteins.  Adults require 0.8 grams per kg of weight.  Following surgery, recommendations for the rapid weight loss phase are based upon 1.2 grams per kg of ideal body weight. 

Actual protein deficiencies are not common after surgery.  Meeting your individual protein goal daily can help to minimize hair loss, muscle tissue loss and keep the immune function working well.  Protein supplements, a concentrated protein source, may be needed for the first months following surgery to meet protein goals.  Low fat meat, fish, eggs, poultry and daily products are good food sources of protein. 

Multivitamin and Mineral Supplements

Vitamins and minerals are nutrients needed in very small amounts for good health. Your body requires the same amount of each vitamin and mineral as it did before the surgery.  Because of the smaller amounts of food and the decreased absorption of nutrients following the surgery, supplementation is needed to be sure your body is getting all of the nutrients it requires to remain healthy.  Chewable or liquid supplements are recommended for the first 3 months after surgery.  If you choose to switch to a “pill” form after three months, be sure that it is smaller than an “M & M” in diameter.  Vitamin and mineral supplementation is recommended for life. 

Individuals may have different needs for specific nutrients or preferences in the type of supplements they choose.  For those reasons, we do not recommend a specific brand or supplement over another.  Choose the type of supplement that meets your needs and preferences using the following information to make an informed decision.  Choose a supplement that contains at least 20 vitamins and minerals essential for good health with no more than 150% of the USRDA for each nutrient.  Some vitamins and minerals will be toxic in larger doses. 

Use caution when using herbal supplements.  There is very little regulation on these substances.  Avoid “weight loss formulas” which may include stimulants or ingredients whose effectiveness has not been proven. 

▪          Natural and synthetic vitamins are virtually identical

▪          Look for the USP (United States Pharmacopoeia) mark on the bottle

▪           The manufacture pays for this testing. 

▪          It means that the listed ingredients are indeed in the supplement and that the supplement will dissolve.

▪          It does not guarantee safety. 

▪          % Daily Values means the same thing as % USRDA (US Recommended Daily Allowance)

▪          Labels use them interchangeably. 

▪          This is the FDA’s advice on how much of the vitamin or mineral to shoot for each day

▪          Check the expiration date on the bottom of the bottle

▪          Store brands are usually just as good as national brands

▪          A multi-vitamin and mineral supplement should contain no more than 150 percent of the RDA for any nutrient

▪          Herbal supplements are not standardized for dose or regulated for safety

▪          Manufactures are responsible for setting their own safety standards-there are no government standards or checks for safe manufacturing

▪          Supplements can be called “High Potency” if at least 2/3 of it’s nutrients have 100% or more of the Daily Value (DV)

▪          “Advanced,” “Complete,” or “Maximum” formulas can mean anything