The Skinny on Weight Loss Surgery & Vitamin Supplements

            Why is it important to take your vitamins after weight loss surgery?  Well I am glad you asked and even if you don’t want to know I am going to tell you anyways.  For those of you who know me I like to ramble on and on about scientific topics.  I think they are cool and I if I like them, then I assume everyone else must want to know about them too.  At least that is what my wife says; I guess I’ll just take her word for it.  When we talk about taking vitamins we need to break it down into three commonly performed surgeries. 

Gastric Band:  People with the gastric band are at average risk for vitamin and mineral deficiencies just like anyone else.  If you are eating a very low calorie diet, however, and not eating perfect everyday, then a multi-vitamin and calcium supplement may help fill the gaps.  I mean who eats perfect everyday?  A person who eats perfect might eat 5 or more servings of different colored fruits and veggies, 2-3 servings of dairy, 4-6 ounces of very lean or lean meats and fish several times a week.  They might also eat 1 ounce of raw, natural, unsalted nuts a few times a week.  They might even limit fried foods, eat fewer sugar calories and avoid excessive refined white bread, pasta and rice.  If they did eat grain it would be high in fiber and 100% whole grain at least 50-75% of the time.  Maybe it would even be mixed grains such as Wheat, Rye, Amaranth, Barley, Buckwheat, Flax, Kamut, Millet, Oats, or Quinoa.   This way their diet would be calorie controlled, adequate in thousands of natural antioxidants and food chemicals that reduce cancer and heart disease risk.  But heck, we can just get all that in a pill right.  I mean, I am always hearing about the next best exotic juice or vitamin pill that will make me taller and prevent everything from cellulite to gray hair.  Ok, maybe not, but a multi-vitamin will help provide you with 100% of the daily value for B-vitamins, antioxidants A, C and E.  They will usually provide you with minerals such as selenium, zinc, magnesium and calcium.  It is important to get at least 400-800IU of vitamin D from your multi-vitamin as well.  People with obesity are at risk for vitamin D deficiency, and possibly low levels of antioxidants and thiamin, a B vitamin needed to metabolize sugars.  In addition to that if you are vitamin D deficient, then you may run the risk of osteoporosis.  So for those losing weight, I also suggest taking a calcium/magnesium supplement with an additional 400-1000IU of vitamin D daily.  The recommendations for the gastric sleeve are similar to the band and can be interchangeable.   In summary take a multi-vitamin with 100% of the DV for most vitamins and minerals similar to your local generic grocery store brand or similar to Centrum®.  If you are looking for a more robust formula, then stop by your local health food store and try Carlson’s Super 1 Daily™ or Solaray® brand.  There are many other supplements all different sizes and shapes, chewable, liquid, gummies and other forms.     

Gastric Sleeve:  For those with the gastric sleeve, no true malabsorption occurs, you really have a small stomach that restricts the amount you can eat and limits your appetite.  For this reason a multi-vitamin daily along with the calcium/magnesium and vitamin D supplement as was recommended for people with the gastric band would be appropriate.  For young women, an iron supplement may help prevent anemia, which you can discuss with your primary care doctor.  Another nutrient, folic acid, is also important for repair of DNA and making healthy red blood cells in the body.  Folic acid is an important nutrient to assist in cellular division as a baby is created.  It is amazing how spontaneous pregnancy can occur with weight loss, so ladies be careful and don’t forget the folic acid.  Men, there is nothing spontaneous about pregnancy, you were there, so make sure your sweetie is taking vitamins.  If she is taking them, then you have to take them too.  So now the new code for baby making is “Honey did you take your vitamins today?”

Gastric Bypass:  For those with gastric bypass surgery, not only do you have a small stomach, but you are also bypassing about 3 to 4 feet of small intestine.  For this reason you have more specific nutrient recommendations that are more a rule than a guideline.  Let’s break it down by nutrients.

Vitamin A:  Vitamin A is essential for vision (especially dark adaptation), immune response, bone growth, reproduction, the maintenance of the surface linings of the eyes, epithelial cell growth and repair, and the epithelial integrity of the respiratory, urinary, and intestinal tracts.  On occasion it has been found that people with bypass surgery may acquire a vitamin A deficiency.  Interestingly vitamin A is bound to a transport protein and among other nutrients, zinc status, protein status and iron status are important in order for the body to utilize vitamin A.  Vitamin A Deficiency may result in nigh blindness, dry hair and skin and broken nails.  Once again, men and women, you may have noticed that vitamin A is important for reproduction and seeing in the dark, both of which are important for baby making.  Sources of Vitamin A include liver, beef, chicken, eggs, fortified milk, carrots, mangoes, sweet potatoes, and leafy green vegetables.  To check you vitamin A status, we check total serum vitamin A (retinol).

Vitamin D:  Vitamin D is a very cool vitamin, because it is actually a hormone.  The major role of vitamin D is to increase absorption of calcium and phosphorus from the intestine.  It is made in the skin via a reaction induced by sunlight and we eat it in vitamin D fortified milk and other dairy products.  It is also found in fatty fish.  The bad news is that vitamin D deficiency has been linked to a lot of bad things such as breast, colon and prostate cancer, type 2 diabetes and osteoporosis.  The good news is that vitamin D supplementation in one study was found to reduce all cause mortality by 7% in 18 different high quality studies.  Vitamin D deficiency may be worse in people of advanced age, those with dark skin, and people who do not drink vitamin D fortified milk.  To check your vitamin D status, we check a serum vitamin D 25 hydroxy level.

Vitamin B12:  This nutrient at its heart has the mineral cobalt.  Yes, like the Chevy Cobalt car, and like this car, B12 has been championed by many over the decades as an energy nutrient built for speed.  Unfortunately, this nutrient has to go through a special process of digestion to get into your body.  Vitamin B12 is attached to animal protein and must be released by acid in the stomach.  After gastric bypass, your stomach does not produce sufficient acid to cleave the B12 from protein.  Another reason for deficiency is due to a lack of intrinsic factor, a molecule that binds to B12 and protects it until it is absorbed in the last part of the small intestine.  Interesting 99% of B12 requires intrinsic factor for absorption, but 1% of B12 gets by and absorbs, which is why you can take B12 supplements by mouth at high doses.  B12 is then taken to cells where DNA is made.  The effects of B12 on your nervous system are not well understood, but B12 plays role in helping maintain how electrical impulses travel through your nervous system.  It also plays a role in the making of serotonin, dopamine and norepinephrine, which are neurotransmitters.  These transmitters help regulate mood and your perceived level of energy and even mental concentration.   So as you can see, we all need energy, focus, healthy red blood cells and a healthy nervous system.  We check you serum B12 level to make sure you have enough.

Vitamin B1 or Thiamin:  Thiamin is a nutrient needed for getting energy out of carbohydrates.  When you eat starches, peas, bread and other sugary foods, thiamin is there to help you metabolize the sugars to supply energy to your body.  When thiamin is not present people can experience two types of diseases, these are called wet and dry beriberi.  The body can store about 30mg of thiamine in the muscles mostly and in as little as one week without enough of this important nutrient symptoms can appear.  Dry beriberi is when people start to have nervous system problems similar to a B12 deficiency, including numbness and tingling of the extremities.  You may also have a more rapid heart rate and weakness.  A very severe form would also give you blurred visions, difficulty with speaking and balance.  Thiamine needs are increased with an overactive thyroid, fever, pregnancy and poor food intake.  Diarrhea can make it difficult to absorb thiamine and vomiting would make it difficult to get enough.  Folic acid deficiency may also contribute to a thiamin deficiency.    The best sources of thiamin are whole grains, nuts, fish, pork, dried beans, and enriched grain products.  To measure thiamin a serum thiamin study is ordered.

Folic Acid:  Ah yes our baby making nutrient.  Folic acid is an essential nutrient for DNA, RNA and proteins; it is interesting that vitamin B12 is needed to convert folic acid into its active form.  When B12 is not present, then folic acid deficiency can occur.  Sources of folic acid include green leafy vegetables, citrus fruits, and animal products.  There are two other things to know about folic acid.  One is that it is also an important nutrient to reduce toxic substances that are associated with the development of hard artery disease known as arteriosclerosis and cancer risk.  You see, because folic acid is important for DNA repair and reduction of toxic chemicals in the blood that can harm your DNA, it has an important connection to cancer.  Cancers are essentially cells that do not shut down or die properly and continue to grow out of control.  Diets low in folic acid and other essential nutrients may fuel this fire.  The body has about 50-100 mcg of folic acid and signs of deficiency and occur in as little as 4 months.  Signs of deficiency are usually related to anemia and include palpitations, fatigue, lethargy, anorexia, abdominal pain and numerous other vague symptoms.  Another symptom is an enlarged, red, beefy, tender tongue or cracking of the sides of your mouth.  To check folic acid and serum folate level is obtained.

Iron:  Iron is an energy nutrient in those who are deficient.  Men have less iron deficiency than women due to a lack of chronic blood loss.  However, iron is a difficult nutrient to digestion and absorb so deficiency can occur in both sexes as gastric bypass surgery.  If iron deficiency is found in a man, however, further work-up is needed to find out why.  Overall iron deficiency is the most common deficiencies there is through out the world.  When we eat foods that contain iron such as red meats, organ meats, shellfish, pumpkin seeds, sunflower seeds, whole grains, nuts, dried beans, and iron-fortified grain products, you may only absorb about 10%.  There are two types of iron, heme and nonheme iron, heme iron usually from red meat and pork is better absorbed.  The next best irons are nonheme iron in the form of ferrous iron.  Ferrous iron comes in many forms such as sulfate and fumerate.  Each form comes in a different pill size and may cause a variety of intestinal problems such as indigestion, nausea and constipation.  To enhance the absorption of iron, it is best taken with a meal, at night and with a small dose of vitamin C.  Deficiency of iron can result in poor immune system, irregular heart beat, and fatigue. Paleness of the mouth and bottom eye lids, soon-like nail beds, and behavioral changes and eating ice chips are signs of iron deficiency.  To check your iron status, an iron panel may be drawn during routine labs. 

Calcium:  Calcium is an important nutrient mainly because of its impact on bone health.  It is only one nutrient, however, important to the structure of bone and I am in the habit of recommending it with other bone nutrients.  I suggest taking it with magnesium, manganese, boron and others typically found in over the counter calcium products.  Typical products such as Citracal® plus minerals or Caltrate® plus minerals usually contain additional minerals and vitamin D.  Vitamin K is another vitamin that may benefit bone health, but is not universally found in calcium supplements unless you buy them from a health food store.  You may not know this, but if you shop at a local pharmacy versus a privately owned health food store or even one of the large chains such as Whole Foods Market® or Central Market®, you will find numerous other vitamin and mineral supplements.  There are so many on the market, mostly good products, and they come in many forms such as liquids, gummies, tablets, capsules and chewable.  One of the better forms of calcium for those with bypass surgery is calcium citrate due to its inherent acidity.  You see, calcium needs to be dissolved first by acid and then it can be absorbed.  Choosing calcium citrate helps with this process, but it is slightly more expensive.  You only have one skeleton, so feed it well and exercise to prevent osteoporosis.

Ok, we talked a lot about the vitamins and what not, so I will stop there.  I know that all this information was exactly what you wanted to read about and would love to talk further, but my wife is telling me to stop.  She says that you’ve probably had enough and are dying of boredom.  In secret, we both know that you love this stuff, so live fresh and we’ll talk again soon.  Men, don’t forget the new code word and everyone take your vitamins.