WHY BARIATRIC VITAMINS? - THE ULTIMATE GUIDE

While many people take a multivitamin for general health, they may not understand how nutrients truly help their body function to its fullest potential.  It is critical for your body to have the right amount of vitamins and minerals to function properly, assist in keeping you healthy, and may potentially assist with reaching weight loss goals.  Vitamins and minerals help regulate your body’s systems, such as:

• Metabolic rate
• Brain activity
• Appetite and hunger
• Metabolism of fat and carbohydrates, including sugar
• Absorption of other nutrients
• Thyroid and adrenal gland function
• Storage of energy
• Assist with healing

The ideal way for the body to get the proper amount of vitamins and minerals is through food.  However, this may not always be achievable after bariatric surgery (also called weight loss surgery).  It is important to keep in mind that getting your vitamins and minerals from food also provides other health benefits, so it is still important to follow a healthy eating plan.  Compared to 50 years ago, individuals do not currently achieve the recommended intake of vitamins and minerals due to eating highly processed foods, selecting poor food choices, and a decreasing quality of food.  In addition, when individuals have extra fat mass certain nutrients are utilized differently in the body creating potential deficiencies.

After talking to their healthcare provider, certain individuals should consider taking a multivitamin.  These individuals include:

• Those who do not get enough vitamins and minerals from food alone
• Those following a low-calorie diet (less than 1,200-1,500 calories per day)
• Those who have a poor appetite
• Those who avoid certain foods (such as strict vegetarians and vegans) (1).

In addition, certain medical conditions will require that patients take certain nutrients found in multivitamins:

• Women who might become pregnant need 400 mcg/d of folic acid from fortified foods and/or supplements
• Pregnant women need an iron supplement as recommended by their OBGYN
• Breastfed or partially breastfed infants should receive vitamin D (400 IU) every day
• Non-breastfed infants who drink less than 1 quart per day of vitamin D-fortified formula or milk should also receive 400 IU of vitamin D daily
• Postmenopausal women may require calcium and vitamin D to increase bone strength and reduce the risk of fractures
• Those over the age of 50 should achieve the recommended amount of vitamin B12 from fortified foods and/or supplements as they may not absorb enough B12 that is naturally found in foods (1).

The above two listings are for the general population and not specific to bariatric patients.  However, it helps to showcase that many people need nutritional supplements and bariatric patients are not excluded from this list.  In this article we will breakdown the specific recommendations for bariatric patients. 

General Reasons for Nutrition Supplementation

Bariatric surgery often leads to weight loss in part due to people eating less and also due to possible malabsorption.  In addition, there may potentially be changes in gut hormones depending upon the type of bariatric surgery that was performed.  While weight loss is a wonderful result of bariatric surgery, another result is a potential change in nutrition status.  Nutrient intake is altered following bariatric surgery for several reasons including 1) possible malabsorption of nutrients, 2) reduced total intake of food decreasing the intake of nutrients consumed, and 3) possible avoidance of certain foods (either due to tolerance issues or to optimize weight loss) reducing the intake of specific nutrients in those foods.

There has been much research showing the potential risk for nutritional deficiencies prior to bariatric surgery.  According to one study, as many as 79% of patients considering gastric bypass surgery do not achieve the proper nutrient intake before their surgery (2).  Also extensive research over the past has been few decades has shown that compared to the general population an additional increase in nutrient deficiency has occurred following surgery.  Another study showed that more than 50% of patients had a low level of vitamins D, E, C, folate, calcium, magnesium, and potassium at twelve months after their gastric bypass (3).  The authors of this study concluded that supplements were necessary to reduce and/or eliminate the risk of deficiencies (3).  Below is a compilation of several studies that have been performed in bariatric surgery candidates and the resultant ranges of pre-operative nutritional deficiency rates.  

Nutrient Function, Resultant Deficiency, Signs of Toxicity, and Major Food Sources

While it is important to understand that pre-operative deficiencies are common, many patients wonder what is so important about each nutrient.  Below are two charts (one for vitamins and one for minerals) explaining the function of each nutrient, as well as some of the signs and symptoms of deficiencies and toxicities.  In addition, food sources that are high in each nutrient are also listed. The chemical name(s) listed for each nutrient are how you might find the nutrient in the supplement facts and/or ingredient listing.  There are many forms of certain nutrients and we will discuss some of those forms in more detail so you have a better understanding of what to look for. 

The solubility section states whether the vitamin is fat-soluble or water-soluble (not applicable to minerals).  In general, fat-soluble vitamins must be absorbed in the presence of fat (i.e., must be taken with a meal that contains fat).  Fat-soluble vitamins tend to be stored in higher amounts in the body and have an increased risk of toxicity compared to water-soluble vitamins.  Water-soluble vitamins do not have to be absorbed in the presence of fat and generally the body does not store large amounts of these nutrients.  Moreover, these nutrients can be excreted through urine if you take more than you need, reducing the risk of toxicity, in general. 

Table 2: List of Vitamins: Function, Deficiency, Toxicity, and Food Sources(12,13)

Bariatric surgery is a personal decision and there are several options available to patients.  It is important to discuss the risks versus the benefits related to bariatric surgery with your physician.  Below is a brief description of some of the more current and commonly performed bariatric surgery treatment options.  For more information, please speak to your physician. 

Bariatric surgery used to be referred to as restrictive (reduces the amount of food consumed), malabsorptive (alteration to the intestines causing malabsorption), or a combination of the two therapies.  Now, we have learned more regarding the mechanisms of action related to various types of weight loss surgery and the bariatric industry now refers to these procedures as either metabolic or non-metabolic (14).  Metabolic means that patients in this group lose weight by altering their gastrointestinal tracts and by doing so, there is a change to the patient’s physiological response to fat loss (14).  Metabolic surgery results in a change in the secretion of the gut hormones (14).  This change in the gut hormones results in a reduction of hunger, which further assists with weight loss (14).  Non-metabolic refers to the grouping of patients that can achieve significant weight loss without an alteration to their physiology of energy (or fat) storage (14).  Examples of metabolic surgeries include the biliopancreatic diversion with duodenal switch, Roux-en-Y gastric bypass, and the sleeve gastrectomy.  Examples of non-metabolic surgeries include the adjustable gastric band and intragastric balloons.  Below is a brief discussion of the most current and common types of bariatric surgery.  Please speak to your physician for more information about each procedure.

Intragastric Balloons. Intragastric balloons are soft, yet durable, silicone spheres that take up space in the patient’s stomach and help reinforce proper portion control by providing a feeling of fullness with decreased food intake.

Adjustable Gastric Band.  This operation involves the placement of an adjustable band around the upper stomach to create a small pouch.  The band diameter is adjustable through introduction of saline via a port under the skin in the upper portion of the abdomen.  The saline travels through tubing connecting the port and the band to either inflate or deflate the band.  When the band is inflated, it slows the passage of food from the upper, small pouch to the lower pouch.  When this smaller, upper pouch fills with food, the patient feels full with smaller portions. 

Sleeve Gastrecotmy.  This operation reduces the size of the stomach to about 25% of its original size by removing a large portion of the stomach, resulting in a more narrow sleeve-like or tube-like structure.  There is no change to the intestines with this procedure.  The smaller stomach allows individuals to feel full on less food and many patients report a reduction in the feeling of hunger with this operation.  In addition, by removing a portion of the stomach this results to a change in the gut hormones.  This change in gut hormones also helps to reduce the feeling of hunger.

Roux-en-Y Gastric Bypass. This operation has been performed since the late 1960's and leads to weight loss through two different mechanisms. The operation reduces the size of the stomach, reducing the amount of food that can be consumed. A small amount of intestine is bypassed leading to an earlier release of gut hormones which helps the patient feel less hungry.

Biliopancreatic Diversion with Duodenal Switch. This operation is similar to the sleeve gastrectomy in that a large portion of the stomach is removed, however the intestines are rearranged in this procedure unlike the sleeve gastrectomy. This procedure results in a malabsorption of fat, calories, and nutrients. The malabsorption helps patients to achieve weight loss combined with a reduced food intake in order to feel full. This procedure also involves a change in gut hormones which helps to reduce the feeling of hunger.

All bariatric surgery patients will require some type of vitamin and mineral supplementation for the rest of their life. One study reviewed all research published between 1980 and 2009 related to micronutrient (i.e., vitamin and minerals) deficiencies after bariatric surgery and suggested that all patients scheduled for bariatric surgery should take daily multivitamin and mineral supplements (15). They also reported that all bariatric surgery patients have some potential risk for the following nutrient deficiencies: vitamins B1, B12, A, C, D, K, folate, and minerals iron, zinc, selenium, and copper (15).

Certain procedures will require a higher level of supplementation compared to other procedures. For example, the biliopancreatic diversion with the duodenal switch has the highest risk of nutritional deficiencies and would likely require the highest level of supplementation. The next highest risk is likely the Roux-en-Y gastric bypass, followed by the sleeve gastrectomy.

In general, the non-metabolic procedures will require that you take a multivitamin and mineral supplement that provides 100% of the daily value for at least two-thirds of the nutrients listed (16,17). Typically, the metabolic procedures require that you take a multivitamin and mineral supplement that provides 200% of the daily value for at least two-thirds of the nutrients listed (16,17).

In addition to the multivitamin, many patients will require additional supplements (these may or may not be included in your multivitamin). Some of these additional nutrients may include, but are not limited to, iron, calcium, vitamin B12, vitamin D, and/or B-complex. Below is a listing of the nutrients of concern (i.e., these nutrients have an increased risk of a nutritional deficiency) for each of the most common procedures.

* = More stars means higher chance of having that nutritional deficiency.

Adjustable Gastric Band (AGB). Many healthcare practitioners originally thought that this procedure did not require nutritional supplementation post-operatively since there is no malabsorption. However, after further review many professionals now realize that poor eating habits, foods low in nutrient content, certain food intolerances, and/or restricted portion size increases the risk of nutritional deficiencies even in a non-metabolic procedure (16). In addition, it is possible for patients with an adjustable gastric band to experience frequent vomiting, which increases the risk for thiamin deficiency (16).

Sleeve Gastrectomy (SG). This procedure is commonly associated with deficiencies of iron, vitamin B12, vitamin D, and calcium (17). If patients frequently vomit, this also increases the risk of thiamin deficiency (16).

Roux-en-Y Gastric Bypass (RNY). This procedure is commonly associated with deficiencies of iron, vitamin B12, vitamin D, and altered calcium metabolism (16). If patients frequently vomit, this also increases the risk of thiamin deficiency (16).

Biliopancreatic Diversion with Duodenal Switch (BPD/DS). This procedure is commonly associated with protein deficiency and nutrient deficiencies including, but not limited to vitamins A, D, E, and K, among many other micronutrients (i.e., vitamins and minerals), and altered calcium metabolism (16).

Post-Operative Nutrient Deficiencies

Below are some common rates of deficiencies for post-bariatric patients. This chart is not all-inclusive of all the published literature related to nutrient deficiencies and bariatric surgery patients. In addition, some laboratory tests for certain nutrients are not very reliable when it comes to how much of that nutrient is actually able to be utilized by the body.

American Society of Metabolic and Bariatric Surgery (ASMBS) Recommendations

The ASMBS is the largest, national, governing body for bariatric and metabolic surgery. It is the foremost leader in bariatric nutrition and science. The ASMBS helps to set clinical practice guidelines to aid healthcare professionals in caring for their bariatric patients.

In 2008, the first nutrition guidelines were presented by the ASMBS. These guidelines have been updated since then and continue to help drive the basics for supplementation following bariatric surgery. Below we will outline some of the recommendations from each edition of these recommendations. These are the basic recommendations and each individual patient may have varying needs based on their individual medical history, medication usage, and nutritional laboratory study results. Speak to your physician to determine your individual supplement regimen.

Below is a comparison of what the recommendations are for the general population and what is recommended currently for bariatric surgery patients. Keep in mind we grouped all the procedures together for this comparison. We believe this chart showcases how a bariatric patient needs additional supplementation above and beyond what they can get from their food and basic, over-the-counter supplementation.

* RDA = Recommended Dietary Allowance; AI = Adequate Intake; UL = Upper Tolerable Intake; DV = Daily Value; M = Male; F = Female; RAE = Retinol Activity Equivalents; S = Synthetic; N = Natural; NE = Not Established; ; Niacin Eq. = Niacin Equivalents; Yrs = Years of Age; DFE = Dietary Folate Equivalents; IM = Intramuscular; SQ = Subcutaneous

# May vary by surgery type; see 2019 ASMBS Nutrition Guidelines for more specific information

Taking a basic multivitamin and mineral supplement (MVI) is unlikely to pose any health risks (1). In general, if you consume fortified foods and beverages with added vitamins and minerals or take other supplements you will want to ensure that the MVI you take doesn't cause your intake of any nutrients to go above the upper limits (1). However, this may not be applicable to bariatric patients as sometimes their needs are much higher than the upper limit as can be seen from Table 9 above. Below are a few specific groups of individuals that may need to be extra cautious with MVI supplementation.

• Women who are pregnant need to be cautious with taking too much vitamin A during pregnancy (1).

• Iron supplements are the leading cause of of poisining in children under the age of six, so keep iron-containing products safely stored away from children (1).

Multivitamins, in general do not usually interact with medications (1). However, since bariatric-specific multivitamins are doses much higher, there is some potential for interactions with medications. Be sure to speak to the prescribing physician and your pharmacist about the medications and supplements you take.

• In addition, if you take certain medicines to reduce blood clotting (such as Coumadin and Warfarin), talk to your doctor about your MVI and how much vitamin K you take (1). Vitamin K lowers the drug's effectiveness and doctors base the dose of the medicine partly on how much vitamin K you generally consume from food and supplements (1). You can also talk to your doctor about new medications recently released that help to reduce blood clotting that do not interfere with vitamin K. The ultimate message is not to avoid vitamin K as vitamin K deficiencies can occur and be quite damaging post-operatively, but rather to be sure to tell your doctor of any new supplements that contain vitamin K and how much vitamin K. It is also extremely critical to be very regimented with your supplements if you are a patient taking these blood clotting medications (i.e., do your best to not skip doses and take at the same time day-to-day).

• Also, certain medications require that you take certain supplements at a different time in relation to the time you take that medication. One example of this includes thyroid medications. Speak to your doctor or pharmacist for more specific information on this matter.

Some patients report nausea when taking vitamin and/or mineral supplements. This is possible even without having bariatric surgery. However, the effect may be worsened in the immediate post-operative period. There are many things that cause nausea and/or vomiting immediately following bariatric surgery (i.e., having surgery, the anesthesia from surgery, drinking too fast, eating too much, etc.). However, there are some things to counteract this effect if it occurs.

• Try taking your vitamins with food.
• This can be challenging immedate post-op as there generally is not enough room (i.e., space in your new smaller stomach) for both food and vitamins. Many patients report feeling full with just taking their chewable vitamins. If that is the case, consider taking them after drinking a liquid protein shake or meal replacement.
• There are also some products that combine the multivitamin supplement with fiber in a liquid consistency that may decrease the effect of nausea. Other products combine the multivitamin supplement with fiber and protein, which may further decrease the effect of nausea.

• Consider splitting up your dose.
• Cut your chewable tablet in half and increase the number of supplement sessions to further decrease the risk of nausea during this short-term period.
• Consider a liquid multivitamin and mineral supplement.
• Taking a liquid supplement helps to decrease the dose of vitamins and minerals hitting the bloodstream at one time since the liquid product is generally consumed over a 10-15 minute period. This lower dose over a longer period of time further decreases the risk of nausea.

Not following your physician's recommendations to take the appropriate vitamin and mineral supplements can lead to severe consequences, including death. In addition, it is extremely important to be sure to follow-up with your physician to have your nutritional laboratory studies completed as recommended. Getting your labs done can help your physician to make adjustments to your supplement plan decreasing the risk of nutritional deficiencies. Below are some of the more common potential nutritonal deficiencies and the potential side effects of not achieving proper nutritional balance.

Vitamin A. Vitamin A plays a role in vision, immunity, and many other processes. Deficiencies of vitamin A may lead to the inability to adapt to darkness, night blindness, and blindness (27). Patients suffering from vitamin A deficiency may also experience an increased susceptibility to infectious diseases and diarrhea (27). It has been shown that a vitamin A deficiency may worsen iron deficiency anemia (27). Low levels of zinc may alter vitamin A metabolism (28,29).

Vitamin C. Vitamin C cannot be made by humans and therefore must be obtained vitamin C from the diet and/or supplements. A deficiency of vitamin C may lead to scurvy resulting in weakness, fatigue, curly hair, and sore arms and legs. Patients may also experience bleeding gums with a vitamin C deficiency.

Vitamin D. A deficiency in vitamin D causes the body to not absorb calcium effectively. In addition, it may lead to liver and kidney disorders, as well as, softening of the bones. The softening of the bones may increase the risk of bone fractures.

Vitamin E. Vitamin E deficiency is rare, but it does affect the ability to use other fat-soluble vitamins (vitamins A, D, and K). It may also lead to sterility in males and spontaneous abortions in females.

Vitamin K. A deficiency of vitamin K increases the risk of osteoporosis and heart disease. It also causes you to bruise more easily. In addition, it legthens the time it takes for your blood to clot (after a cut for example or larger internal injury).

Thiamin. A thiamin deficiency affects the heart, digestive system, and nervous system and can result in severe consequences, including death. If this deficiency is not detected and quickly treated, the patient's learning and memory can be permanently altered. Coma and death can be the end result if treatment is not initiated.

• The initial stages of thiamin deficiency include indigestion, constipation, malaise, heaviness and weakness of the legs, tender calf muscles, "pins and needles" feeling and numbness in the legs, and increased pulse rate and heart palpitations.
• Wet beriberi leads to edema, tense calf muscles, a fast pulse, distended neck veins, an increase in blood pressure, and decreased urine output.
• Dry beriberi leads to worsening of the early stage symptoms, such as the weakness and numbness of the hands and feet, difficulty walking, and Wernike-Korsakoff syndrome (WKS). WKS leads to a loss of immediate memory, disorientation, jerky movement of the eyes, and a staggering gait.
• While this condition is relatively rare among bariatric surgery patients, it is possible after surgery due to the changes in eating habits, and a potential reduction in nutrient absorption. This risk of WKS is increased if the patient is experiencing frequent vomiting.
• Ultimately, if not caught and left untreated, a thiamin deficieny can lead to cardiac failure and death.

Keep in mind this nutrient is not stored in large amounts in the body and MUST be replenished daily through either food or supplementation (or a combination of the two).

Riboflavin. A riboflavin deficiency may lead to tearing, burning, or itching of the eyes; soreness and burning of the lips, mouth, or tongue; inflammation or swelling at the corner(s) of the mouth; a purple and swollen tongue; and peripheral neuropathy. Peripheral neuropathy results in damage to the peripheral nerves that often causes weakness, numbness, and pain generally in the hands and feet.

Niacin. A deficiency in niacin may lead to muscular weakness, indigestion, tremors, a sore tongue, confusion, disorientation, and pellagra. Pellagra is characterized by the 4 D's - dermatitis (condition related to the skin), diarrhea, dementia, and death).

Vitamin B6. A deficiency in vitamin B6 may lead to a type of anemia, peripheral neuropathy (results in damage to the peripheral nerves that often causes weakness, numbness, and pain generally in the hands and feet), convulsions, and irritability.

Folate. A folate deficiency may also lead to a type of anemia. If a deficiency occurs during pregnancy, this may result in neural tube defects of the child.

Vitamin B12. A deficiency in vitamin B12 may lead to fatigue, pale skin, tingling in the hands, and may eventually lead to anemia, and neurological disorders. Other symptoms of vitamin B12 deficiency include heart palpitations, shortness of breath, lightheadedness, diarrhea, vision loss, memory loss, and depression.

Iron. Iron deficiency may cause anemia (when the body does not have enough red blood cells and is not able to carry enough oxygen throughout the body), which results in fatigue, pallor (unhealthy pale appearance), hair loss, and an inability to be physically active to your full potential (i.e., you feel winded doing things that were relatively easy previously).

Calcium. Calcium deficiency may lead to osteoporsis and/or an increased risk of bone fracture.

Magnesium. A magnesium deficiency may lead to muscle tremors, convulsions, irritability, and tetany (a condition marked by intermittent muscle spasms). This deficiency may also lead to hyperreflexia which involves overactive or overresponsive reflexes. Another possiblity is hypoflexia which involves below normal or absent reflexes.

Zinc. A zinc deficiency may lead to brittle nails, hair loss, and skin changes. A zinc deficiency also makes it take longer for wounds to heal and may lead to hypogonadism (when the sex glands produce too little or no sex hormones). A mild anemia may also occur due to low levels of zinc. Patients may experience a change in taste acuity (tastes are not as strong) with a zinc deficiency. Another possible symptom related to zinc deficiency is diarrhea.

Selenium. A selenium deficiency can lead to muscle pain and tenderness, and more importantly cardiomyopathy (a condition that causes heart muscle weakness that can lead to an increased risk of death). In addition a deficiency in selenium may lead to the pancreas not functioning at 100%, meaning that it is not as effective at secreting enzymes that help aid in digestion and hormones that help regulate the metabolism of sugars.

Copper. A copper deficiency may lead to an unhealthy appearance, edema, an increased risk of osteoporosis, testicular failure, changes in eye health, and cardiomyopathy (a condition that causes heart muscle weakness that can lead to an increased risk of death). A deficiency in copper may also reduce your immune function.

The only way to find out if you have some of the above deficiencies is through regular nutritional laboratory testing. Some symptoms from nutritional deficiencies will look like other side effects associated with bariatric surgery and a physical exam may not be enough to diagnose some of these deficiencies. Keep in mind, if you are not seeing your bariatric surgeon for post-operative care, it is important to see a physician that understands your post-operative needs. In general, the standard yearly physical labs that your family doctor (or primary care physician) may complete DO NOT cover the nutritional laboratory tests necessary following bariatric surgery.

Most products available to bariatric patients use a standard preparation of fat soluble nutrients (vitamins A, D, E, and K). This type of preparation requires that patients take the supplement with fat to optimize absorption, however many bariatric patients do not consume enough fat at the same time as taking their supplements to facilitate absorption of these critical nutrients. Another preparation is available to bariatric patients to help enhance the absorption of the fat soluble nutrients. This preparation is called water-miscible or the dry form of vitamins A, D, & E. By using the water-miscible form of these nutrients, they can be absorbed regardless of fat intake, which enhances absorption and optimizes the nutritional status of patients. Keep in mind not all "bariatric" vitamins use this dry form of the fat-soluble nutrients. So do your homework and ask questions!

In the field of medicine, bariatric surgery is still a relatively young field where we are constantly learning more every decade. In fact, very little was known about nutritional deficienies related to bariatric surgery in the beginning. During the 1990s and 2000s much more research started being published demonstrating a relationship between bariatric surgery and the increased risk of nutritional deficiencies post-operatively. However, another novel relationship was also developing in the mid 2000s. Research suggested that many patients have vitamin deficiencies pre-operatively and many surgeons started doing pre-operative laboratory studies to further understand each patient's individual nutritional status. During this time many patients were treated for pre-operative nutritional deficiencies in order to improve nutritional status for surgery and hopefully set the patient up for success. While nutritional deficiencies are still common post-operative, it is just as important to understand the pre-operative status of patients and consequently practitioners are starting to look at the trends over time.

In the beginning, since much less was known regarding the nutritional needs of bariatric surgery patients, general chewables were recommended following bariatric surgery. As the field of bariatrics has evolved, speciality bariatric-specific supplements have been developed and continue to evolve over time to better meet the nutritional needs of the bariatric surgery patient. As you can see from this article, the recommendations for what weight loss surgery patients need have changed over the years. It is good advice to make sure that your "bariatric-specific" vitamin is also evolving and improving to match the needs of the bariatric patient.

While every company is different, we can speak to how Celebrate ^® develops our bariatric-specific multivitamins. We determine the critical elements of the product from a formulation standpoint. When determining the formulation, we look to the ASMBS guidelines. We use the most up-to-date research to determine how our product should be formulated in order to provide the best nutritional supplements for bariatric surgery patients. We are committed to staying abreast of new research and reformulating our products as necessary to make them even better for patients, which is evidenced by our reformulations in 2010 and 2015.

We also consider the form of each nutrient to ensure maximum bioavailability (i.e., the ability of a nutrient to be absorbed). While some companies cut corners by using less expensive forms of nutrients, we want to be sure to provide a product that has the highest level for absorption in bariatric patients, while still providing our product at a competitive price.

We also take into account the delivery system (i.e., the format in which the product is delivered to the body). Celebrate^® offers supplements in multiple delivery systems to maximize compliance. All delivery systems will breakdown in the bariatric gut, again maximizing absorption. We offer nutritional supplements in a capsule or tablet format, hard chewable tablet, soft chew, and liquid or shake delivery systems.

Next, we take into consideration taste and texture. Ultimately, a bariatric patient is going to take a product that is pleasant to the taste and long-term use is extremely important when it comes to nutritional supplementation. If patients enjoy the taste and texture of their supplements, they are much more likely to take them long-term, thereby reducing the risk of nutritional deficiencies.

Another point related to formulation, involves following the basic rules of biochemistry. Certain nutrients inhibit the absorption of others and there are certain nutrients that you can only take a certain amount per dose period. We follow these rules of absorption so patients can be sure they are getting the most bang for their buck and maximizing their nutritional status while using Celebrate® products.

• One example includes taking iron and calcium separate by at least two hours. When iron and calcium are taken at the same time (or in the same product), it inhibits the absorption of iron, which is common nutrient deficiency for bariatric patients (30).

• Another example of this includes only taking 500-600 mg of calcium per dose period as this is the most the body can absorb at one time (4,16,17). While some products provide 1,000-1,200 mg of calcium in one dose period, your body still only absorbs somewhere in the range of 500-600 mg.

• A final example includes following the proper ratio of zinc-to-copper. If this ratio is not followed appropriately, then it can put someone at risk for a copper deficiency. For every 1 mg of copper, a product should contain 8-15 mg of zinc (4). If a product contains zinc, but no copper, then this dramatically increases the patients risk of a copper deficiency.

If you are going to commit to long-term health and wellness and you are spending your hard-earned money to buy your bariatric vitamins, be sure you are getting the most that you can for your money and maximizing your nutritional health and wellness!

First talk to your physician before starting any new supplement. Let him or her help guide you in determining which supplement(s) are right for you.

Make sure you bariatric multivitamin is complete, meaning that it contains all of the key vitamins and minerals. Some supplements, even those marketed by bariatric companies are missing copper, selenium, magnesium, manganese, etc. As you can see from the above ASMBS recommendations, this is not appropriate. Many over-the-counter (OTC) options are also not appropriate for this reason. In fact, some OTC gummy vitamins are completely missing thiamin and that is very scary! Some children's formulas are also not complete.

Make sure the product follows the rules of absorption (see the section above for more detailed information).

• Ensure the product does not contain both calcium and iron together.
• Ensure the product only allows for 500-600 mg of calcium to be taken at one dose period.
• Ensure that the product follows the proper zinc-to-copper ratio.

The elephant in the room - everyone wants vitamins to taste like candy! I know this is harsh, but it must be said. In general, if your vitamin tastes like candy, it probably is. Check the sugar content. Check the nutrition facts label - is it a complete multivitamin? Is it missing key nutrients? Is it lower in key nutrients (like Thiamine, Zinc, or Copper)? Unfortunately vitamins taste like vitamins and while there are some techniques and flavors that can help mask this taste and make them better, they are never going to be candy. There are many options available to you that meet the ASMBS recommendations that do actually taste good!

Choosing the right formulation for your supplements following your bariatric surgery is extremely critical, it is also important to ensure that you take the supplements. The best product out there will not do any good if a patient never takes it. So make sure that you find something that you like and are willing to take. Remember, this is long-term; this is not for the first one to two years post-op. Nutritional deficiencies are easier to prevent than to treat. Following your surgery your risk for developing nutritional deficienices does not go away. In fact, your risk goes up the further out you are from your surgery, so supplementation becomes that much more important. Staying on top of your laboratory studies and supplement regimen will help you with your health and success.

Ask your doctor exactly what they recommend for you as an individual. Find out what their standard protocol is for supplementation for your particular surgery. Then ask to have nutritional laboratory studies completed if necessary. Finally, determine if your supplement regimen should be altered from their standard protocol based on your medical history, medication usage, and nutritional laboratory study results. Also, be sure to share with your doctor all medications and supplements you take (including vitamins, minerals, and herbals).

As a bariatric surgery patient, you have more than likely seen the endless possibility of vitamins available to you from over-the-counter options to bariatric-specific options. So what exactly is a bariatric-specific multivitamin?

A bariatric-specific multivitamin is one that was designed specifically for the bariatric patient. Some are even designed for certain types of bariatric surgery and may have slight differences among formulations since the nutritional needs may vary among various bariatric procedures. A bariatric-specific multivitamin is designed to provide the appropriate level of supplementation to support the needs of a bariatric patient as their needs are different from the general population.

Another difference among bariatric-specific multivitamins is the forms of each nutrient used. Generally, bariatric multivitamins use the form of the nutrients that are most bioavailable, meaning that nutrient has the best chance for absorption. However, this can vary among brands, so be sure to do your homework when looking for the right bariatric supplements for you.

A bariatric-specific multivitamin should meet the minimum recommendations and guidelines set forth by the American Society for Metabolic and Bariatric Surgery (ASMBS). However, again not all companies follow these recommendations and patients should educate themselves and talk to their bariatric surgeon about what type of supplementation regimen is appropriate for them. Some companies may even claim to meet these recommendations, when after close review this is in fact false.

According to Shankar et al., over-the-counter multivitamin preparations do not provide adequate amounts of nutrients (15). Another study by Gasteyger et al demonstrated that almost 60% of patients were taking 3 supplments every day within 2 years after gastric bypass in addition to their multivitamin (31). Almost 40% of patients were taking 4 or more supplements every day in addition to their multiviamin (31). These authors stated the most common supplement prescribed in addition to the multivitamin was vitamin B12 (80% of patients at 2 years post-op), followed by iron (60% of patients at 2 years post-op), then calcium and vitamin D3 (60% of patients at 2 years post-op), and folic acid (45% of patients at 2 years post-op) (31). These authors concluded that standard multivitamin supplementation is not enough to prevent deficiencies after gastric bypass (31).

There are several factors that may come into play when considering how much your bariatric supplements will cost. One of the first factors is the type of surgery you choose. A biliopancreatic diversion with duodenal switch patient should expect to spend more on bariatric supplements than a patient that has chosen to have the adjustable gastric band or intragastric balloon. Keep in mind there is a wide variance in the cost of products among brands, as well as a variance in what each patient needs to take each day. However, we have provided some common estimated ranges of monthly supplement costs for each of the more common surgical procedures based upon current ASMBS guidelines for core supplementation.

Secondly, your individual medical history and any pre-exisiting nutrient deficiencies will determine your individual vitamin and mineral supplement regimen. Based on your history, it may be required that you take additional supplements, which would potentially increase your monthly cost.

Finally, where you purchase your supplements from can play a role in your monthly cost for vitamin and mineral supplementation. While "going cheap" is not recommended for bariatric vitamins since nutrient deficiencies can be quite severe and detrimental, it also does not mean that you have to spend a small fortune each month on your bariatric supplements. It pays to be a smart shopper even when it comes to bariatric vitamins and minerals. Many practitioners believe in recommending a bariatric-specific supplement after bariatric surgery, but like anything in life, do your homework and compare brands. Some brands require that you spend more each month even though the formulation is not superior. Alternatively, other brands are less expensive, but do not include all of the nutrients that you need following bariatric surgery. The latter will end up costing more once you add all the extra required supplements to meet the core recommendations from the ASMBS.

As previously discussed, it is critical to take vitamin and mineral supplements as directed in order to maintain normal laboratory studies and reduce the risk of nutritional deficiencies. Maintaining normal nutritional laboratory levels may also assist with reaching and maintaining weight loss goals. However, it is also important to follow a few other guidelines.

• Complete pre-operative laboratory studies. Establishing a baseline helps to determine if your post-operative levels are improving, staying the same, or declining. Following trends allows your healthcare practitioner to better set treatment plans and goals.

• Take your vitamin and mineral supplements as prescribed. Be sure to follow the instructions of your physician regarding your vitamin and mineral regimen. If you find that you are struggling to be compliant with your regimen, be sure to discuss this with your physician. There may be alternative options available to you that will help you to be more compliant. In addition, if it is simply forgetfulness, there are apps available on your smartphone that can help you to remember taking them.

• Complete post-operative laboratory studies. Be sure to follow-up as recommended by your physician and complete all requested laboratory studies. It is much easier to treat a deficiency the earlier it is caught. In addition, many nutritional deficiencies are completely reversible if caught and treated early.

• Look for high-quality supplements. Do your homework and ask questions about the products that you want to take. Unfortunately, not all supplements are created equal. Some companies cut corners by using inferior forms of nutrients, including nutrients that inhibit the absorption of one another, not following the proper ratios of certain nutrients, and/or not following the maximum absorption rate of certain nutrients. In addition, you want to be sure that the product you are taking includes what is stated on the label and that the product is screened for contaminants.

• Do not self-prescribe. Just as you would not change your prescription medication regimen without first speaking to your physician, the same is true for vitamin and mineral supplements. Also, be sure to provide a complete list of medications, vitamin and mineral supplements, herbal supplements, and any other types of supplements to all of your physicians and pharmacist. They can help you check for interactions between various products.

A daily multivitamin is an insurance policy and extremely critical for bariatric patients. It helps to fill the nutrient gaps missing in your daily food intake, ultimately optimizing your nutritional status.

While YOU are ultimately responsible for your own health, it is advisable to have a good team behind you to cheer you on along the way! If you are just starting the process of considering bariatric surgery, be sure to look for a bariatric program that will partner with you and support you for life following your bariatric surgery. It is important to know that you will have a good team behind you helping you along the way to health and wellness!

In summary, we hope this helps to explain exactly what a bariatric-specific multivitamin is and why you should consider taking one following your bariatric surgery. Read the facts, talk to your bariatric surgeon, and make the best decision you can for yourself regarding your individual health and wellness goals, while being sure to follow the instructions of your bariatric surgeon regarding proper supplementation.

* Proper supplementation should be viewed as an individualized regimen based upon each patient's individual medical history, laboratory studies, and current medication use. Patients should follow the instructions of their bariatric surgery team. Patients should also be sure to follow-up with their bariatric surgery team at frequent intervals as recommended and stay up-to-date with requested lab work.

** The information contained within this article is for general information purposes only and is not intended to serve as medical advice. It is designed to support, not replace your relationship with your physician. Please seek the guidance of a physician before applying any of the discussed information provided within this article.

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