Aug. 26, 2022 - Weight Loss Surgery: Multivitamin Use After Bariatric Surgery 

For this Bariatric Friday, Kemal Erkan, Chairman of American Surgery Center, is joined by Dr. Isaias Irgau, President of Christiana Institute of Advanced Surgery (CHRIAS). Dr. Irgau specializes in bariatric surgery, which is also known as weight loss surgery. Weight loss surgery is the most effective way to help with morbid obesity. A person is considered morbidly obese when their weight is at least one hundred pounds higher than their ideal body weight with a body mass index (BMI) of at least forty. People who have a BMI of thirty-five with previously developed illnesses related to morbid obesity, such as high blood pressure, type 2 diabetes, or sleep apnea, can also be eligible for bariatric surgery.   

Today’s conversation is about multivitamin deficiencies in regards to bariatric patients. Erkan reintroduces the patients going through bariatric surgery. It is important to note, the names of the patients are fictional; however, the situations being discussed are accurate in manner of what bariatric patients are going through at this time. First, we have Denise; she is thirty-two years old with a BMI of forty-three. Her A1C is 9; an A1C exemplifies the diabetes level, so by her A1C, it is apparent she has diabetes. Denise’s TSH is 1.5, and her hemoglobin is 9. Patrick is the next patient; he is thirty years old with a BMI of fifty. His A1C is 6, and his hemoglobin is 12. Patrick’s TSH is 7; a TSH of that level indicates he has a thyroid problem. This is being addressed prior to the surgery. Karen is the third patient; she is fifty-two years old with a BMI of forty-one. Karen’s A1C is 11, meaning she has diabetes. Her TSH is 2 while her hemoglobin is 12.5. She also has heartburn; because of the heartburn and her age, she will not be receiving a gastric sleeve and instead undergoing a gastric bypass.  

There is currently a misconception that after bariatric surgery, because the patients look much better in regards to weight, that they cannot have a vitamin deficiency. Dr. Irgau begins by defining a human’s basic needs, “they need water, they need what we call macronutrients, these are carbohydrates, proteins, and fats, and then they need what we call micronutrients and vitamins fall into the micronutrients category”. Micronutrients are needed in very small quantities, but they are essential. “If we were living in a society where we had access to fresh food all the time, in other words, we had an imaginary garden or what not in the backyard we would go get our food cook it and eat it, then we would probably have all the micronutrients that we need, and we would not need any additional vitamins,” Dr. Irgau explains, “but as you know, we live in a society where most of the food that we get is processed food, in other words, time passes when the food was actually gotten from nature and when it reached our kitchen”. During this time in between, the food loses a lot of the essential vitamins, so this is why consuming vitamins is important for one’s health. It is even more important for a patient to take vitamins after bariatric surgery. “The reason for that is with bariatric surgery, we are bringing some type of change to the digestive tract, for instance, with the gastric sleeve that Denise and Patrick are going to have, we make the stomach a lot smaller than the original stomach,” Dr. Irgau states, “ which means that the amount of food that Patrick and Denise are going to consume is going to be much less than what they are consuming now before surgery”. They need additional vitamins because the amount of avoidable vitamins that are incorporated in their food every day will be much smaller. Certain vitamins also require the stomach acid, which has been reduced due to bariatric surgery, to be absorbed well. Bariatric surgery patients need doses of multivitamins that are much higher than a person who has not undergone weight loss surgery. Dr. Irgau mentions that it is even more crucial for Karen, “Karen is going to have a gastric bypass, and with a gastric bypass, not only do we make the stomach small, which means that the amount of food that Karen is going to be eating is a lot smaller than what she eats now, but we have rerouted her intestine in such a way that her ability to absorb nutrients from what she eats is a lot less than it is now, so she is even in more danger of becoming vitamin deficient after surgery”. Part of the patients’ preparation prior to surgery is learning the importance of taking adequate amounts of vitamins after the procedure.  

The vitamins that are critical for bariatric patients to be taking are B12, vitamin D, and folic acid, as well as the minerals calcium and iron. Erkan inquires about the best way to take B12. Dr. Irgau mentions that a shot works well because it goes directly into the bloodstream without interacting with the digestive tract, but that method is not always for everyone. To his patients, Dr. Irgau recommends taking at least 1,000 micrograms of B12 per day. As time passes after the surgery, while examining blood tests to monitor the B12 levels, patients are often prescribed an even higher dose. “B12 is a very important vitamin because it’s essential to manufacture red blood cells… and for the health of our nervous system,” Dr. Irgau proclaims, “if they have a deficiency of B12 that goes on for too long, eventually, they could develop nerve damage that is permanent”.  

Before surgery, like anyone else, bariatric patients should be taking multivitamins; however, after surgery, it is non negotiable. Patients must be taking the correct vitamins regularly and at a high enough dose. The dose is approximately two hundred percent higher than the dose for someone who has not gone through weight loss surgery. In regards to vitamin D, patients must take at least 3,000 international units of vitamin D on a daily basis. Iron is also important because almost all gastric bypass patients, and many gastric sleeve patients, will suffer from iron deficiency, so Dr. Irgau recommends 40 to 45 milligrams of iron supplements every day. This is extra important for young women who are bariatric patients. Women lose iron with blood loss during their menstrual cycle, so they need even more iron than normal. This may seem like a lot of pills, but American Surgery Center has bariatric advantage multivitamins in a variety of formulations to ensure adequate amounts of each vitamin in a single tablet. If the tablet is too large for a patient, there are also options where the formulation is distributed correctly between two tablets. Calcium, however, has to be taken separately. It is recommended that patients consume 1,000 or 1,200 milligrams of calcium per day; this typically means a patient consumes calcium citrate two or three times daily. Dr. Irgau clarifies, “one thing that we tell our patients is that they should never take the iron and the calcium together because calcium interferes with the absorption of iron, so they have to separate them by about two hours”.  

“It is not just the surgery, it is everything else that we do in the program all together,” Erkan states. American Surgery Center has nutritionists that work with the patients the entire time through their bariatric journey, starting from their first consultation. The patients are educated on what their body needs in order to prepare for bariatric surgery, and what their body needs following the procedure. “We are trying to actually help our patients from the nutrition standpoint to promote better eating, more mindful eating,” Erkan explains. Just because someone is overweight, it does not mean they are well nourished. If a person is not aware of the nutritional value in the food they are consuming, they could be malnourished from a macronutrient or micronutrient point of view, and this could lead to more problems such as weakened liver health, poor nervous system health, or a low red blood cell count. “Our goal is not to just get the patient to the time of the surgery, but after the surgery, what we can do to keep them in the program… so that they can actually… maximize their benefit from the surgery”. A patient needs to come to their appointments, take their vitamins, and utilize the support provided to them in order to maximize the benefits of the surgery. Attending follow up appointments and following the instructions of the doctor is paramount to maintaining good health because being monitored during that time can prevent muscle loss, anemia, and fatigue. “Bariatric surgery is not just about the surgery… we are making some important changes to the digestive system that have implications in the long term, and those implications have a lot to do with the nutrition, so this time that we spend preparing for bariatric surgery includes extensive sessions with our dieticians where patients will have much better knowledge about what nutrients are… in today's session, we are emphasizing that all three of our patients, Denise, Patrick, and Karen, are going to be affected in terms of how they will deal with micronutrients after surgery,” Dr. Irgau reiterates. Erkan concludes by saying, “hopefully we can make an impact on their choices that they make with this program, it is extremely rewarding for us to be able to be part of their journey… we are happy to continue to do that”.