What vitamin and mineral supplements are recommended for patients after bariatric surgery?

Post-Bariatric Surgery Vitamin and Mineral Supplementation Recommendations

After bariatric surgery, all patients should take a complete multivitamin and mineral supplement daily containing thiamine, iron, selenium, zinc, and copper, with additional specific supplements based on the type of procedure performed. 1

Core Supplementation Requirements

Basic Multivitamin and Mineral Supplement

• A complete multivitamin and mineral supplement containing thiamine, iron, selenium, zinc (minimum 15 mg), and copper (minimum 2 mg) is recommended daily for all bariatric surgery patients 1
• Supplements should be reviewed regularly and adjusted according to laboratory results 1

Iron Supplementation

• After adjustable gastric banding (AGB), a multivitamin containing the recommended daily allowance of iron is usually sufficient 1
• After sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or malabsorptive procedures like biliopancreatic diversion with duodenal switch (BPD/DS), additional elemental iron is required 1
• Recommended starting doses: 200 mg ferrous sulfate, 210 mg ferrous fumarate, or 300 mg ferrous gluconate daily (twice daily for menstruating women) 1
• Take iron supplements with citrus fruits/drinks or vitamin C to enhance absorption 1
• Take calcium and iron supplements at least 2 hours apart as they inhibit each other's absorption 1

Vitamin B12

• After SG, RYGB, or BPD/DS, routine vitamin B12 supplementation with intramuscular injections every 3 months is recommended 1
• B12 deficiency may present several years after surgery due to depletion of body stores 1
• Deficiency can cause megaloblastic anemia and irreversible neuropathies 1

Vitamin D and Calcium

• Adjust vitamin D3 supplementation to maintain serum 25-hydroxyvitamin D levels ≥75 nmol/L 1
• Maintenance doses of 2000-4000 IU vitamin D3 daily are typically required after SG and RYGB, with higher doses needed after BPD/DS 1
• Ensure adequate dietary calcium intake and consider calcium supplements if parathyroid hormone (PTH) is elevated despite normal vitamin D levels 1
• For optimal absorption, take calcium in divided doses; calcium carbonate with food; calcium citrate with or without food 1
• Calcium citrate may be preferred for patients at risk of kidney stones 1

Folic Acid

• Take a complete multivitamin providing 400-800 μg folic acid daily 1
• Folic acid deficiency can mask vitamin B12 deficiency, so monitor both nutrients 1

Additional Supplements Based on Procedure Type

For Malabsorptive Procedures (BPD/DS)

• Vitamin A: 10,000 IU (3000 μg) daily 1
• Vitamin E: 100 IU daily 1
• Vitamin K: 300 μg daily 1
• Zinc: At least 30 mg daily 1
• Consider water-miscible forms of fat-soluble vitamins to improve absorption 1

Monitoring Schedule

• Check laboratory values at 3,6, and 12 months in the first year post-surgery, then at least annually thereafter 1
• Recommended laboratory tests include:
  • Complete blood count and ferritin 1
  • Folate levels 1
  • Vitamin B12 levels 1
  • 25-hydroxyvitamin D levels 1
  • Calcium levels 1
  • Renal and liver function tests 1
  • Consider zinc, copper, and selenium if clinically indicated 1

Special Considerations

Pregnancy After Bariatric Surgery

• Women should avoid pregnancy for 12-18 months after surgery to allow weight stabilization 1, 2
• Women planning pregnancy should take additional folic acid: 400 μg/day if BMI <29.9 kg/m² or 5 mg/day if BMI >30 kg/m² or with diabetes 1, 2
• Replace vitamin A supplements from retinol to beta-carotene form during pregnancy 1, 2
• Pregnant women need nutritional screening each trimester, including ferritin, folate, vitamin B12, calcium, vitamin D, and vitamin A 1, 2

Adolescents

• Adolescents require regular monitoring for dietary adherence and nutritional assessment due to changes in body composition, growth, and sexual development 1

Common Complications and Management

• For prolonged vomiting or dysphagia, refer back to the bariatric center and provide additional thiamine (200-300 mg daily) and vitamin B co-strong (1-2 tablets, three times daily) 1
• For unexplained anemia, check for protein, zinc, copper, and selenium deficiencies 1
• When giving additional zinc and copper, maintain a ratio of 8-15 mg zinc to 1 mg copper 1

Follow-up Care

• Postoperative follow-up should include a multidisciplinary team with a surgeon, bariatric dietitian, and psychologist or social worker 1
• Recommended dietitian appointments: 1-2 weeks post-surgery, then at 1,3,6,9, and 12 months, followed by annual visits 1
• Long-term follow-up should focus on screening for micronutrient deficiencies, bone health, and management of nutrition-related conditions 1

Remember that patients who have had malabsorptive procedures have a higher risk of nutritional deficiencies and should remain under specialist care 1, 3, 4.