What additional supplements are recommended for a patient?

Recommended Supplementation Regimen

All patients should receive a comprehensive daily multivitamin-mineral supplement containing at least 200% of the RDA for thiamine, iron, folic acid, zinc, copper, and selenium, along with calcium citrate 1200-1500 mg daily (divided doses), vitamin D3 2000-4000 IU daily, and vitamin B12 1000 mcg daily. 1, 2

Core Daily Supplementation

Multivitamin-Mineral Foundation

• Two complete adult multivitamin-mineral supplements daily (or one if only LAGB procedure) containing iron, folic acid, zinc, copper, selenium, and thiamine at 200% of the RDA 1
• This forms the backbone of deficiency prevention and should never be skipped 1

Calcium Supplementation

• Calcium citrate 1200-1500 mg daily divided into doses no larger than 600 mg each 1, 2
• Calcium citrate is superior to calcium carbonate for absorption, especially if taking acid-reducing medications 2
• Take calcium doses at least 2 hours apart from iron supplements to avoid absorption interference 2

Vitamin D3

• Start with 2000-4000 IU daily to achieve serum 25-hydroxyvitamin D levels >30 ng/mL (>75 nmol/L) 1, 2
• After malabsorptive procedures (BPD/DS), may require 3000 IU daily with titration based on levels 1
• Higher doses up to 5000-10,000 IU daily are safe long-term if deficiency persists 3, 4

Vitamin B12

• 1000 mcg daily sublingual or 1000 mcg weekly for maintenance 1, 2
• Hydroxocobalamin or methylcobalamin preferred over cyanocobalamin 2
• After RYGB and BPD, may require 1000-2000 mcg daily or 3000 mcg every 6 months intramuscularly 1

Iron

• 45-60 mg elemental iron daily from multivitamin and additional supplements 1, 2
• Take with vitamin C or citrus to enhance absorption 2
• Separate from calcium by 1-2 hours 2

Protein Requirements

• Target 60-80 g daily or 1.1-1.5 g/kg ideal body weight (BMI = 25) 1
• After BPD/DS, increase to 90-120 g daily 1
• For sarcopenia prevention in older adults, aim for 1.0-1.2 g/kg body weight daily distributed throughout the day 2
• Prioritize high-quality protein sources rich in leucine: whey protein, soy products, eggs, lean meat, hard cheese 1

Additional Micronutrients After Malabsorptive Procedures

Fat-Soluble Vitamins (BPD/DS patients)

• Vitamin A: 10,000 IU daily, adjusting based on blood results 1
• Vitamin E: 100 IU daily (or 400 IU if deficiency develops) 1
• Vitamin K: 300 mcg daily 1
• Water-miscible forms improve absorption after malabsorptive procedures 1

Zinc and Copper

• Zinc: 15 mg daily for SG/RYGB; 30 mg daily for BPD/DS 1
• Copper: 2 mg daily for all patients 1
• Maintain zinc:copper ratio of 8-15:1 to prevent zinc-induced copper deficiency 1
• If doubling multivitamin (Forceval contains 15 mg zinc and 2 mg copper), this may suffice 1

Critical Thiamine Considerations

Routine Prevention

• At least 12 mg daily thiamine from multivitamin, preferably 50 mg once or twice daily from B-complex supplement 1
• Consider additional thiamine or B-complex for first 3-4 postoperative months 1
• For chronic diuretic therapy, provide 50 mg oral thiamine daily 5

High-Risk Situations (Prolonged Vomiting, Dysphagia, Poor Intake)

• Immediately administer 200-300 mg oral thiamine daily plus vitamin B compound strong 1, 5
• If unable to tolerate oral: 500 mg IV thiamine three times daily for severe deficiency 5
• Never give glucose before thiamine in at-risk patients—this can precipitate Wernicke-Korsakoff syndrome 1
• For refeeding syndrome: 300 mg IV thiamine before nutrition therapy, then 200-300 mg IV daily for 3+ days 5

Special Population Adjustments

Pregnancy Planning

• Folic acid 5 mg daily (not 400 mcg) for women with obesity or diabetes, from preconception through 12 weeks gestation 1
• Use β-carotene form of vitamin A (not retinol) if pregnant or planning pregnancy 1
• Avoid pregnancy for 12-18 months post-bariatric surgery 1

IBD Patients

• Monitor magnesium, potassium, and vitamin D closely 1
• Magnesium supplementation may be needed (oral can worsen diarrhea; consider IV) 1
• Vitamin D deficiency prevalence is 66-69% in IBD; supplement aggressively 1

Monitoring Schedule

• Initial: 3 months, 6 months, 12 months, then annually 2
• Check: B12, vitamin D (25-hydroxyvitamin D), complete blood count, ferritin, calcium, albumin, thiamine (if high-risk) 2
• For fat-soluble vitamins after BPD/DS: vitamin A, E, K levels 1
• Zinc and copper levels if supplementing above standard doses 1

Critical Pitfalls to Avoid

• Never rely on BMI alone—body composition changes are common and BMI misses sarcopenia 1
• Never delay thiamine treatment while awaiting lab results in symptomatic patients 5
• Never give single large vitamin D doses (300,000-500,000 IU)—these should be avoided 6
• Never ignore prolonged vomiting or dysphagia—always investigate and refer back to bariatric center 1
• Never supplement one mineral (zinc or copper) without monitoring both—they have inverse absorption 1