Vitamin and mineral supplements following bariatric surgery

All bariatric surgical procedures compromise nutrition to varying extent, and have the potential to cause clinically significant deficiencies. The British Obesity and Metabolic Surgery Society (BOMSS) has issued guidelines on biochemical monitoring and micronutrient replacement following bariatric surgery (see here).

Micronutrient replacement during the immediate post-operative period falls under the remit of specialist follow-up. The formulary provides guidance for long-term vitamin and mineral requirements for adults following bariatric surgery. All patients should have been given a long-term management plan by the specialist centre, including guidance on vitamin, mineral and trace element supplementation. Patients will be required to stay on life-long nutritional supplements in addition to having a balanced diet and have life-long monitoring of their nutritional status.

This guidance covers gastric balloon, gastric band, gastric bypass and sleeve gastrectomy procedures. Thee biliopancreatic diversion/ duodenal switch procedure, which has the greatest impact on nutrition, has been superseded in clinical practice. See BOMMS guidance for nutritional requirements for patients who have undergone this procedure and refer to bariatric surgery centre for advice.

Gastric band and gastric balloon

The gastric balloon and gastric band have no direct impact on absorption of nutrients though they help patients to eat less resulting in reduced nutrient intake. Patients may experience vomiting or regurgitation and develop food intolerances. A complete multivitamins supplement with minerals and trace elements (containing iron, selenium, zinc and copper) is recommended after all bariatric procedures. Some multivitamin supplements may not contain sufficient amounts of certain vitamins, minerals and trace elements to counteract the effects of bariatric surgery. Forceval is the only formulary multivitamin preparation which is suitable for patients who have undergone bariatric surgery. See specific recommendations for patients who are planning pregnancy or who are pregnant.

BOMSS guidance includes a range of over-the-counter "complete" vitamin and mineral supplements which meet the requirements for patients who have undergone gastric band or gastric balloon. If patients are intending to purchase their own products, it is important they purchase from this list or follow guidance provided by their specialist centre.

Guidance from local bariatric surgery centres on supplementation following surgery may differ from BOMSS guidance:

  • Musgrove Park Hospital guidance can be found here
  • University Plymouth Hospitals follow BOMSS guidance, found here
  • For other patients, follow current guidance from bariatric surgery centre or BOMSS guidance, found here

Vitamin and mineral requirements following gastric band or gastric balloon (BOMSS guidance):

Vitamin and mineral supplement
  • Forceval, take one capsule daily (see 9.6.7 Multivitamin preparations), or
  • Over-the-counter "complete" vitamin and mineral supplement recommended by patient's specialist or BOMSS, take one tablet/ capsule daily
  • See specific recommendations for patients who are planning pregnancy or who are preganant
Iron
  • It should be possible for patients to meet their iron requirements by oral diet and a complete multivitamin and mineral supplement containing the recommended daily allowance of iron
Calcium and Vitamin D
  • Patients who were found to be vitamin D insufficient prior to surgery are likely to remain on supplements following surgery. Seek advice from specialist if there is uncertainty over the treatment required
  • BOMSS recommend treatment and adjustment of vitamin D supplementation in line with National Society of Osteoporosis Guideline: Vitamin D and Bone Health (see Management of Vitamin D deficiency)
  • The following colecalciferol (vitamin D3) plus calcium products are included in the formulary (see 9.6.4 Vitamin D). It is accepted that patients post bariatric surgery may require non-formulary products and/or off-label doses. Specialists should be consulted for further advice

Accrete-D3®

  • Tablets calcium 600mg, colecalciferol 10 micrograms (400 units)

theiCal-D3®

  • Tablets (chewable) calcium 1g, colecalciferol 22 micrograms (880 units)

Notes

  1. theiCal-D3® is a once daily preparation which may aid patient compliance

Calfovit D3®

  • Powder, calcium 1.2 g, colecalciferol 20 micrograms (800 units)

Gastric bypass and sleeve gastrectomy

The gastric bypass impacts on the absorption of iron, vitamin B12, calcium and vitamin D. The longer term impact of the sleeve gastrectomy on nutrition is less well known but there are reports of low vitamin B12 levels and iron deficiency anaemia.

Some multivitamin supplements may not contain sufficient amounts of certain vitamins, minerals and trace elements to counteract the effects of bariatric surgery. Patients who have undergone gastric bypass or sleeve gastrectomy require a complete multivitamin and mineral supplement including iron, selenium, copper (2mg minimum) and zinc (ratio of 8-15mg zinc for each 1mg copper). Forceval is the only formulary product which is suitable for patients who have undergone bariatric surgery. See specific recommendations for patients who are planning pregnancy or who are pregnant.

BOMSS guidance (includes a range of over-the-counter "complete" vitamin and mineral supplements which meet the requirements for patients who have undergone bariatric surgery. If patients are intending to purchase their own products, it is important that they purchase from this list or follow guidance provided by their specialist centre. For over-the-counter products, patients should take two daily to meet the requirements following gastric bypass and sleeve gastrectomy.

Guidance from local bariatric surgery centres on supplementation following surgery may differ from BOMSS guidance:

  • Musgrove Park Hospital guidance can be found here:
  • University Plymouth Hospitals follow BOMSS guidance, found here
  • For other patients, follow current guidance from bariatric surgery centre or BOMSS guidance, found here

Vitamin and mineral requirements following gastric bypass and sleeve gastrectomy (BOMSS guidance):

Vitamin and mineral supplement
  • Forceval, take one capsule daily (see 9.6.7. Multivitamin preparations), or
  • Over-the-counter "complete" vitamin and mineral supplements recommended by patient's specialist or BOMSS, take two tablets daily
  • See specific recommendations for patients who are planning pregnancy or who are pregnant
Iron
  • Ferrous sulphate 200mg, or ferrous fumarate 210mg, or ferrous gluconate 300mg, take one tablet daily (see 9.1.1. Iron deficiency anaemias)
  • Menstruating women: ferrous sulphate 200mg or ferrous fumerate 210mg, take one tablet twice daily
Hydroxocobalamin (vitamin B12)
Calcium and Vitamin D
  • Patients are likely to be taking at least 800mg calcium and 20 micrograms vitamin D, however, many patients will require additional vitamin D
  • BOMSS recommend treatment and adjustment of vitamin D supplementation in line with National Society of Osteoporosis Guideline: Vitamin D and Bone Health (See Management of Vitamin D deficiency)
  • The following colecalciferol (vitamin D3) plus calcium products are included in the formulary (see 9.6.4 Vitamin D). It is accepted that patients post bariatric surgery may require non-formulary products and/or off-label doses. Specialists should be consulted for further advice

Accrete-D3®

  • Tablets calcium 600mg, colecalciferol 10 micrograms (400 units)

theiCal-D3®

  • Tablets (chewable) calcium 1g, colecalciferol 22 micrograms (880 units)

Notes

  1. theiCal-D3® is a once daily preparation which may aid patient compliance

Calfovit D3®

  • Powder, calcium 1.2 g, colecalciferol 20 micrograms (800 units)

Preconception and pregnancy

Seek specialist advice on nutritional supplementation for women who have undergone bariatric surgery and are planning to become pregnant or who are pregnant.

Women, as part of preconception care, are advised to avoid vitamin and mineral preparations which contain vitamin A in the retinol form in the first 12 weeks of pregnancy. Supplements containing retinol may increase the teratogenic risk especially in the first trimester. Prescribers should check that any supplements contain vitamin A in the beta carotene and not retinol form. Forceval capsules contain vitamin A in the beta carotene form and may be taken preconception and during pregnancy. Forceval soluble tablets contain vitamin A in the retinol form and should not be taken preconception and during pregnancy. BOMSS provides guidance on vitamin and mineral supplements which may be taken preconception and during pregnancy.

 

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