malabsorption of major micronutrients after bariatric procedures

Malabsorption of Major Micronutrients after Bariatric Procedures P a g e | 1

Malabsorption of Major Micronutrients after Bariatric Procedures, Physical Effects of Deficiency, and Preventive Measures

Kyle Valeski

University of Delaware


Abstract

The purpose of this paper is to examine the link between weight loss surgeries, otherwise

known as Bariatric surgeries, and the increased risk of nutrient deficiencies after surgery. These

types of surgical procedures severely limit the amount of calories and nutrients absorbed into the

body. Steps are generally taken to prevent these patients from experiencing any form of nutrient

deficiency in the form of vitamin supplementation, which is sometimes not enough nutritional

value, Patients are on a high protein diet, up to 100 grams per day (depending on their height),

which can make it difficult to consume foods high in micronutrients. This paper explores

research done on micronutrient malabsorption and deficiencies for post-operative patients, as

well as preventative measures that can be taken to avoid said deficiencies. Information sheets

have been created to aid those who may think they are at risk for micronutrient deficiencies, and

are based on previous research. These sheets contain information on common deficiencies and

preventative measures, vitamin supplementation information, and tips for proper hydration after

surgery. This information is meant to present vital information in a simple manner to individuals

who may not have a proper nutritional background.

Keywords: Bariatric surgery, malabsorption, micronutrients


Within the past three decades, bariatric weight loss procedures have become a safe and

effective method of modern day obesity prevention. Surgical procedures such as the gastric

bypass and stomach banding have helped a magnitude of people lose most of their excess fat and

return to a healthier lifestyle within a matter of months or years. While the results of a weight

loss surgery usually take place quickly, this weight loss only comes if the patient alters their

lifestyle choices, such as their diet and physical activity output. The diet of a bariatric patient is

somewhat of a drastic change, as the stomach is physically altered to retain much less food.

With less food comes less nutrients, which can cause an array of long lasting health issues. Steps

are taken to help the individual avoid suffering a deficiency through nutritional supplementation,

yet this option is not always enough for some individuals. The patient’s diet is very limited, and

due to such a high need for protein and very little room in the stomach, most of their food intake

does not include vital vitamins and minerals. Based on previous research, bariatric patients are

at a higher risk of developing vitamin and mineral deficiencies due to nutrient malabsorption,

and must use alternate diet strategies combined with supplements to ensure they are achieving

proper daily micronutrient intake.

Much of the basis for nutrient deficiency after weight loss surgery does not lie in the

patient’s inability to follow instructions as far as dieting goes, but insufficient changes in the diet

itself. Many patients are driven to meet their protein goals, and can cause patients to have a diet

of strictly focused on protein. Protein is an essential part of weight loss surgery, as protein

satisfies hunger quickly and promotes weight loss and maintenance. (Faria) Protein can be

consumed in either its natural form, which would be from food sources, or synthetic protein,

which is in the form of protein supplements such as protein bars and drinks. Both forms of


protein are acceptable, yet can be difficult to achieve when put on a low calorie diet following

surgery. Based on previous research, “Dietary Protein Intake and Bariatric Surgery Patients: A

Review”, it is stated that “an individual consuming a 478-kcal/day very-low-calorie diet would

need to consume 47% of their calories as proteins to obtain a minimally acceptable protein intake

of 52 g/day”. (Faria) This is still a minimal amount of protein for bariatric patients, as most

bariatric patients require 60-120 grams of protein, depending on height, body weight and the

level of weight loss. (Faria) Protein deficiencies are very rare among bariatric patients, yet can

occur, usually within the first 12 months following surgery. This is due to intolerance to protein

rich foods combined with a calorie restrictive diet for a long period of time (Moize). The main

deficiency issue after surgery is not protein, but micronutrients, which is something that patients

will usually focus less on compared to their protein intake.

With a low calorie diet and a focus on protein, patients may have difficulty finding ways

to create a diet that has adequate protein, low calories, and correct amounts of supplementation

throughout the day. While patients do have the option to supplement vitamins and minerals, this

is not always a reliable option as patients may have difficulties with ingesting their pills or

simply forget to take their supplements on a daily basis. Previous research has shown that due to

the malabsorptive nature of most weight loss surgeries partnered with the patients altered diet

containing low fat causes a higher chance of developing a deficiency in fat soluble vitamins.

(Xanthakos)

Vitamin D deficiency is prevalent in the United States; it is thought that up to fifty eight

percent (58%) of Americans suffer from some form of vitamin D deficiency. (Flancbaum)

Vitamin D is easily accessible, and can be obtained from sunlight, natural sources and

supplementation. After surgery most patients are prescribed a multi-vitamin, which must be


taken throughout the day to have any form of proper health benefit. Many studies have been

done on the recommended amount of vitamin D needed post bariatric surgery, as a deficiency in

vitamin B can have long lasting health issues. One study, titled “Serum fat-soluble vitamin

deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery “, suggests

that patients should intake a multivitamin containing 1200 IU (International Unit) of vitamin D

(Slater), while another study, “Preoperative nutritional status of patients undergoing Roux-en-Y

gastric bypass for morbid obesity’, suggests that 1200 is not a high enough dosage for post

bariatric patients, and that over time research will show a need for a higher doses of vitamin D.

(Flancbaum) While the exact dose is still unclear, it seems that the current vitamin dosages are

not offering a correct amount of vitamin D to post bariatric patients. One example is a

commonly used bariatric vitamin by the name of Bariatric Fusion. According to their nutritional

information published on their website, one vitamin contains 500 IU of vitamin D. (Nutritional

Information, Bariatric Fusion) Low dosages of vitamin D means that either the patients must rely

on taking multiple pills throughout the day, or find other sources of vitamin D. This company

also does not clarify if this pill contains vitamin D2 or D3, as vitamin D3 is a more efficient

storage form of vitamin D, yet usually D2 is found in most supplements. (Xanthakos) Taking

pills post-operation can be difficult for bariatric patients, as the stomach opening is smaller in

size. One study has shown that following a one year check-up of 46 post bariatric patients, all of

which received malabsorptive surgeries, stated that upwards of 57 percent (26 patients) were

considered vitamin D deficient. (Slater) Vitamin D deficiency can negatively affect the innate

immune system, which can lead to health problems such as “increasing risk of cancers, diabetes

mellitus, autoimmune diseases and cardiovascular disease”. (Xanthakos) Calcium absorption is

also greatly affected by a lack of vitamin D, which can lead to a variety of health problems


connected to a loss of bone tissue. (Xanthakos) Avoiding vitamin D deficiency can be difficult,

but one method is to inplement supplementation alongside natural sources like fortified foods,

milks that are low in fat and calories, eggs and fish (NIH, Vitamin D), and exposure to sunlight.

A sedentary period after surgery can lead to reduced sunlight, so it is vital that patients make an

effort to avoid sitting too long and try to walk outside in direct sunlight to increase vitamin D

levels. (Xanthakos)

Vitamin D may be the most prominent vitamin deficiency after Bariatric surgery, yet

vitamins A, K, and E are also an issue for bariatric patients, both pre-operative and post-

operative. According to the FDA daily reference values, a person on a 2000 calorie diet should

have an average intake of 5000 IU of vitamin A, 80 micrograms of vitamin K, and 30 IU of

vitamin E. (FDA) Supplementation for these vitamins is usually prescribed through a

multivitamin, yet comparing Bariatric Fusion multivitamins to FDA guidelines shows that none

of these vitamin needs are met through one Bariatric Fusion pill, and must be taken multiple

times throughout the day to ensure proper nutritional supplementation. One pill contains 1875

IU of vitamin A, 7.5 IU of vitamin E, and contains no vitamin K. (Nutritional Information)

Patients who suffer from a lack of micronutrients can experience an array of of health issues if

the patient is left deficient in vitamins A, E, and K.

Vitamin A plays a vital role in protecting the body from free radicals, as vitamins A is an

antioxidant. Antioxidants protect the body from oxidative stress, which can lead to chronic

illness and cancers. (Pereira) Based on information from the research article “Class III Obesity

and its Relationship with the Nutritional Status of Vitamin A in Pre- and Postoperative Gastric

Bypass,” 28.1% of their 114 participants showed signs of light vitamin A deficiency (0.7-1.5

mmol/L) after 180 days post-op, while 10.5% suffered from moderate vitamin A deficiency


(0.35-0.69 mmol/L)after 180 days post-op. (Pereira) Serum retinol and B-carotene were also

tested against participants BMI pre-op, 30 days post-op, and 180 days post-op. These results

showed little negative correlation, yet do not dismiss that even minimal vitamin A deficiencies

can pose an issue. (Pereira) Deficiencies in Vitamin A primarily affect eyesight, causing

conditions such as xerophthalmia, which is irritation of the corneas, and nyctalopia, which is a

condition causing night blindness. (Xanthakos) Vitamin A is easy to finds in many foods, many

of which are nutrient dense and low in calories. Spinach is an excellent source of vitamin A,

containing 229% of the daily value intake, and is extremely low is calories. Carrots are another

vital source of vitamin A, containing 184% of the daily value intake per half cup serving. (NIH,

Vitamin A) Combining low calorie, highly nutrient dense foods such as spinach and carrots with

vitamin A supplementation can aid bariatric patients in avoiding vitamin A deficiency.

Vitamin E and Vitamin K, the two remaining fat soluble vitamins, are rarely a health

issue for bariatric patients, yet can create health complications if there is an occurrence of

deficiency. According to the research article “Serum fat-soluble vitamin deficiency and

abnormal calcium metabolism after malabsorptive bariatric surgery,” Vitamin E deficiency is

quite rare, showing that the greatest incidence of vitamin E deficiency in their study (Less than

7mmol/L) was at two years post op, with six patients experiencing deficiencies out of 42 total

participants. (Slater) A deficiency in vitamin E, while being rare, can create issues regarding

malabsorption of Alpha-tocopherol, the form of vitamin E that is absorbed into the body.

Inability to absorb this form of vitamin E may have links with diseases such as Cystic fibrosis

and pancreatogenic steatorrhea. (Farrell) In the same research article, Vitamin K deficiencies

were found to be quite drastic; according to the researchers, by the end of the fourth year follow

up, “42% of patients had serum vitamin K levels below the measurable range of 0.1 nmol/L


compared with 14% at the end of the first year.” (Slater) Another study states that up to 68% of

post-op Biliopancreatic diversion patients experience some form of vitamin K deficiency.

(Xanthakos) While there are various research studies done to prove that bariatric patients suffer

from some form of vitamin K deficiency, there has been little evidence of major health effects

after surgery. Deficiency in vitamin K can lead to issues with blood clotting and gastrointestinal

bleeding, there is documented cases linked between vitamin K and severe bleeding of the

intestines after malabsorptive surgeries (Slater). Vitamin E is mainly found in seeds and nuts,

such as almonds (6.8 mg per ounce, 34% DV) and sunflower seeds (7.4 mg per ounce, 37% DV),

yet both type of nuts are usually avoided after bariatric surgery due to their higher fat content.

Oils, such as vegetable oil and wheat germ oil, are also higher sources of vitamin E, with wheat

germ oil contains nearly 100% daily value of vitamin E. (NIH, Vitamin E) Vitamin K can be

found in leafy greens, which are nutrient dense. Greens such as Kale, spinach, and turnip greens

contain 113 micrograms (141% DV), 145 micrograms (181%) and 426 micrograms (532% DV),

respectively. (NIH, Vitamin K)

Vitamin B12, while not a fat soluble vitamin, can pose a risk for bariatric patients if

absent from their diets post-operation. According to the FDA daily intake values, a standard diet

should consist of 6 micrograms of Vitamin B12 daily. (FDA) Vitamin B12, otherwise known as

Cobalamin, is a water soluble vitamin, which means that these vitamins are not stored in the

body’s fat, and access of these the vitamins not used by the body will be lost through sweat and

urine. Water soluble vitamins are needed throughout the day, which can be difficult for bariatric

patients who already have difficulty retaining nutrients. Vitamin B12, like other protein bound

nutrients, are greatly limited after malabsorptive procedures due to much of the intestinal tract

being passed over and reduced secretion of stomach acid. (Xanthakos) A 2008 study,


“Prevalence of Iron, Folate, and Vitamin B12 Deficiency Anemia after Laparoscopic Roux-en-Y

Gastric Bypass”, analyzed the data of 74 post bariatric patients up to three years post-operation.

The studies found that out of 30 patients in a six month follow up, two tested for vitamin B12

deficiency (less than 150 pg/ml), three out of 30 in the one year follow up, five out of 30 in the

two year follow up, and two out of 11 in the three year follow up. (Vargas-Ruiz) Based on this

evidence, patients gradually developed vitamin B12 deficiencies up until two years post

operation. Time seems to play a slight role in deficiency, as each data set showed a slight

increase of deficient patients over time. A similar study, “Vitamin B12 Deficiency After Gastric

Bypass Surgery for Obesity”, came to a similar conclusion regarding B12 deficiency after

bariatric surgery. This research tested 50 patients, 21 having normal B12 levels and 29 having a

below average B12 serum level, and gave all participants vitamin B12 supplementation daily for

a three month time span. 47 of the 50 had an increase in their B12 levels, yet the mean of all the

participants serum B12 levels still fell below average. (Shilling) Multiple articles of research

show that even with proper supplementation, post bariatric patients still suffer from low levels of

B12, which can lead to anemia if left unchecked for a substantial period of time. (Vargas-Ruiz)

Many food sources that are high in protein also contain high amounts of B12. Seafood is an

excellent source of B12, such as tuna, trout and salmon. These fish are all low calorie, high

protein foods, and contain anywhere from two to four micrograms of B12 per 3 ounce serving.

Bariatric patients may not be able to handle large portion right after surgery, yet smaller portions

still contain adequate amounts of B12. Yogurts containing fruits, which are usually implemented

into bariatric diets, contain 1.1, or 18% daily value of B12. (NIH, Vitamin B12). While some

patients might finds it difficult to reach their B12 threshold every day, the body can store around

2000 micrograms, as long as B12 intake is spread out in a timely manner throughout the day.


(Vargas-Ruiz) Vitamin B12 should not be overshadowed by fat soluble vitamins, as each

vitamin is essential for bariatric patients to fulfill their goal of a healthier lifestyle.

Among all micronutrients deficiencies, minerals are the most common and recognizable

deficiencies in post bariatric patients. Trace minerals, which are needed in very small amounts

in the body, often do not make their way into the diets of post bariatric diets. Iron, a trace

mineral, is an extremely common deficiency, occurring in up to an estimated 47% of post

bariatric patients at some point in time, (Xanthakos) while other studies have found even higher

levels of iron deficiency in their testing groups, such as 54% in three year range post-operative

patients. (Vargas) The daily intake value for iron falls at 18 mg. (FDA) Due to iron being

absorbed mainly in the duodenum and jejunum, both of which are bypassed after malabsorptive

surgery, many patients suffer any inability to properly absorb most of the iron they take in.

(Vargas-Ruiz) A 1999 study titled “Iron Absorption and Therapy after Gastric Bypass” explores

iron absorption in bariatric patients both with and without an iron supplement in the form of

ferrous gluconate. Their findings showed that out of the 55 patients who took the 50 mg iron

supplement, 19 of the patients experienced a below average iron absorption rate. (Rhode) 29 of

the same participants also underwent a second clinical trial, this time taking an iron supplement

for one month, followed by an iron supplement combined with a vitamin C supplement. While

the iron supplement alone increased ferritin levels, the groups noticed a larger ferritin increase

when paired with vitamin C. (Rhode) With iron having such a large impact in red blood cells, it

is common for iron deficient patients to develop anemia. (Vargas-Ruiz) To prevent iron loss and

potentially anemia, patients need to find a balance between artificially made iron supplements,

and naturally occurring ferritin in foods. This can be a difficult task, as many foods do not

contain a high serving of iron. Many breakfast cereals are fortified with iron; it is important to


find a cereal that is low in calories and does not contain artificial sugars, as artificial sugars turn

to fat and can lead to Dumping Syndrome. Beans are source of iron that is also abundant in

protein and various other micronutrients, containing up to 44% daily intake for a cup of beans.

(NIH, Iron)

With such a large focus on fat soluble vitamins and retaining iron and calcium after

surgery, some micronutrients are looked over in regards to their deficiencies post operation.

Zinc has become one of the larger researched trace minerals after malabsorptive surgeries, as

many studies provide evidence of excessive loss of zinc, even with supplements. In the research

article “Vitamin and Trace Mineral Levels after Laparoscopic Gastric Bypass”, 36% of their 33

one year checkup patients suffered from abnormal zinc levels. (Madan) This data is somewhat

concerning, as zinc is already a common deficiency in pre-operative patients who are obese.

(Salle) Patients that have a difficult time absorbing zinc, while post-bariatric patients experience

continued absorption difficulties with malabsorption procedures. A similar study, “Zinc

Deficiency: A Frequent and Underestimated Complication After Bariatric Surgery”, conducted a

similar study, yet with a larger patient group and a larger breakdown of data. 266 pre-surgical

patients were selected, and 8.1% of the patients suffered from zinc deficiency pre-surgery. All

266 patients underwent Roux-en-Y gastric bypass surgery, and no patients took zinc

supplementation before their surgical procedure. Post-surgical data showed that out of the 146

patients that were consulted in the follow up blood plasma testing, 40.7 of these patients suffered

from zinc deficiency, while 17 of these patients were taking some form of zinc supplementation.

There is a positive correlation between successful malabsorptive surgical procedures, yet zinc

deficiency levels seem to level off after one year, as opposed to iron levels constantly decreasing

over time. (Salle) At 12 months, 146 patients experienced a mean total mass weight loss of


32.4% of their total weight, showing that their procedure triggered a substantial amount of

weight loss. These studies show that zinc deficiency is common in both obese and bariatric

malabsorptive patients, yet the latter suffer from a sharp increase and need increased

supplementation to avoid the negative health risks associated with a loss in zinc. The main issue

is that zinc deficiency can be overlooked, yet is a commonly occurring deficiency coupled with

protein deficiency. (Salle) One case of an acrodermatitis enteropathica based rash occurred in a

gastric bypass patient. While she suffered from multiple nutrient deficiencies due to avoiding her

multivitamin supplements, acrodermatitis enteropathica based rashes have been found to have a

link to zinc deficiencies. (Helen) To avoid a zinc deficiency, patients should aim for 11 mg of

zinc a day, and always choose a multivitamin that also has a focus on trace minerals, and not just

the major fat soluble vitamins. Proper nutrition after surgery is also an essential step, yet can be

challenging as very little foods naturally contain large amounts of zinc. Oysters, at three ounces,

contain 74 mg of zinc, which is 493% the daily intake recommendation. This number may seem

impressive, but the body has little ability to store zinc, as zinc storage in the body is limited to

around 3 mg. (Salle) Crab meat (3 ounces) contains 43% daily value intake (6.5 mg), and is a

food that is high in protein. Many other sources of zinc are various meats, such as beef, (5.3mg

at 3 ounces) pork (2.9 mg at 3 ounces), and lobster (3.4 mg at 3 ounces). Various nuts contain

small traces of zinc, yet contain phytates which limit the bioavailability of zinc. (NIH, Zinc)

After a patient undergoes any form of bariatric surgery, a major concern is proper

consumption of fluids post-operatively. Post-op patients should avoid liquids with artificial

sugars and beverages that contain carbonation. Alcohol should be avoided for the first year after

surgery; it is recommended that the patient stop drinking alcohol for the rest of their life.

Recommended liquid intake is a minimum of 64 ounces daily. (Elkins) In the study


“Noncompliance with Behavioral Recommendations Following Bariatric Surgery”, 100 post-

surgical bariatric patients were tested on various noncompliant factors, such as continued soda

use, and limited attempts to increase proper liquid consumption. At a six month follow up, 4%

were still drinking soda, and 14% were not meeting recommended liquid intake. At 12 months,

2% were still drinking sodas, while 7% were not drinking enough water. (Elkin) Most patients

understand the importance of hydration, and understand that dehydration is a major health issue

after surgery. This data shows that many bariatric patients understand how to properly hydrate

themselves after a surgical procedure with the correct amount of liquids.

Based on previous research done on malabsorptive practices and its effect on

micronutrient absorption, three fact sheets have been created to properly educate pre-bariatric

patients on their nutrient status after surgery. A large focus before surgery is about obtaining the

proper amount of protein needs. Protein is the key component in regards to nutrients after

surgery, yet this extreme focus makes it seems as though other nutrients do not matter as much as

protein. Patients are also taught about proper vitamin supplementation, yet many believe that

this supplement is all they need for micronutrients. Micronutrients from natural sources carry a

higher amount of bioavailability, and are needed in case patients either forget to take their

supplemental pill on a daily basis or have difficulty ingesting pills. Each fact sheet covers a

specific subject, such as nutrient comparisons for supplemental vitamins, proper hydration, and

vitamin/mineral nutrient information from natural sources. These fact sheets contain information

that is simple to understand, as patients come from all educational backgrounds. Assuring that

every patient can comprehend the information presented in essential to properly assisting patients

in their post-operational healthy lifestyle.


The first information sheet titled “Is My Multivitamin Enough?” (Pages 18-19), which

explains the concept of malabsorption in a simple manner, so that the rest of the information

sheets are easier to comprehend. The definition of micronutrients is also explained in case the

patient viewing the information sheet does not have a strong nutritional background. The data

presented compares a standard Bariatric vitamin that is taken by post-operative patients to up to

date RDA guidelines. This data is comparing the serving for one bariatric multivitamin, which

does not supply a full dose of dietary intake values for most micronutrients available in the pill.

The patient can use this information to either realize that many doses of multivitamins are

needed throughout the day, or to supplement micronutrients while obtaining micronutrients from

natural food sources. Five healthy food choices are also presented on this information sheet,

containing information regarding protein, fat, micronutrients, and calories.

The second collection of information sheet, “Vitamins and Minerals after Surgery” (Page

20), educates the patients on the different types of bariatric procedures. These forms are aimed

more towards those patients who will undergo a form of malabsorptive procedure. Patients

should understand the difference between a restrictive surgery and a malabsorptive surgery, as

each function differently and have a different effect on nutrient absorption. Once the patients

understand the difference between the two major forms of bariatric surgery, they can read about

major vitamin and mineral deficiencies commonly found post-operatively. The sheet focusing

on vitamin deficiency, “Adding Vitamins to your Diet” (Page 21) explains which deficient

vitamins are fat soluble, and which water soluble are. Due to bariatric surgery patients having

limited fat intake after surgery, fat soluble vitamins are harder to retain in the body. Vitamin

deficiencies in vitamins A, K, D, and B12 and presented for the patients so that can have a basic

understanding of some of the warning signs of a deficiency issue. Examples are then listed for


foods that provide a sufficient amount of vitamins, while also provided some form of protein

(disregarding vitamin K dense foods). Patients can use this information to find ways to add

natural sources of vitamins to their daily diet routine. “Adding Minerals to your Diet” (Page 22)

expands on the concept of major minerals and trace minerals. The information focuses on the

two larger minerals deficiencies, calcium and iron. Deficiency signs are presented for both

minerals, so that the patients has a clear understanding of what signs to look for if the patient

suspected they suffer from a deficiency. Calcium deficiency is largely associated with loss of

vitamin D. The information sheet explains that calcium and vitamin D both play a large impact

on bone density, and that a deficiency in vitamin D means there is a chance that there is a

deficiency in calcium. Iron is largely associated with anemia. This information sheet explains

the signs of loss of oxygenated blood cells so that the patient can identify if they may be

suffering from anemia. As many deficiencies share common signs, patients should be aware that

only a blood test can truly identify which deficiencies are present. These sheets are for

informational use and to aid in micronutrient consumption before a deficiency occurs.

The final information sheet presented, “Hydration and You” (Pages 23-24) focuses on

creative ways to incorporate water around the patient’s diet. Bariatric patients are advised to not

drink water while eating and to drink water in small sips throughout the day, which in some

cases can cause patients to forget to properly hydrate. Each of the four categories mentioned in

this information sheet gives suggestions to ensure the patients remembers to drink acceptable

liquids. The first category informs the patient on acceptable liquids after surgery. Decaffeinated

coffees and teas are liquids with additional health benefits and are considered acceptable liquids

after bariatric surgery. Flavored waters are another method to create a more diverse variety of

liquids for the patient. Many bottled water companies sell flavored waters based on fruit flavors.


Patients can create their own flavored water by adding fruits and vegetables to water. These

mixtures can be used to hydrate and to receive the health benefits from the fruits and vegetables

being used. The final category informs patients on larger water containers that can contain a

days’ worth of liquid. Seeing the amount of liquids consumed for that day can help a client

realize how much more they need to drink, or if they are not drinking at an adequate pace for that

day.

Weight loss surgeries have become a revolutionary method in a world where obesity has

become an epidemic. Every year more individuals are diagnosed as obese, and more people turn

to bariatric surgeries to create a better life for themselves. Weight loss surgeries are a gateway

for individuals who want to live a healthy lifestyle, and keep the excess weight off for life.

These weight loss procedures are very beneficial and have a high success rate, yet come with

additional health risks. One of these higher risks is developing a micronutrient deficiency. With

the proper preventative information and dietary supplementation, weight loss patients will be

able to fulfill their goal of weight loss without suffering from the negative health issues

surrounding deficiencies from micronutrients.

Is my Multivitamin Enough?


After bariatric surgery, your body may lose some of its ability to absorb nutrients from food and limits the amount of food you can take in at once. The body doesn’t always get the proper amounts of micronutrients after surgery. Micronutrients are vitamins (vitamin A, vitamin D, etc.), minerals (iron, potassium, iodine, etc.). Multivitamins are a great way to add needed vitamins and minerals to your diet. These vitamin supplements are essential in almost any post-operative diet, but are they giving you all the nutrients your body needs? Let’s compare Bariatric Fusion Vitamin nutritional info with RDA daily guidelines:

Vitamin A

Vitamin D

Vitamin E

VitaminB6

Vitamin B12

Calcium Iron Iodine Zinc

Bariatric Fusion (One pill=one serving size)

1875 IU 500 IU 7.5 IU 0.5 mg 140 mcg

300 mg 7.5 mg

37.5 mcg

7.5 mg

RDA Guidelines (as of July 2016)

3000 IU (Men)2300 IU (Woman)

600 IU 22 IU 1.3 mg 2.4 mcg 1000 mg

18 mg

150 mcg

11 mg (Men)8 mg (Women)

Many of these single serving Multivitamins do not meet the RDA doses!!!

Not only that, but this is considering that all of the nutrients are being absorbed, while some of these vitamins and minerals will not be fully absorbed. An example is Vitamin A; this multivitamin contains 65% the daily dose for men, and around 82% for woman, but what if only 900 IU gets absorbed? That would drop these percentages by over half! One solution is to take more than one multivitamin throughout the day. Ask your doctor how many multivitamins you will need in a day. Make sure to take these at different times of the day, as the body can only absorb so much at once! To get the right amount of vitamins and minerals into your daily diet, try some of these super foods that contain not only contain lots of vitamins and minerals, but are low in calories as well!


Salmon: This fish is high in oily fats, high in protein, and contains good amounts of vitamin A and potassium. Salmon is a lean meat with little calories making it very nutritious!

Kale: This leafy green is extremely low in calories and fat, yet very high in essential vitamins like vitamin A and C!

Sardines: Like most fish, sardines are high in protein and fats, and

contain great amounts of potassium and calcium.

Eggs (with yolk): Eggs are a good source of protein, vitamin A, vitamin C, calcium, and Iron. Try cooking eggs in a variety of ways to mix up your diet!

Quinoa: Adding quinoa throughout your diet can be a high source of fiber and protein, while getting much needed amounts of minerals such as copper and iron.


Vitamins and Minerals after SurgeryWhile much of the emphasis post-surgery is all about protein, remembering to take vitamins and minerals is very important. After surgery, it is very difficult to eat enough foods to meet vitamin and mineral needs. To prevent malnutrition, you must take the vitamins your doctor advises you to take, as well as eat foods high in vitamins and minerals.

Did you have…

A restrictive surgery? Ie. Gastric Band or Sleeve

Restrictive surgeries limit the amount of food that can enter the stomach at once. These procedures allow for more nutrients to be absorbed than other weight loss surgeries.

A malabsorptive surgery? Ie. GBP or BPD This type of surgery involves removing or bypassing most of the stomach and alters the path in which food takes in the intestinal track to limit caloric absorption. The diversion can also be combined with the duodenal switch. This type of surgery allows fewer nutrients to be absorbed than a restrictive surgery.

Below are the vitamins and minerals that are at a high risk of deficiency after surgery.

Vitamins Minerals

Vitamin A Vitamin D Calcium Iron

Vitamin K Vitamin B12

Adding Vitamins to your Diet


Vitamins A, D, and K are fat soluble vitamins. The post bariatric diet is low in fat, making it difficult to absorb enough vitamins. It is important to know the warnings of low vitamin intake, specifically the fat soluble vitamins. B12 is also a common vitamin deficiency, but is water soluble and easier to obtain in a diet.

Vitamin A: Inability to see well in the dark, inability to produce tears (xerophthalmia) prone to infections

Vitamin D: Weak bone density, bones softening (osteomalacia)

Vitamin K: Excessive bleeding from wounds, bruising, blood in urine and/or stool

Vitamin B12: Fatigue, anemia, neurological damage, numbness, depression, memory loss

Try adding these foods to your to reduce your risk of vitamin deficiency and mix up your diet. Most of these foods are also high in protein!

Vitamin A: Eggs with yolk, cheese, milk, oatmeal

Vitamin D: Milks, cheeses, sardines, cod, egg yolks, tofu, pork

Vitamin K: Kale, spinach

Vitamin B12: Fish (cod, sardines), eggs with yolk, red meats (steak, beef, etc.), milk and yogurt

Adding Minerals to your Diet


There are many minerals that the body needs to stay healthy before and after surgery. Bariatric patients display lower levels of calcium and iron, which can have lasting health effects. These deficiencies can be hard to treat, so make sure to know the signs!

Calcium Iron

-Numbness in various aspects of -Headaches and dizziness

the extremities, such as hands and feet -Fatigue and overall weakness

-Muscle spasms -Chest pains/irregular heartbeat

-Depression -Cravings for non-nutritious substances

-Brittle nails that break off easily

Calcium and iron deficiencies can lead to very serious health issues long term. Calcium and vitamin D deficiencies, can lead to serious bone problems like osteopetrosis. Iron deficiency leads to iron-deficiency anemia. The main concern with iron deficiency anemia is long term issues with the heart if not treated. Make sure to take the recommended dosage of minerals through supplements combined with these foods to ensure adequate intake.

Calcium: Egg yolks, milk, cheeses, spinach, chickpeas, almonds, soybeans

Iron: Tofu products, potatoes, soybeans, peanuts and peanut butter, wheat products, chickpeas, spinach

Hydration and You


After your bariatric surgery, it is important that you drink a good amount of liquid on a day to day basis. Since eating and drinking have to take place at different times after surgery, it may be difficult to remember to drink throughout the day. Planning your diet is important, and so is planning your drinking! Try to drink at least 64 ounces of liquid a day! Here are fun ways to make hydration more interesting.

Mix it up! All 64 ounces don’t have to be water. Try drinking decaf coffees or decaf teas (With no sugars) to take a break from plain water. Coffees and teas also have their own health benefits, such as antioxidants and reduced risk of diabetes!

Try flavored waters! Many companies make waters that are flavored after fruits like blackberry or strawberry. These waters usually do not have any added calories or sugars, but always be sure to check before you buy!

DIY Flavored water! Adding fruits and veggies to your water can be a fun way to stay hydrated. Try out different varieties to find which combo is your favorite!

Keep your liquids in one place! Instead of drinking many small portions throughout the day, keep a large container of water with you. 64 ounces of water is the same as a half-gallon, so filling up a half gallon of water will give you that days’ hydration requirements! This way, you can see how much you have drunk for already, and how


much more you need to drink. Try adding labels to the side of the container that will give you a time frame of how much has been drunk already.

Look out for the signs of Dehydration!!!

Fatigue Whitened tongue Excessive thirst

Dried Skin Headaches

Light-headed Cloudy/yellow urine Infrequent urination

Make sure to drink more if you experience one or more of these symptoms!

If symptoms persist, talk to your doctor, or go to the nearest ER Facility!

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