If you are considering or have already undergone Bariatric surgery, you are probably aware that you should take some form of nutritional supplementation for the rest of your life. The American Medical Association recently made a recommendation that everyone should take a daily multivitamin and mineral supplement based on evidence that our diets don't really supply the nutrition we need.
This is even truer after gastric bypass for two primary reasons:
1) typical bypass surgery changes the way some critical nutrients are absorbed.
2) the reduced food portions and dietary restrictions that are required after surgery mean that even fewer nutrients are consumed.
So the question is not should you supplement, but rather what should you look for when you choose a supplement to take. While new labeling laws have required manufacturers to put more information on their labels to inform consumers, most people would still need a degree in nutrition and a good magnifying glass to decipher it. The following is a list of relatively simple things you can look at when evaluating a nutritional product with some special considerations for gastric bypass patients.
1. Start by looking at the nutrition facts box. This is the place on the label where the amounts and usually forms of the nutrients are listed together with the percentage of the Recommended Daily Allowance (RDA). It is best for vitamins to be at least 100% of the RDA and for minerals except iron, fluoride, phosphorus and electrolytes (such as sodium and potassium) to be at least 50%. Many formulas really skimp on minerals because they take up a lot of space. The average once daily multivitamin contains 100 milligrams or less of calcium, for example. Since bone loss may be more pronounced after gastric bypass, this is important to consider.
2. Many higher quality products are not in once daily preparations. Why? One reason is space for denser nutrients such as minerals. Another thing to consider is absorption. Just as we want to divide our food intake throughout the day to maximize nutrient intake and maintain our energy, the same can be said for vitamins.
3. Are the nutrients labeled as USP and or NF? A USP designation means that the ingredient meets the criteria of the United States Pharmacopoeia. An NF designation means then the nutrient meet the criteria for the National Formulary. These are standards of quality control and reflect pharmaceutical quality for an ingredient. These standards are currently available for around 1800 substances, so not all nutrients are available in this form.
4. Does the product meet the USP requirements for disintegration and dissolution? This is very important after gastric bypass as this means that the product has been rigorously tested to make sure that it breaks down in the digestive system in a certain amount of time. This information may not be on the label – you may need to contact the manufacturer to find out. The USP requirement for capsules is 30 minutes, for tablets 45. For this reason, a USP tested capsule or a chewable formula may be best after bypass surgery.
5. Next look at the total ingredients list. This is a long list of everything that goes into the product. This list should disclose everything including non-nutritional ingredients.
6. Look specifically at the vitamin A. How much is from non-toxic beta-carotene. It is best to get vitamin A in this form, as it cannot be overdosed.
7. Look at the vitamin E. Is it in a natural form? The natural forms of vitamin E are listed as “d” forms such as d-alpha tocopheryl acetate or succinate. If the form is preceded by “dl” then it is synthetic. Natural forms of vitamin E are significantly more bioavailable . You may need to look in the total ingredient listing to see this information.
8. Look at the vitamin D. Is it D2 (synthetic, ergocalciferol) or D3 (natural, cholecalciferol)? This is important for gastric bypass patients because patients with clinical morbid obesity may not be able to convert D2 to the active form of vitamin D needed for bone health.
9. What forms are the minerals in? Many supplements use inorganic oxides that are hard to digest and have relatively poor bioavailability . It is best to see the minerals as citrates, malates, gluconates or amino acid chelates. Some specific minerals have special forms that are more bioavailable such as selenomethionine for selenium and the picolinoate or polynicotinate form of chromium. Many forms of iron can cause constipation – especially ferrous sulfate. Look for a citrate, glycinate or chelate.
10. Does the product contain herbs or herbal extracts? This is important to consider especially if you are taking prescription medications as there may be interactions . While it is becoming quite popular to include herbs in vitamin supplements now, it would be best to seek the advice of your physician before taking something with herbal ingredients.
11. What else is in your vitamin? Many people are shocked to find the number of “other” ingredients in their supplements. Some things that you may find on a label that don't need to be there include:
Artificial colors – these are there for looks alone and have the potential to cause allergic reaction in sensitive individuals. They are not essential for health.
Artificial flavors – most common in chewable formulas
Sugars – common are fructose (fruit sugar), lactose (milk sugar), glucose and sucrose. This is important to consider if you are restricting sugars, have diabetes, or are intolerant to milk sugar/lactose.
Artificial sweeteners – such as acesulfame-K or aspartame. Again, no health benefit and may be harmful to some individuals. A better choice is sucralose, which is derived from sugar, or sugar alcohols such as sorbitol, xylitol, or maltitol in small amounts (although large amounts of sugar alcohols can cause gas and diarrhea).
Other ingredients that sometimes show up are hydrogenated or partially hydrogenated fats, starches, and preservatives.
Bottom line – the shorter the list of “other” ingredients, the better.
12. You might also want to ask you doctor for his or her recommendation. Some physicians recommend additional minerals, sublingual B12, or other special nutrition based on your health and laboratory data.
Choosing a good quality supplement after gastric bypass is an important part of promoting your lifelong health. While this list is not exhaustive, it provides some basic things to help you evaluate the quality and value of what you are purchasing. Higher quality products may come with a higher price tag, but can be worth it if the nutrients are better absorbed, don't upset your digestive system, and don't contain a lot of non-nutritive ingredients.
Regardless of what you choose to take, ultimately the most important thing you can do is to take it. I am fond of telling my patients that an unopened bottle sitting on shelf won't do anything for you. Taking vitamins is a habit, and just as you need to take on new dietary habits after gastric bypass, you will need to learn to fit supplementation into your life. So once you have found a product that works for you, find a regimen that works for you as well.
Even if you are taking your supplements regularly, there is still the possibility of developing nutrient deficiencies. For this reason, it is important to have a regular physical and blood work. Your surgeon may recommend special tests to evaluate nutritional status in addition to standard blood work. If you develop a new symptom such as persistent fatigue, it is important to inform your doctor so that appropriate evaluation can be done.
Ask your physician
Even if you are taking your supplements regularly, there is still the possibility of developing nutrient deficiencies. For this reason, it is important to have an annual physical and blood panel. Your Primary Care Physician (PCP) may recommend special tests to evaluate nutritional status in addition to standard blood work. If you develop a new symptom such as persistent fatigue, it is important to inform your doctor so that appropriate evaluation can be done.
Weight loss success after Bariatric surgery does not rely on a reduced calorie diet alone. The surgery you underwent will control your hunger and will make you full and satiated from small amounts of food. You will have successful weight loss if you follow the rules, and eat healthy and nutritious meals.
You will never have to go on a diet again, but you will have to choose what you eat wisely. We hope you will come to realize that once your meal portions are reduced to 1 to 1 1/2 cups of food per meal, your meals will have to be nutritious because you are now eating very little food and you have to make better food choices to stay healthy.
A diet that is low in carbohydrates and fats and high in quality protein is essential, along with vitamin and mineral supplementation, to lose weight successfully and stay healthy. 70% of your calories have to be protein, with a minimal intake of 60 to 75 gm of protein per day. Poor protein intake will result in muscle wasting, hair loss and poor ability to heal. When the body does not take in enough protein through diet it will look for it in muscle, and cause muscle breakdown. The body cannot make the essential amino acids to make protein; diet is the only source of these amino acids.
At least half of every Bariatric patients’ meal has to be protein (20 to 30 gm), next on your plate should be a fruit or vegetable. Always eat protein first, then the other things on your plate. This way if you get full, you at least ate your minimum of protein per meal. Starches and fats have the least nutritional value to a Bariatric patient.
Protein will be the most important nutrient in your diet. Protein is the basic building block our bodies use to repair and replace tissue. You will need to monitor your protein intake for the remainder of your life (minimum 60 to 75gm/day). This is a normal amount of protein that every human being should be eating daily. The reason why a Bariatric patient needs to be aware of his/her protein intake is because after surgery they are unable to eat 60 to 100gm of protein in one meal anymore. On average, after weight loss surgery a person can only eat 20 to 30gm of protein per meal. Without adequate protein, serious complications can arise, including neurological deficits as well as heart, liver and kidney problems long term.
You can purchase a paperback book that lists protein and carbohydrate content in foods in grams. Use it until you have developed a good feel for which foods are rich in protein as well as which foods are not. Also learn how much protein certain foods have compared to others. If you have protein with every meal, and at least half of every meal is protein (a deck of playing cards is about 3 ounces of meat or fish) you should be able to eat 21 to 24 gm of protein per meal, ensuring at least 60gm of protein per day. By making half of every meal a high quality protein you can avoid the protein counting.
Examples of foods high in protein:
Sugars / Carbohydrates
Avoid simple carbohydrates or white sugar/starch (refined/simple sugars/corn starch), especially in liquid form! Simple sugars, particularly in the liquid form are known to cause the Dumping Syndrome and weight gain.
A very important part of your diet change will be eating complex sugars instead of simple, refined sugars found in candy, pastries, cake, pasta, white bread, flour, chips, pretzels, cookies, ice cream, chocolate, soda, flavored coffee drinks, juices, smoothies or when corn starch is listed as the main ingredient. Simple sugars, especially in liquid form, cause weight gain. It will not matter how small we make your pouch – liquids will pass thru very quickly without giving you any satiety, but a lot of calories. None of the obesity surgery operations can protect you against weight gain if you continue to drink high calorie liquids. The surgeries are designed to work against solid foods (meat and potato kind of meals).
Sugar and foods high in sugar should be avoided because of high calories. Sugar is such a poor nutrition source, we recommend that patients avoid simple sugars altogether and concentrate instead on protein intake. Complex carbohydrates (complex sugars) are better tolerated, and in general should be kept to approximately 15 to 20% of your diet to avoid weight gain and dumping.
Recommended complex carbohydrates:
High fat foods, like sugar, can cause weight gain. Avoid fried foods, and high fat content foods. Fat is a great energy store but has low nutritional value. Become a label reader.
Below is a list of recommendations. Fat is allowed in your diet, but choose wisely – fat is often accompanied by high sugar content foods.
To stay hydrated, you will need to drink clear liquids almost constantly. Everyone should drink approximately 8 (8oz) glasses of water per day (about 2 liters of fluid per day). If you are thirsty or your urine is very dark with a strong odor, you are not drinking enough. Use your thirst and your urine output as a guide to drinking liquids. Sip as much clear, sugar-free liquids as you can tolerate except for 15 minutes before a solid meal, during your meal and 90 minutes after a solid meal. Otherwise there are no restrictions on how much you can drink. You will also notice that you may not be able to drink a glass of water in a few seconds. It will likely take you a few minutes to drink a glass of water after the surgery.
Recommended clear liquids:
Please note, your liquids have to be low in sugar or sugar free. Choose juices that are 100% fruit juice with no added sugar. Consumption of high calorie liquids will result in poor weight loss. Limit high calorie liquids (example: juices to 4oz/day).
Because of the protein–rich, sugar-restricted diet, the body enters a state of ketosis (breaking down fat to create sugar). When the body creates sugar in this way it also creates waste, which the kidneys eliminate. Water is very important in helping the kidneys eliminate the harmful waste and avoiding kidney problems. There is no limit on how much clear liquids you can take.