Section 16: Supplements and blood tests

Supplements

Due to the ways in which the gastric bypass and sleeve gastrectomy work, your ability to absorb micronutrients (vitamins and minerals) is permanently compromised. This puts you at risk of developing various nutritional deficiencies. It is therefore recommended that you take vitamin and mineral supplementation for life in addition to eating a varied and balanced diet.

In October 2014, BOMSS (the British Obesity & Metabolic Surgery Society) produced guidelines on the micronutrient (vitamin and mineral) supplements recommended following surgery. This forms the basis of the advice given below.

Remember

Solid tablets should be completely avoided for at least the first 4 weeks after surgery; chewable or soluble varieties should be used during this time. 

Tablets less than 1cm in diameter can be recommenced 4 weeks after surgery if you have progressed onto solid food.

Tablets larger than 1cm in diameter can be recommenced:

• 6 weeks after surgery (gastric bypass)
• 12 weeks after surgery (sleeve gastrectomy)

Multivitamins and minerals

Requirement: must contain iron, selenium, 2mg copper and 16-30mg zinc in a daily dose.

The only variety available in the UK that meets these requirements is called Forceval.  This is only available on prescription or over-the-counter from a pharmacy, including our pharmacy (at additional cost). It is available in soluble and capsule versions. The capsule version is more than 1cm in diameter, so the soluble version should be used until you can re-start capsules of this size (see above).

There are no off-the-shelf chewable or soluble varieties widely available in the UK which meet the recommendations. The one that comes closest is called Centrum Fruity Chewables, and should be taken twice a day.

Once you are able to take solid tablets again, if you are unable to obtain or tolerate Forceval, there are a number of off-the-shelf varieties, which if taken twice daily will provide the recommended amounts:

• Aldi Activ-Max A-Z Multivitamin & Mineral Tablets
• Asda Wellbeing A-Z Multivitamins & Minerals https://groceries.asda.com/product/adult-multivitamins/asda-wellbeing-a-z-multivitamins-minerals-1-a-day-tablets/910001558934
• Boots Vegan A-Z Wellness Formula https://www.boots.com/boots-vegan-a-z-wellness-formula---60-tablets-10270058
• Lloyd’s Pharmacy Tesco A-Z Multivitamins & Minerals http://www.lloydspharmacy.com/en/lloydspharmacy-a-z-multivitamins-minerals-90-tablets
• Morrison’s A-Z Multivitamins & Minerals https://groceries.morrisons.com/products/morrisons-a-z-multi-vitamins-363141011
• Sainsbury’s A-Z Multivitamins & Minerals https://www.sainsburys.co.uk/gol-ui/product/vitamins-and-supplements-/sainsburys-a-z-multivitamins---minerals-x-180
• Sanatogen A-Z Complete https://www.sanatogen.co.uk/en/sanatogen-range/sanatogen-az-complete/index.php
• Superdrug A-Z Multivitamins + Minerals https://www.superdrug.com/Health/Vitamins-%26-Supplements/Multi-Vitamins/Superdrug-A-Z-Multivitamins-with-Minerals-Tablets-X-30/p/766756
• Tesco A-Z Multivitamins + Minerals https://www.tesco.com/groceries/en-GB/products/285513527
• Valupak Multivitamin & Minerals http://www.valupak.co.uk/documents/content/63/VP354.pdf
• Vegan Vitality Multivitamins & Minerals with High Strength B12, D3 & K2 https://vegan-vitality.co.uk/products/multivitamins-minerals-with-high-strength-b12-d3-k2

Calcium and vitamin D

Requirement: must contain at least 800mg of calcium and 20µg (micrograms) vitamin D in a daily dose.

Tablet/caplet versions of calcium and vitamin D supplements are larger than 1cm in diameter, so chewable or soluble varieties are advised until these can be recommenced (6 weeks after bypass, 12 weeks after sleeve). These are only available on prescription or over-the-counter from a pharmacy, including our pharmacy (at additional cost). There are several varieties which meet the requirements.

If taken twice daily:

• Adcal D3 chewable tablets
• Calceos 500mg / 400unit chewable tablets
• Calcichew D3 Forte chewable tablets
• Cacit-D3 effervescent granules sachets
• Kalcipos-D3 chewable tablets
• Netecal D3 chewable tablets
• SunVit-D3 400unit with Calcium 500mg chewable tablets

If taken once daily:

• Accrete D3 One a Day 1000 mg / 880 IU chewable tablets
• Calcichew D3 1000mg/800unit Once Daily chewable tablets
• theiCal-D3 chewable tablets

Once you are able to take solid tablets larger than 1cm in diameter again, you can, if you wish, change to one of the following (taken twice daily):

• Accrete D3 film-coated tablets - available on prescription or over-the-counter from a pharmacy, including our pharmacy (at additional cost)
• Calcichew-D3 500mg/400 unit caplets - available on prescription or over-the-counter from a pharmacy, including our pharmacy (at additional cost)
• Vitabiotics Ultra Calcium & Vitamin D - available from the Vitabiotics website

Iron

Requirement:

• Women who are not currently menstruating (at all) and men: 45-60mg daily, provided by either 210mg ferrous fumarate or 200mg ferrous sulphate
• Women who are menstruating: 100mg daily, provided by either 210mg ferrous fumarate or 200mg ferrous sulphate

Weeks 1-4 after surgery: liquid varieties only. The only two available (both on prescription or over-the-counter only) are shown below.

Week 5 after surgery onwards: if you have progressed onto solid food and wish to change to a tablet variety of 210mg ferrous fumarate or 200mg ferrous sulphate, then do so.  Regardless of the type you choose, it is required once daily if you are a woman not currently menstruating (at all) or if you are male, or twice daily if you are a woman who is menstruating.

Vitamin B12

The way in which vitamin B12 is absorbed from food is affected by both the gastric bypass and sleeve gastrectomy. It is therefore recommended that you have 1mg intramuscular injections of vitamin B12 instead of taking it orally. These should commence three months after surgery and take place every three months afterwards. You can arrange these with your GP surgery or we can provide them at additional cost.

Important:

• Avoid taking any supplement on an empty stomach - ideally take an hour after drinking a source of protein (e.g. milk, meal replacement drink, soup) or, once you have progressed onto food, an hour after food.
• Space out all your supplements by at least 2 hours - do not take them all together; this includes any supplements that need to be taken more than once e.g. calcium. This helps to enhance their absorption.

Baricol Complete

Baricol Complete is a complete vitamin and mineral supplement specifically designed for people who have had a gastric bypass or sleeve gastrectomy.

It contains all the vitamins and minerals you need, including the recommended amounts of calcium, vitamin D and iron stipulated in the BOMSS guidance mentioned above. The calcium used is calcium citrate, which is thought to be better absorbed that other varieties after weight loss surgery. It also contains 700µg of vitamin B12, over 400 times the average daily requirement for an adult who has not had weight loss surgery (1.5µg). A study by the manufacturer suggests that by taking such a dose, you sufficiently offset the poor absorption and therefore consume enough. Should you decide to opt for Baricol Complete, we strongly recommend that you have your blood level of vitamin B12 tested regularly (mentioned below) to ensure that additional supplementation via injection is not required.

Baricol provide various options, including chewable tablets (three daily), effervescent tablets (two daily), sachets of flavourless powder that can be mixed with food (two daily) and capsules (five daily).

Baricol recommend that you do not start taking it until 2-3 weeks after surgery to allow any nausea to settle and also for internal healing. They also recommend that you build up gradually to the full dose.

It is only available online, direct from their website: baricolbariatrics.com. You can obtain a free sample by emailing [email protected], mentioning that you are having or have had surgery with The Hospital Group.

Blood tests

After having the gastric bypass or sleeve gastrectomy, you can be prone to nutritional deficiencies and therefore need regular blood tests to ensure that the additional supplementation is having the desired effect. You may require additional supplementation depending on the results of your blood tests; everyone is different.

The guidance produced by BOMSS recommends the tests shown in the table below.  These can be carried out by your GP surgery. Alternatively, we can provide these at additional cost.

*Only required if not having 3-monthly vitamin B12 injections.

It may be recommended to have further tests in certain circumstances e.g. selenium, vitamin A, vitamin E, vitamin K. Your dietitian will advise accordingly.

If you have any questions or would like to speak a dietitian, please contact us.